(2021) 18:96
Sarfraz et al. Reprod Health
https://doi.org/10.1186/s12978-021-01149-0
Open Access
RESEARCH
Role of social network in decision making
for increasing uptake and continuing use
of long acting reversible (LARC) methods
in Pakistan
Mariyam Sarfraz1* , Saima Hamid1,2, Patrick Rawstorne3, Moazzam Ali4 and Rohan Jayasuriya3
Abstract
Introduction: Despite evidence from recent Demographic Health Surveys that show 98% of the adult Pakistani
population have an awareness of at least one modern contraceptive method, only 25% of married couples in Pakistan used a modern method of contraception. Of the modern contraceptive methods, LARC usage has increased
only from 2.1 to 3%. This low uptake is puzzling in the context of high awareness of LARC methods and its availability
through public sector facilities at subsidized costs. This study aimed to understand the social influences in initiating
and continuing use of an LARC methods for contraception in a rural setting in Pakistan.
Methods: In-depth interviews were conducted with 27 women who were using a LARC method for contraception.
Data was managed using NVivo 12 and themes were identified using a content analysis approach to analyze the
transcripts.
Results: Four key themes, supported by sub-themes relating to a temporal model, were identified to explain
women’s experiences with initiating and continuing use of a LARC. The themes were (i) Use of trusted networks for
information on LARCs; (ii) Personal motivation and family support in decision to use LARC; (iii) Choice of LARC methods and
access to providers; and (iv) Social and professional support instrumental in long term use of LARC. Results highlight the
significant role of immediate social network of female family members in supporting the women in initiating LARCs
and maintaining the method’s use.
Conclusion: This study contributes to an in depth understanding of the decision-making process of women who
adopted LARC and maintained its use. Women who proceeded to use an LARC and who persisted with its use despite
the experience of side effects and social pressures, were able to do so with support from other female family members and spouse.
Plain English summary
High proportion of married women do not use an effective contraceptive method and is a public health concern
that is associated with unintended pregnancies, unwanted births, and unsafe abortions. This is also associated with
*Correspondence: msarfraz@hsa.edu.pk
1
Health Services Academy, Islamabad, Pakistan
Full list of author information is available at the end of the article
© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
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licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco
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Sarfraz et al. Reprod Health
(2021) 18:96
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increased risks of pregnancy and childbirth-related maternal morbidity. The decision to initiate use and continue
the use of contraceptives is influenced by a number of factors. A greater understanding of these factors will inform
policymakers, programmers, and other stakeholders to strengthen family planning and other health intervention
programs to achieve the SDGs targeted maternal and under-5 child mortality reduction. Thus, the main objective of
this study was to understand the social influences in initiating and continuing use of an LARC methods for contraception in a rural setting in Pakistan, using qualitative research. The analysis was done from a total of 27 women, aged
15–49 years, who started the use of long acting reversible contraceptive in the year preceding the study. The findings
have an implication for policymakers, programmers, health care providers, and other stakeholders to evaluate and
strengthen the provision of different contraceptive methods and improve support provided to women through the
family planning programs. The findings of this study strongly recommended the provision of quality counseling on
side effects and availability of contraceptive methods, peer support, and support for decision-making regarding long
acting reversible contraceptive use.
Keywords: Long acting reversible contraceptives, Contraceptive use decision making, Social networks, Pakistan,
Married women, Family planning, Birth spacing
Introduction
While annual global population growth rates have
declined since the 1960s, population sizes in the least
developed countries of Asia and in sub-Saharan Africa
have been growing fast and are predicted to grow at substantial levels in the coming decades [1]. Alongside, the
prevalence of contraceptive use has increased worldwide [2], however, millions of women in low and middle income countries (LMIC) remain vulnerable to short
spaced, unintended pregnancies due to limited access to
suitable contraceptives. Recent UN and WHO estimates
suggest that more than 220 million women of childbearing age in LMIC are not using any method of contraception [2–4].
The long acting reversible contraceptives (LARC)
including implants and intrauterine device (IUD) are
highly effective contraceptives. The LARCs are suitable
for women of all ages; in comparison, there is significant
contraceptive failure with other contraceptive methods
(including pill, patch, or vaginal ring), particularly among
younger aged women [5]. Moreover, LARCs convey many
other advantages for clients in terms of convenience,
satisfaction, ease of continuation, likelihood of avoiding
unintended/unwanted pregnancy, and non-contraceptive benefits [6–8]. However, LARC use in South Asia
accounts for only 2% of the total modern contraceptive
methods mix [4, 9]. Barriers for uptake of LARC include
issues of access, affordability and insufficient promotion
and misconceptions about their effects [10, 11].
