In this qualitative study, twenty FGDs were conducted;10 with men and 10 with MWRA, between January 2017 and February 2017, to understand participants’ perceptions and experiences towards the acceptability of contraceptives and their use. FP services offered by CHWs under Sukh initiative (Table 1). The demographic characteristics of FGD participants, including MWRA and men, are presented in Table 2. Based on the data collection and thematic analyses, three overarching themes were identified: (I) Appropriateness and means to promote contraceptive use in catchment population of Sukh Initiative; (II) Equity and Accessibility to contraceptives in catchment population of Sukh Initiative; and (III) Perspective on available FP services in the area in relation to cost, and quality of service. These themes are presented below with illustrative quotes
Table 1: Study participants
Table 2: Profile of FGDs participants
Theme 1. Appropriateness and means to promote contraceptive use in catchment populations of Sukh Initiative
Under the theme of appropriateness, the matters discussed were; source of and process to receive information on family planning methods, autonomy to use of family planning methods, change in the behavior and communities’ suggestions to promote contraception in the community.
Source and process of providing information
Both men and women, in all the FGDs, were aware of the family planning services offered by Sukh Initiative in their areas. This has received information on family planning mostly through Aman community health workers who visited their homes regularly. Few men mentioned receiving text messages on cell phones by Aman tele-health services and having met with male workers from the Sukh initiative to discuss spacing births and use of family planning methods. Those who had interaction with male motivators expressed their desire to receive family planning methods as well in addition to information.
We receive information through text messages and phone calls. We get information from Aman male worker. Some men get messages on phone some don’t (Man, FGD- Korangi Town, Station 05)
In all the focus group discussions except one, both men and women mentioned free camps being organized in their areas from where they get information on family planning and obtain contraceptives free of cost. Men and women also appreciated free transport services to visit a health facility by Sukh initiative.
The community men and women were well aware of other community resources providing information and services for family planning. They mentioned community Health center by Aga Khan University in one area, private clinics, Marie Stopes clinics, government-run family welfare centers, medical stores, NGOs offering FP services such as Green Star and HANDs, internet, hospitals and, general clinics and Lady Health Workers of government Primary Health care and family planning program. However, with the presence of Sukh initiative, they are not only receiving information but are also getting free of cost pills, condoms and injections at their doorsteps which is cost saving for them. Both men and women expressed that the presence of men and women workers of the Sukh initiative had created a platform for friends, family members and, spouses to discuss and exchange knowledge related to family planning methods and their use. Men and women both mentioned that the presence of Aman health workers in their areas had made the accessibility and availability of information and services easy for them. It should be noted that male workers were far less in numbers as compared to female community workers hired by Sukh Initiative.
Attending meetings have raised awareness in us, which we never had before (MWRA, Bin Qasim Town, Station 03)
In almost all the FGDs, men mentioned that female CHW of Sukh Initiative provides information mostly to their women and ask them to share this information with their husbands. Very few men mentioned CHWs talking to them directly. Men expressed their concerns about not having any facility especially for them to provide firsthand information to them on family planning methods
Make some system such as a center or a clinic where men and women can go and get some information on family planning, it does not look nice that CHWs come to our house again and again. (Men, Bin Qasim Town, Station 2)
Men and women mentioned that they only get information through CHWs as there is no other source for them to get information or supplies. Men raised concerns about women not having the privacy at home to discuss methods or their issues comfortably as other family members are also present at the time of the CHW’s visit and women feel embarrassed to discuss openly.
Some men from Bin Qasim and Landhi town had conservative views for use of family planning methods and considered this against religion. Some counter-argued that parents are answerable to God and to their children for providing good food and education to children and with small families they can do it easily.
There are many religious institutes in these communities that don't support FP; this is the reason people don’t want to use a family planning method. (MWRA, Bin Qasim Town, Station 3)
Meetings with Sukh’s counselors and religious leaders have removed many of our misconceptions, and now we think positively about family planning and are also allowing our children to have polio drops. (Men, Landhi Town, Station 9)
Autonomy to use FP methods
In conservative populations of Bin Qasim and Landhi Towns, different views were expressed by women for use of family planning methods; in some focus groups, women mentioned strong role of husbands in their decision-making for going out of the house or to use a family planning method and mentioned that having information on family planning methods would have no effect on its use, as their husbands do not approve use FP methods. While in other groups, women mentioned having conditional autonomy to go out of home and use FP methods in mutual agreement with husbands, while some use FP without husbands or anyone else’s knowledge. In some FGDs women mentioned that men would not want any protection for themselves but would not stop women to use methods to prevent pregnancy.
While some men mentioned that their women generally stay at home, don’t interact with neighbors and do not share any information with each other either. Men from Landhi area mentioned feeling embarrassed to discuss FP related matters in front of elders or younger family members. However, both men and women believed that the decision to use family planning methods rests with individual families and there were no communities or institutional pressures against its use.
‘We were initially not aware of the FP methods, now we are aware about women’s health and education. We know that spacing of two years after birth help mother to regain her health”
FGD-Men Rehri Goth
Regarding cultural barriers, men in almost all the focus group discussions denied such barriers and mentioned that education is becoming common and people have information. Women do consult their husbands or in some cases, men’s permission is sought and couples decide jointly about matters especially related to family planning and health. The role of other family members such as mother in law is declining to a large extent, and the nuclear family is becoming a norm.Men and women from Malir and Korangi, which are relatively liberal areas, were supportive of the use of family planning methods. Men said they have no restrictions on their women to use family planning methods. Some women mentioned using implants without the permission of their husbands and had faced no reaction from their husbands.
