Dr Huma Sheikh MRCOG, Senior consultant gynaecologist, Gujranwala District, Punjab, Pakistan, is a sexual and reproductive health and rights (SRHR) champion working with the RCOG to advocate for increased prioritisation of SRHR in overseas development.
Here, she makes the case for sufficient and stable investment in contraception services in Pakistan and around the world.
Introduction
50% of women and girls aged 15–49 in Pakistan who want to avoid a pregnancy have an unmet need for modern contraceptive methods[1]. As clinicians, we see the benefits of contraception access for our patients’ sexual and reproductive health and rights. We also witness the dire consequences when donors, like the United Kingdom, cut their once world-leading investment in contraception services[2]. World Contraception Day is the perfect time to advocate for stable and sufficient funding for contraception supplies and counselling. These essential SRHR services must be prioritised, all year round.
Barriers to contraception services
Many women and girls across Pakistan face myriad barriers to accessing contraception services and counselling. These barriers disproportionately affect those who are already marginalised, exacerbating health inequalities for people living in poverty, disabled people, those in rural communities, young people and LGBTQ+ people. Patients have to overcome stigma as well as financial and logistical difficulties to seek out contraception services. Without investment in community-centred services or the mainstreaming of contraception within primary care, many women and girls are left with few choices, unable to exercise their sexual and reproductive rights[3].
Recent, catastrophic flooding across much of Pakistan has added to and aggravated these inequalities of access to contraception. According to the British Red Cross, around 33 million people – or 1 in 7 people in Pakistan – have been impacted by the floods so far[4]; people’s lives have been thrown into turmoil in flood-affected areas and health services across the country are stretched beyond capacity. As we have seen during the COVID-19 pandemic, there are also concerns that contraception and other SRHR services will be deprioritised, both in the immediate response to the floods and during the recovery period that will follow[5].
Underfunding also restricts the availability of contraception. At a basic level, many methods of contraception only work if the patient has consistent access to supplies. Patients are also likely to disengage from contraception services if, after overcoming all the aforementioned barriers to care, their preferred method is not available[6]. Finally, access to the full range of modern contraception methods allows women and girls to choose what works for them; this choice is essential, not only in terms of contraceptive efficacy but also for patients’ full ownership of their sexual and reproductive health. Women and girls must be able to rely on well-resourced and affordable contraception services.
Funding cuts and underfunding
To break down these barriers to care, contraception services need stable and sufficient funding. In Pakistan, contraception service providers are still reeling from deep cuts to the UK bilateral donor assistance (also referred to as official development assistance (ODA)), announced in November 2020. The cuts resulted in a 54% drop to UK aid to Pakistan, totalling approximately £150 million[7].
The UK Government has long been a world-leading funder of SRHR services and a champion of women’s global health: between 2015 and 2020, over 900,000 women and girls were able to use modern methods of contraception with the support of UK funding[8]. The UK Government’s decision to cut ODA spending and deprioritise SRHR has left a devastating burden of unmet need for contraception in its wake.
The knock-on effects of unmet need
When funding to contraception is cut, women and girls cannot exercise their bodily autonomy or decide the number or spacing of their pregnancies. In terms of physical health, the impacts of unintended and non-spaced pregnancies are felt across the life course: as rates of unintended pregnancies rise so do rates of unsafe abortions, maternal mortality and life-changing conditions like obstetric fistula and genital prolapse[9]. The Guttmacher Institute has calculated that, worldwide, cuts to UK ODA would mean 4.3 million more unintended pregnancies and 8,000 more maternal deaths[10]. In addition, integrated sexual health and contraception services play a vital role in STI prevention. Well-trained SRHR workers are a lifeline for those experiencing gender-based violence. When contraception services are cut or underfunded, many lose their escape route from reproductive coercion or abuse. Ultimately, access to contraception across the life course has a significant bearing on other equality markers, including education, health outcomes and life expectancy[11].
Conclusions
In Pakistan and around the world, contraception services sit at the heart of SRHR. With sufficient and stable funding, contraception services can provide quality healthcare, reach out to marginalized communities and empower women and girls to exercise their bodily autonomy. As clinicians, we know that access to contraception counselling and supplies can be life changing – and often lifesaving – for our patients. We must, therefore, raise our voices on World Contraception Day and beyond to call for investment in this essential part of healthcare.
[1] https://www.guttmacher.org/regions/asia/pakistan. Accessed 15 September 2022
[2] https://www.guttmacher.org/just-numbers-impact-uk-international-family-planning-assistance-2021-2022. Accessed 21 September 2022
[3] Khan AA. Family planning trends and programming in Pakistan. J Pak Med Assoc. 2021 Nov;71 (Suppl 7)(11):S3-S11. PMID: 34793423.
[4] https://www.redcross.org.uk/stories/disasters-and-emergencies/world/climate-change-and-pakistan-flooding-affecting-millions. Accessed 12 September 2022
[5] https://www.guttmacher.org/article/2022/08/impacts-covid-19-contraceptive-and-abortion-services-low-and-middle-income-countries. Accessed 16 September 2022
[6] Khan AA. Family planning trends and programming in Pakistan. J Pak Med Assoc. 2021 Nov;71 (Suppl 7)(11):S3-S11. PMID: 34793423.
[7] https://devtracker.fcdo.gov.uk/countries/PK/. Accessed 21 September 2022
[8] https://devtracker.fcdo.gov.uk/countries/PK/. Accessed 21 September 2022
[9] https://www.guttmacher.org/fact-sheet/adding-it-up-contraception-mnh-pakistan. Accessed 16 September 2022
[10] https://www.guttmacher.org/just-numbers-impact-uk-international-family-planning-assistance-2021-2022. Accessed 21 September 2022
[11] Starrs AM et al., Accelerate progress—sexual and reproductive health and rights for all: report of the Guttmacher-Lancet Commission, Lancet, 2018, 39(110140):2642–2692, https://doi.org/10.1016/S0140-6736(18)30293-9.