Despite evidence from DHS surveys that 98% of the
adult Pakistani population have an awareness of at least
one modern contraceptive method [12], only 25% of married couples in Pakistan used a modern method of contraception. LARC usage has increased only modestly over
the past decade in Pakistan, from 2.1 to 3% [12–14]. Such
low uptake of LARCs appears somewhat puzzling in the
context of high awareness of modern methods and LARC
methods being made available through public sector
facilities at subsidized costs [15, 16]. This level of use is
lower than in other areas of South East Asia, particularly
neighboring Iran, where LARC methods are used by 8%
of contraceptive users [17].
Past research exploring Pakistani women’s perceptions
about LARCs, especially about IUCDs, showed similar
barriers in other countries, including fear of side effects,
husband disapproval and religious opposition [18–24].
Women with a higher educational level, employment status and in a more favorable economic position were significantly more likely than other women to use LARCs
[25]. Availability and affordability of LARC methods are
documented to be barriers to the use of LARCs, particularly among postpartum women [26–28]. There is a
need for better understanding the issues affecting LARC
uptake, to increase use and create demand for all FP
methods using mass media, community health workers
and subsidized services.
Previous research on contraceptive use among Pakistani women has focused on assessing reasons for nonuse of modern contraceptives, documenting knowledge
gaps and access barriers; but it has not investigated in
depth, social networks associated with the uptake, and
motivations to use, LARCs [23, 29–32]. This study aims
to fill this gap and to develop an in-depth understanding
of social influences in initiating and continuing use of an
LARC methods, including married women’s motivations,
information pathways accessed, decision making process,
for contraception in rural Pakistan.
Methods
Study setting
This study derives from a larger research project that
sought to study the FP knowledge and practices among
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married men and women living in rural Islamabad, Pakistan, conducted in six rural communities. Driven by the
study objective, the study population was identified from
those rural areas where contraceptive products and services were provided through both public and private sector providers [12]. In the public sector, the Department
of Health (DoH) provides services through a network of
Reproductive Health Services (RHS) clinics attached to
hospitals and the Population Welfare Department (PWD)
provide services through Family Welfare Centers (FWCs)
in rural areas and Mobile Service Units (MSUs) for hardto-reach areas. A female community health worker (Lady
Health Workers—LHWs), based in each village, have
records of each household where they counsel women,
provide advice on the benefits of family planning and
also provide women a selected range of contraceptives.
DoH and PWD clinics provide LARCs at a subsidized
cost, such that IUCDs cost Rs. 200 (US$ 20 cents), while
implants are provided at no cost.
In the six study areas identified for this research, five
Basic Health Units (BHU), one Rural Health Center
(RHC), and three Family Welfare Centers (FWC) were
operational and providing family planning products
(condoms, pills, hormonal injections and IUCD) and services through a medical doctor and licensed midwives
(Table 1).
Study design
Data examined in this paper includes in-depth interviews with women identified during a broader study of
FP knowledge and practices, with 800 married men and
women, living in rural communities of the study area
[33]. As the objective of this study was to understand
factors affecting use of LARC among married men and
women in rural communities of Islamabad, a sufficient
sample size for undertaking logistic regression modelling
was recruited.
Sampling and recruitment
The respondents for the qualitative study were identified
from among the 400 women who participated in a reproductive health and family planning survey conducted in
six rural areas of Islamabad [33]. For the survey, married
women who were less than 35 years of age and whose
youngest child was ≤ 5 years of age were identified by
local LHWs, from their household records. Among those
women, 47 married women were identified as being a
current or past user of LARC and invited for participation in this study. However, after subsequent screening
to exclude those who had used a LARC over the past
twelve months back and those who had discontinued,
27 respondents fulfilled all criteria. These women were
interviewed in their own homes, in the local language
(Punjabi Potohari) by the first author (MS) and a research
associate (RA); both women and trained in qualitative
research methods.