Change in behavior/thinking
Men in almost all the FGDs mentioned that FP use is most beneficial to their children and family in terms of the provision of food and education. But now they are equally concerned about the health of their women due to repeated and closely placed pregnancies.
Prior to this (CHWs giving awareness of FP to community), we did not think about the health of women but now we do and do spacing of 2 years. (Men, BinQasim Town, station 2)
Some of the reasons for the change in behavior against large family size were related to low financial resources, increasing interest in educating children, and health concern of spouses. Through Sukh Initiative the accessibility and availability of knowledge, information and services had made the use of FP easier for both men and women. The openness in discussions and mutual transfer of information had increased, resulting in a positive attitude towards the use of family planning methods. Men and women both showed the desire for having separate sessions on family planning for unmarried boys and girls in privacy.
The way you are guiding our married ladies about family planning, you can guide our unmarried ladies, so that in future they can plan their family better. (Men, Malir Town)
Theme 2. Equity and accessibility to contraceptives in catchment populations of Sukh Initiative
As far as affordability of the commodities is concerned men and women both mentioned that some people can afford the cost of family planning methods and most cannot.
Men mentioned that in spite of other resources available in the area, they prefer community health worker of Sukh initiative for providing information and methods such as condoms, pills, and injections at homes and providing the transport, cost of IUCD, and Implant and their insertion charges free of cost through Sukh initiative.
We used condoms even before Aman CHWS were here and would get them from family welfare centers, now we receive these at our homes free of cost. (Men, Bin Qasim Town, station 2)
Theme 3. Perspective on available FP services in the area in relation to cost and quality of services
Methods and preferences
Nearly in every FGD, men were of the opinion that the use of condoms is easy; it is free of side effects and easily available. Men mentioned that other methods such as IUCD and implants from the private sector are expensive and treatment of side effects gets even more expensive, and then there is added cost of transport. In addition, the value of time spent on waiting and travel was also mentioned as a barrier for use of FP methods.
Women voiced concerns about the affordability of the family planning methods. They mentioned that due to high living cost it gets difficult to make ends meet, so cheaper methods are preferred such as condoms and pills. Men mentioned that only 10 percent of women might be using injections, because of its cost. condoms are cheap and easily available.
Injection and condoms are cheaper and safer; the rest of the methods are too expensive. (Men, Korangi Town, Station 7)
Women mentioned that in case they don't get a method from CHW or from a family planning clinic in the area, then their men buy these from shops. Men said that in case of non-availability of FP methods from the clinics or CHWs they usually get these from the open market where the cost of the FP method is dependent on the duration of spacing they provide and also on quality, the service inclusive of IUCD is expensive, which many people cannot afford.
Quality of Services- Concerns
Women mentioned side effects related to injection, IUCD, and implant as the main deterrent for their use. The main side effects mentioned were feeling of general tiredness, breakthrough bleeding, bloating, amenorrhea, weight gain, low BP and weak eyesight. Women stated that in case of any side effects they discuss with Aman health worker, or visit government-run facility.
The withdrawal method did not work for us and I had my daughter, so I switched to injections but my health got badly affected and I have stopped using any FP method. (Woman, Landhi Town, station 9)
I have an IUCD placed, for the last 2 months and I am having bleeding. The health care provider gives me 3-4 tablets to take and asks me to tolerate it. This is not solving my problem. (Woman Landhi Town, Station 9)
It appeared that women want a long duration of spacing but are perplexed with their side effects, its related cost of management, difficulty in performing religious rituals and intolerant behavior of husbands for denial of sex. They raised their concerns about the inability of the health care providers (CHWs and facility staff) to advise them on side effects. In all the FGDs women mentioned that they were not appropriately counseled about the side effects and its management. The Sukh initiative health workers have limited knowledge and generally refer them to health care providers. Both men and women mentioned that CHWs also give referral slips, but when they reach a facility with this slip the story gets different, they ask for money for everything and at times misbehave too. Women had complaints about lack of professionalism especially, of government healthcare providers, about the high cost of the private sector and of doctors who place IUCD but don't manage complications.
Women also had interesting perceptions about the treatment for side effects of a method. They dislike just receiving counseling or some tablets to stop bleeding and expect some dietary advice, an intravenous infusion with iron or just an infusion. It seems important to educate women, men, FP providers including CHWs about the side effects of FP methods and their management. The women should know about the side effects and their management of long-acting family planning methods.
Women and men both complained about the bad attitude of the staff at public health facilities. The bad attitude of government staff impels them to consult the private sector which is far more expensive but the attitude of the provider is good, surroundings are clean and the method of choice is available. However, they all were appreciative of the low or free of cost services from the government sector.
When asked about the ideal FP services, men and women responded by saying that services should be closer to their homes, there should be proper counseling, methods should be free of cost or of minimal cost.
The facility should be nearby otherwise we are dependent on others; if it is near we can easily go there (MWRA, Malir Town, Station 10)
Staff should talk to clients with respect, show caring attitude, be cordial and have a soft demeanor. Drugs should not be of the expiry date, there should be less waiting time and side effects should be treated free of cost. Ideal timings for facilities mentioned were in the afternoon from 3-4 p.m. when women had taken care of all the household chores.
Men mentioned that they are on job all day and are back in the late afternoon or early evening, they should have separate clinics in the evening, and men should talk to men. Women suggested having centers close to their houses where they can go themselves. Men, whereas mentioned having informational pamphlets that they can view in their own privacy.