Using a semi-structured, in depth interview guide
respondent’s knowledge of contraceptive and FP methods, sources of information, current and past use of
contraceptives, reason for using selected method, and
experience with the acquired method and its continuing use or non-use, role of social networks and decisionmaking process on use/non-use of LARC was collected.
Although data saturation was achieved after interviews
with 12 women, it was decided to interview all women
identified to develop insights on differing perspectives.
Interviews, lasting 30 to 60 min, were recorded with
respondents’ permission, transcribed into English by the
RA, verified and finalized by main author (MS), detailing context, where necessary, using notes taken during interviews and field visits. Daily field notes and a
reflexive journal were also maintained by the interviewing researcher to record social and interactive nuances
observed, as well as to contextualize and corroborate
information gathered from interviews.
Data analysis
Table 1 Population and family planning services in study area
Study area
Islamabad
capital
territory
Population size
LHWs
BHU/RHC
PWD facility
Bhimbar Tarar
6815
10
1 BHU
1 FWC
Bukar
4468
09
1 BHU
1 FWC
Chirrah
14,536
26
1 BHU
–
Tumair
12,173
12
1 BHU
–
Jagiot
7936
22
1 BHU
1 FWC
Tarlai
39,649
33
1 RHC
–
LHW Lady Health Worker, BHU Basic Health Unit, RHC Rural Health Center; PWD
Population Welfare Department
Interviews were conducted in the local language and
audio-recorded with respondents’ permission. The data
were transcribed directly to English by a person fluent in
both English and Potohari. MS checked the transcripts
against the recordings to ensure accuracy and appended
the field notes taken during the interactions. Transcripts
were discussed with participants for checking reporting
accuracy. The final transcripts were deidentified prior
to data analysis using qualitative analysis software program, NVivo 12. The data was analysed using content
analysis approach, keeping in mind the context of the
study [34]. Research team members undertook an iterative, inductive process of data analysis by independently
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reading a few of the transcripts to identify meaning
units, emerging patterns, and develop a coding structure. The developed codes were then discussed among
the research team members to compare and resolve discrepancies. Three transcripts were also shared with two
other qualitative researchers for independent coding and
verification; differences in interpretation were addressed
through discussion and incorporated in the coding structure. The final coding structure, from codes to categories
and themes was then used to code all the transcripts.
The themes connecting the codes within each category
were then identified and are reported descriptively in
this manuscript. The Consolidated Criteria for Reporting
Qualitative Studies (COREQ) 32-item checklist [35] was
followed to ensure reporting consistency.
Trustworthiness of qualitative data
Methodological rigor for this research was achieved
through first author’s prolonged engagement with the
respondents, respondent validation, maintaining a
chronological audit trail, team debriefings and triangulation for data analysis, with the co-authors (SH and RJ)
[36, 37]. Some of the data were also collected, transcribed
and coded by the Research Assistant (RA), to ensure that
the first author’s (MS) professional orientation as medical doctor and public health researcher did not impact
on data collection approach and analysis process. Probes
were used to explore the responses and provide context for the information shared. Throughout the process
of data collection and analysis, ongoing critical reflection, peer discussions, as well as respondent validation
ensured interpretative accuracy of the results. Contextual details of the study site were captured through field
notes, pictures of some areas, and a reflexive journal,
all of which were used to provide a holistic description
of the study area setting and participants. Neutrality of
findings was maintained through debriefings within in
the team, combining perspectives of the entire research
team.
Ethical approval
Ethical approval for the study was obtained from Human
Research Ethics Committee (HREC) of University of New
South Wales and National Bioethics Board (NBB), Pakistan. Informed consents were solicited, and participants
were assured of confidentiality of information shared; initials have been used throughout to protect participants’
identities.
Results
Participant characteristics
The age of the 27 participants ranged from 20 to 33 years
and had 2 to 4 children each. 55% had attended primary
Page 4 of 11
school only and none were formally employed, and all
were housewives. Most of the women interviewed had
used other types of modern contraceptive methods prior
to using an LARC, with 63% using condoms. Currently
23 (85%) were using IUCD (both copper and hormonal
devices) as LARC.
Qualitative study findings
Women’s experiences with initiating and continuing use
of an LARC are explained under four themes, (i) Use of
trusted networks for information on LARCs; (ii) Personal
motivation and family support in decision to use LARC;
(iii) Choice of LARC methods and access to providers; and
(iv) Social and professional support instrumental in long
term use of LARC, supported by sub-themes.
The figure below (Fig. 1) shows a conceptual model of
LARC use decision making, which emerged inductively
from the data. It illustrates women’s staged decisionmaking process about LARC uptake and use, providing
a framework for understanding important influences
at each stage. The model identifies the social influences
operating at each stage, provided social relationships and
personal interactions. As shown in the model, women are
interested in initiating use of a contraceptive due to personal motives. They then proceed to gathering information about methods and providers from trusted sources,
including female relatives and local LHWs. Experiences
of satisfied users lessened women’s reservations about
LARC methods; any lingering doubts were also addressed
by skilled providers, helping them overcome this barrier
to adopting use of a LARC. Women then proceeded to
deciding the type of method to use, with support from
their spouse, who also accompanied them to the provider. After initiating use of a LARC method, ongoing
support of spouse, and skilled providers gave women the
confidence to continue use of this contraceptive method.
Use of trusted networks for information on LARCs
Women sought to obtain information about different
types of contraceptives, particularly about LARCs from
different sources when they were contemplating using an
LARC.
Communication networks
Most stated that their source of information about contraceptives in general and LARCs, were predominantly
from female relatives (mothers, sisters, aunts, cousins). In
all cases, these female relatives had also used contraceptive methods, including LARCs, mostly IUCDs. It seems
a common practice, even normative, for married women
to share their experiences of contraceptives with other
women in their relatives network.
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Page 5 of 11
Fig. 1 Conceptual model of women’s decision making about LARC use in Pakistan; (social groups identified in different colors. Legend: LHW Lady
Health Worker; FP Family Planning)
My older sisters are married, and they would talk
about family planning methods; so, I knew from
them that there were things you can use for having
[a] gap in children. One of my sisters has been using
the ring (IUCD), for 5, 6 years now. When we have
a health problem, we first ask our mother or sister,
sometimes mother-in-law also … [Respondent 3,
30-year-old]
In cases where, had medical interventions (e.g. cesarean section) they received information about LARC
methods by their obstetricians and nurses. However, they
consulted with family members about such advice:
Doctor said that I should have a gap of at least 3
years between children, because of operation (C-Section). She told me that the hospital has Family Planning clinic and I can get the challah (IUCD) and
capsule (implant) from there, after my post-partum
period (chillah) ends. I asked my mother about this;
she and my sister had also used challah (IUCD)
and they also told me to start using something …
[Respondent 6, 26-year-old]
Verifying information from experienced users
and professionals
Various misconceptions about both LARC methods were common. Many mentioned knowing someone who had experienced adverse side effects of IUCD
(such as perforation through uterine wall and migrated
to the abdomen or kidney) or they knew women who
had become pregnant while using these contraceptive
methods:
… My younger sister also had it, but she conceived
with the tube (IUCD) inside and had her daughter
same time as my son [Respondent 12, 24-year-old]
Information fueling these misconceptions was reportedly shared through social networks, where sometimes
the use of a particular LARC was discouraged, even by
the LHW:
…. I have heard that the rods (implant) can stop
menstrual cycles and cause infertility, if used for
a long time; so, I decided to use the ring (IUCD)
[Respondent 18, 33-year-old]
It was also found that in addition to seeking information from female relatives, women sought advice of local
LHWs, which was sometimes biased.
… My sister-in-law was using the capsules
(Implant) so I asked her about her experience with
using it; she said it was easy to use and she had no
problems. Then I asked Baji (LHW) about it but
she said the capsules (implant) can cause problem
in the woman’s system, like I can stop having my
periods or I can have too much bleeding or spotting. She also told me that some women had to
Sarfraz et al. Reprod Health
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take treatment before they could become pregnant
again. She said better to get the tube (IUCD), so I
decided to get that [Respondent 16, 27-year-old]
Some of the women who had experienced regular
interactions with a doctor or a nurse at ante natal clinics and hospital following cesarean section were more
likely to take advice from their doctor or a nurse about
starting the use of an LARC.
… both my children were born by operation
(C-Section); after my second operation, doctor
told me to use a family planning method. She said
they have capsules, which they put in the arm …
[Respondent 14, 27-year-old]
Personal motivation and family support in decision to use
LARC
Personal circumstance motivates decision to use LARC
Women’s concerns for their own or their child(ren)’s
health was found to be a primary determinant in their
decision to start using an LARC method, especially
when traditional methods failed.
… the LHW told me that I will not get pregnant
if I breastfeed the baby, but I became pregnant
again when my daughter was 7 months old. Both
my children were born by c-section operation. It’s
very difficult to care for two young children, especially after operation so I thought I will have a
gap of four, five years before having another baby
[Respondent 11, 25-year-old]
A common factor among all the women who opted
for LARC was the prior use of other modern contraceptive methods; condoms had been used by all, while
some women had also used the contraceptive pill and
injections. Women reported the desire to start using
a long-term method, citing their husband’s reluctance
to use condoms as well as their own difficulties with
adherence to the regular taking of pills and receiving
injections:
… we used Saathi (condoms) a few times; but my
husband did not want to use the condoms and
we did not want another child for some time, so
I decided to get the tube (IUCD) [Respondent 24,
26-year-old]
Capsules (Implant) are good; better than injection
or the tube (IUCD). With the tablets, you have to
remember to take it every day and sometimes you
can forget to take it on time. Injection also same
problem [Respondent 7, 30-year-old]
Page 6 of 11
Support of spouse in decision making
All the women shared that they had discussed child
spacing with their husbands and had together considered the long-term contraceptive methods available,
the duration of each, and the number of children they
wanted. Since there is a cultural norm in Pakistan of
seeking the approval of one’s husband in such matters
of having an LARC.
My husband is also in favor of having gap in children. I told him about the tube (IUCD) and I can
have it for five years or ten years; he said to get the
5 year one [Respondent 6, 26-years-old]
I talked to my husband about it (IUCD); he told
me to get the IUCD when we had our first daughter (after two sons), but I wanted to have another
girl before getting this (IUCD) [Respondent 30,
28-years-old]
Importance of support from female family members
in decision making process
The supportive role of an older female relative, most
typically mother, mother-in-law or elder sister was significant for respondents in choosing an LARC method
and even influencing the spouse.
Both my children were born with gap of just six
month and I wanted to have some gap before
another child. So, I talked to my husband about
this challah (IUCD) method and told him that
there is option for 5 years and 10 years; but he did
not allow me. Then I asked my mother-in-law and
she told him to give permission to get the challah
(IUCD) [Respondent 34, 24-years-old]
This supportive role of older female relatives was also
observed in situations where a female relative (mostly
a mother or sister-in-law) of the respondent expressed
support for the decision of the respondent, citing reasons of low income, and high costs of living:
…. I got the IUCD after I had two children …
(Respondent 9, 26-years-old); (MiL joined in discussion) …. after her second daughter, I told her to
get the tube (IUCD); I also told my daughter the
same thing; for me, both (daughter and daughterin-law) are equal and having a boy or girl is Allah’s
decision. Nowadays, everything is so expensive and
raising children properly in limited income is difficult
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Choice of LARC method and access to providers
After having decided on starting use of an LARC,
women selected the appropriate LARC method and
provider. Both these decisions were driven by the experiences of trusted members in their social networks.
Testimonies of LARC users
Page 7 of 11
hers from there, so I asked her to go with me (user)
[Respondent 5, 29-years-old]
…. she (mother-in-law) took me to N Baji’s (LHW)
house and asked her to go with us to the doctor in
Falahi Markaz. My mother-in-law said to get the
tube (IUCD) which is for 10 years and I had that
placed from there. [Respondent 13, 20-years-old]
Respondents sought trusted female family members to
enquire about appropriate LARC methods and providers.
Their experience with either of the two LARC methods
influenced respondents in deciding the choice of method
and provider.
The respondents mentioned the availability of LARC
methods at the local public sector health facilities,
including local primary health care and Population Welfare Department clinics. The respondents had easy access
to these facilities.
I got the capsules (implant) because two, three of my
relative got the challah (IUCD) and they suffered
from a lot of health problems. They said not to get it
(IUCD) [Respondent 27, 29-year-old]
…. I had the tube (IUCD) placed from Falahi
Markaz here in our village; other women in the village also got it from there. It’s also near my house
and was easy for me to go to … [Respondent 7,
28-year-old]
Women also preferred getting advice about LARC
methods from providers recommended by a trusted
relative:
… I asked my cousin also about the tube (IUCD),
I knew she had it; she said she got it from NIH. So,
I went there after the post-partum period ended
[Respondent 17, 27-year-old]
Social and professional support is instrumental
in continuing use of LARC
Women who were using an LARC were generally satisfied with the method and planned on continuing use for
spacing or having reached their desired number of children, intended to continue it.
Endorsement by professionals
Spousal and family support for continued use of LARC
LHWs are generally trusted for advice about women’s
health, especially reproductive health, as well as their
knowledge of contraceptive methods and their recommendations about suitable LARC providers. Some
women also relied on their local LHW to accompany
them to the selected LARC provider. Respondents invariably approached the LARC provider who was recommended by either a relative or the local LHW or their
obstetrician:
In continuing to use an LARC, the level of support
from one’s spouse and social networks was found to be
important. Women countered any negative social criticism when they had the support of their husband. They
considered women who did not have support of their
husband to be helpless and vulnerable to multiple pregnancies interspaced with very short time intervals:
I asked Baji (LHW) about the capsules, she also said
it is good and very easy to use. She went with me
also, to Poly Clinic to get the capsules …. [Respondent 18, 28-year-old]
Ease of access to providers
None of the respondents indicated access issues about
LARC use, including distance to provider or affordability.
If the chosen provider was at some distance from their
residence, respondents generally travelled via public
transport, often accompanied by a female relative, local
LHW or spouse/husband:
I went to Poly Clinic on the local transport from
here, with my sister-in-law (bhabi). She had also got
I told my neighbor about this method as well, but
she said her husband did not agree and now the poor
thing (bechari) is pregnant again, with her third
child. It’s all about the husband’s support in using
the contraceptive methods! People say all kinds of
things to me, but I say if my husband is with me on
this, then I don’t care what you say. [Respondent 2,
24-years-old]
Women reported seeking advice from female family
members about side effects and any discomfort experienced. They were generally advised by female family
members not to worry about side effects as they were
told these effects would settle over time. Women were
reportedly reassured by such supportive advice, especially those who were using an LARC for the first time:
Few days after I had my ring (IUCD) placed, I felt
some irritation and burning. I told my sister about it
Sarfraz et al. Reprod Health
(2021) 18:96
and she said it happens for some time, but it will go
away in some days, so don’t worry about it. She said
she also had it after she got hers (IUCD) but then it
was fine. (I: When did she get her IUCD?) She has
had it for four, five years now; actually, she had told
me to get it after my daughter was born [Respondent
19, 27-years-old]
Seeking counselling and timely treatment from health care
providers
Normality in monthly cycles was considered important
by all participants; a deviation from routine was worrisome, leading to fears of this being an imminent sign of
developing side effects. Respondents shared that their
initial experience of some side effects like pain or some
spotting or of heavier menstrual bleeding than normal,
was alarming for them, and they were anxious about
developing more serious health problems. Women
reported dreading the thought of having the LARC
removed, as they did not want another child at that time.
Initially I did not have any problem; but after about
three months, I had some spotting two or three
times. That really scared me, because I had heard of
other women who had similar problems. But then it
settled with the medicine doctor had given me; and
now I’m afraid to share with anyone that all is ok
for fear that I might develop some side effect again!
[Respondent 35, 32-year-old]
Both current and past LARC users appeared to have
been counselled well by their provider about the method
and any expected side effects. As a result, when women
initially noticed side effects, they reported not seeking
immediate care in anticipation of the side effects resolving or subsiding with time. LARC providers were generally approached when side effects continued or increased
in intensity:
After the IUCD, I had prolonged monthly bleeding,
like it was 8 or 9 days and I was still having bleeding. So, I went back to the Falahi Markaz and doctor there gave me a medicine to take for one week,
told me not to worry about this …. I took the medicine and now it’s been almost a year and thank God
I have not had any problem again! [Respondent 16,
28-year-old]
Discussion
This study set out to investigate social influences on
women’s decision making about LARC use and provides
an insight on women’s motivations, information pathways accessed, and decision-making process for LARC
Page 8 of 11
uptake in rural Pakistan. Where previous studies examined barriers to and discontinuance of LARC [18, 23,
30, 38], this is the first study offering insight on key people and their various roles in influencing and supporting women in their decision to use and continue to use
LARCs. The study identifies four themes in the pathways
of married Pakistani women choice to take up an LARC
and continue its use: (i) Use of trusted networks for information on LARCs; (ii) Personal motivation and family
support in decision to use LARC; (iii) Choice of LARC
methods and access to providers; and (iv) Social and professional support instrumental in long term use of LARC.
Each of these themes fit a temporal sequence in adoption
of LARC but cannot be taken as stages as often there is
overlap between each of them and are discussed together.
Policy implications of the findings are also discussed in
the context of current policy in Pakistan.
The effects of social networks and inter-personal communication on shaping women’s attitudes about family
planning and contraceptives is well established in social
networks research, which has shown to have had effect on
contraceptive use behavior [39–42]. Research evidence
from regional countries, similar in context to Pakistan,
have also reported that women’s communications with
female family and social network members influenced
their knowledge and attitudes towards contraceptive
use in family planning [43–45]. However, in the current study, the “trusted” social network was comprised
mainly of female relatives rather than friends or “experts”
external to the family. This difference may be attributable to the culture of consanguineous marriages, norms
of socio-cultural interactions limited to extended family,
and restrictions on women’s mobility without a male or
an older female escort in Pakistan [32, 46]. Conversations
about contraceptive use are rare and unconventional with
non-family members of one’s social network and may
contravene established social and cultural norms in Pakistan. As such, it remains to be seen whether the diffusion
of LARCs could be enhanced through extended female
social networks that have used LARCs or whether such
conversations will generally be confined to female family
members and FP providers.
Prior qualitative studies have shown that Pakistani
women have had some reluctance to use contraceptives,
especially LARCs, because of myths and misconceptions about long term side-effects, which have largely
been driven by rumors and shared through social communications [23, 29]. The current study also found such
occurrences, some which were spread by providers,
specifically the LHW. However, what this study found
was that women who adopted LARCs, were able to
discuss this with trusted female family member. The
shortcomings of the LHWs may be because of gaps in
Sarfraz et al. Reprod Health
(2021) 18:96
their knowledge and deficits in counselling skills, arising from limited training as community health workers, as well as a lack of formal training in health care,
which were factors identified in an external evaluation
of the LHW program [47, 48]. The National Population
Policy [49] identifies LHWs as key personnel to provide
counselling to reduce the unmet need for contraception
on Pakistan. It would be fair to surmise that uptake will
increase when a sufficient cohort of older female family
members with experience of an LARC are available to
counter these myths and misconceptions.
The study findings suggest that increasing Pakistani
women’s access to satisfied LARC users, within peer
networks have the potential to support women in their
decision making for uptake and use of LARCs. Experience of neighboring countries with interventions for
increasing use of LARCs may also offer ideas for implementation in Pakistan. For example, in countries such
as India, Nepal and Bangladesh, where women are
influenced in their decisions about maternity care and
contraceptive use by other women in their social networks [50–53], those countries have introduced behavior change communication programs. Such programs
are aimed at improving uptake of contraceptive methods through joint discussions with women’s groups
comprising younger married women alongside other
experienced women including mothers and mothersin-law [39, 54]. However, it remains unclear whether
such strategies would suit the cultural conditions in
Pakistan.
Husband endorsement and their shared role in family planning decision-making was acknowledged by the
women as necessary for their LARC uptake as well as for
their continued use of an LARC. Participating women
told us how they tried to influence their spouses to arrive
at a joint decision and when such a joint decision was not
forthcoming how they relied on more senior women in
their husband’s family to influence their husband. The
pivotal role of spousal support in contraceptive choice is
highlighted in research from Pakistan which has explored
men’s roles in family planning and have promoted couple counselling based on that premise [40, 41, 55]. Previous qualitative research which explored men’s family
planning attitudes and information needs, has also highlighted the importance of involving husbands in family
planning discussions and the need to establish forums
for men as a way of raising awareness, addressing myths
and concerns, and advocating for supporting women’s
use of LARC [40, 42]. While husband endorsement to
use a modern contraceptive was vitally important for
the women in the current study, the greatest influence
on their decision to use an LARC appeared to be older
female family members.
Page 9 of 11
Limitations and strengths
As the study concentrated only on current users of LARC,
the views of non-users and those who discontinued was
not available for a nuanced comparison. However, given
issues of non-use and discontinuation have been looked
at in other studies, this study sought a unique contribution. Another limitation is the relatively small number of
hormonal Implant users, as compared to the IUCD users.
However, as per the PDHS 2017–2018, in the overall contraceptives mix use in Pakistan, Implants are used by only
0.4% women and this disproportion is also reflected by
our study sample. As with any study based on convenience samples, caution is needed before generalizing the
findings beyond the sample group.
A key strength of the study was identification of
respondents for the qualitative research, subsequent
to a community survey; this allowed triangulating the
qualitative findings such as contraceptive knowledge
and practice gaps, and the role and influence of peers in
promoting the use of contraceptives. In addition, these
study findings have importance beyond the sample studied as they contribute valuable insight for policy makers and program managers for family planning services
development.
Conclusion
Much of the existing body of research on women’s use
of LARCs in Pakistan is based on surveys, measuring
women’s knowledge and use of all types of contraceptives, including LARCs. This study was unique in exploring in depth the decision-making process of women who
adopted LARC and maintained use. Results have highlighted the significant role of their immediate social network of female family members as the key influencers of
decisions at all points of the process. Women who proceeded to use an LARC and who persisted with its use
despite the experience of side effects and social pressures,
were able to do so with support from their spouse and
other female family members. Study findings have to be
considered in light of national policy of using the LHW
to motivate use of modern contraceptives. Creating
informed demand for LARC in Pakistan requires more
intensive community-level efforts. It is proposed that as
more women in an area adopt LARCs, access to satisfied
users within social networks should be facilitated, which
can increase and create a more favorable environment for
uptake of LARCs, expanding women’s choice.
Abbreviations
ANC: Antenatal care; BHU: Basic Health Unit; CPR: Contraceptive Prevalence
Rate; DHQ: District Headquarters Hospital; DHS: Demographic and Health Survey; FGD: Focus Group Discussion; FP: Family planning; FPAP: Family Planning
Sarfraz et al. Reprod Health
(2021) 18:96
Page 10 of 11
Association of Pakistan; FWW: Female Welfare Worker; ICT: Islamabad Capital
Territory; IDI: In-depth interview; IMR: Infant Mortality Rate; IUD: Intra Uterine
Device; KPK: Khyber Pakhtunkhwa (Province); LHS: Lady Health Supervisor;
LHW: Lady Health Workers; LMIC: Low- and middle-income country; mCPR:
Modern Contraceptive Prevalence Rate; MNCH: Maternal and Child Health;
MMR: Maternal Mortality Ratio; PDHS: Pakistan Demographic and Health
Survey; PHC: Primary Health Care; PWD: Population Welfare Department; RH:
Reproductive Health; RHC: Rural Health Unit; SDGs: Sustainable Development
Goals; STI: Sexually transmitted infection; TBA: Traditional Birth Attendants; TFR:
Total Fertility Rate.
5.
Acknowledgements
The authors thank our colleagues for their contributions to various aspects
of this study. We are grateful to our dedicated team of field coordinator and
interviewers; without whose efforts and persistence this study could not be
realized.
9.
6.
7.
8.
10.
11.
Disclaimer
This report contains the collective views of an international group of experts
and does not necessarily represent the decisions or the stated policy of the
author’s institutions.
Authors’ contributions
MS, RJ and SH participated in the design of the study and performed the
data analysis. PR and MA contributed to interpretation of data. MS drafted the
manuscript, which was reviewed and revised by all authors. All authors read
and approved the final manuscript.
12.
13.
14.
15.
Funding
Research reported in this publication did not receive any financial support.
This study was a part of PhD thesis.
16.
17.
Availability of data and materials
Data used in this study can be made available, in an anonymized format.
18.
Ethics approval and consent to participate
This study has the ethical approval of the Human Research Ethics Committee (HREC) of the University of New South Wales, Australia (Approval number
– HC 17253, dated July 2017) and National Bioethics Committee (NBC) of
Pakistan (Approval number – NBC 280, dated October 2017). All participants
were informed about the aim of the study and written informed consent was
obtained from all participants.
19.
20.
Consent for publication
Not applicable.
21.
Competing interests
Authors declare that there is no conflict of interest.
Author details
1
Health Services Academy, Islamabad, Pakistan. 2 Fatima Jinnah Women University, Rawalpindi, Pakistan. 3 School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia. 4 Department of Sexual
and Reproductive Health, World Health Organization, Geneva, Switzerland.
22.
23.
Received: 14 December 2020 Accepted: 5 May 2021
24.
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