Population Welfare and Family Planning

Sathar et al. (2013). Capturing the Demographic Dividend in Pakistan. Population Council, Islamabad.
This volume revisits the population and development debate through the demographic dividend framework, which links the issues of family planning, education, and employment in a single paradigm. According to this book, Pakistan is at a critical point in its demographic transition. After decades of rapid population growth, the prospect of slower growth lies ahead because fertility is declining. The future trajectory of population growth is very sensitive to the timing and extent of further fertility declines. Thus, there is need to strengthen the family planning program. Women in Pakistan have high levels of unmet need for contraception, and as a result many unplanned and unwanted pregnancies occur each year. Preventing such pregnancies and reducing fertility and population growth will lead to a variety of health, social, and economic benefits. There is now increasing recognition that the Departments of Health and Population Welfare have to collaborate more closely. The main advantage of having the health sector to focus on family planning is that its larger infrastructure and its wider reach can deliver family planning services much more effectively than Population Welfare departments. The health sector’s greatest shortcoming is that it has yet to make family planning a priority.
http://www.popcouncil.org/uploads/pdfs/2013_CapturingDemoDivPak.pdf

K, Ayesha and K, Adnan. (2012). The Contribution Of Lady Health Workers Towards Family Planning In Pakistan.Research and Development Solutions, Policy Brief Series, 15.
This policy brief looks at the Lady Health Worker program, which helps improve family planning, particularly amongst the poor. It shows that LHWs account for around a 10{5fae829be7f2ac2fe240ef3893666b371329fe804754bc76382cc5045395a053} increase in knowledge about the source of family planning (FP) methods and 6{5fae829be7f2ac2fe240ef3893666b371329fe804754bc76382cc5045395a053} increase in ever use of FP. However, there appears to be no mechanism to ensure that LHWs ask women about their FP needs or to ensure women use long term or permanent methods. The limited time spent on FP, the few women seen per week and the level of stock-outs have likely contributed to the limited progress the program has made during the past decade in family planning. Thus it is suggested that better programming may include development of institutional mechanisms such as checklists to ensure that LHWs ask about clients FP preferences and revisit these choices once or twice a year since they may change.There is also a need to ensure that remuneration to LHWs and their supplies of family planning commodities remain uninterrupted for the LHWs as well as for the facilities that LHWs refer to. These changes will help improve their performance.
http://www.resdev.org/files/policy_brief/15/15.pdf

K, Ayesha and K, Adnan. (2012).The Community Midwives Program In Pakistan. Research and Development Solutions, Policy Brief Series, 20.
This policy brief describes the experience of Pakistan with Community Midwives CMWs, to examine implementation issues and lessons from this experience. This policy brief shows that the community members are unaware about the availability and purpose of CMWs, which affects the success of the program. This is due to ineffective communication strategies and the non-engagement with the community at the time of deployment. Furthermore, there are problems like insufficient training, delays in certification and deployment of CMWs which results in them seeking jobs elsewhere, mobility and security problems particularly due to their young age and unmarried status and lack of coordination with other service providers like LHWs. Therefore, this policy brief recommends that the CMW program should be reviewed to incorporate comprehensive community participation and community representatives should be a part of their selection procedure. It should also ensure that the CMWs acquire a high standard of skill-set that is based on appropriate practical experience and better communication skills. This will allow better utilization of their presence.
http://www.resdev.org/files/policy_brief/20/20.pdf

Feisal et al. (2012). Are CMWs Accessible in Punjab & Sindh? Research and Advocacy Fund.
This qualitative research seeks to gauge whether the deployment of Community Midwives (CMWs ) in Punjab and Sindh, has improved the accessibility of skilled birth attendants to the rural population or not. The study used delivery as an indicator of accessibility, since the major goal of the Programme was to provide skilled birth attendants in low-income communities. The findings show that in Punjab, overall, the CMWs were accessing pregnant women in about two-thirds of the assigned areas. However, their utilisation as birth attendants was low, even within areas they were accessing. In Sindh particularly, CMWs are working in only a limited geographical area around their homes, as they have not been assigned any areas. However, even in these areas not many women are aware of their existence, and even if aware, many lack trust in them. Thus, the report recommends that the MNCH Programme should increase the awareness of the community people about CMWs, advocate CMWs as trained and competent birth attendants, and compare them with daiyanto increase trust in CMWs. Moreover, LHWs should be compelled to cooperate with CMWs and refer pregnant women to 
them.
http://www.rafpakistan.org/userfiles/S3_1_RAF Annual Conference_ AAA.pdf

Khan et al. (2012). How far can I go? Social mobility of CMWs in AJK.Research and Advocacy Fund.
This research was undertaken through the support of Maternal and Newborn Health Programme Research and Advocacy Fund (RAF) and assesses the social mobility of community Midwives with reference to geographical and economic accessibility, social acceptability and relationship of these Midwives with other care providers. A mixed method research was used including GIS Mapping of all the CMWs in AJK, as well as in-depth interviews and focus group discussions. Results demonstrate that accessibility is a very intricate issue, primarily due to distant locations of health facilities, lack of transport facilities, the cost of services and socio-cultural barriers. GIS Mapping of CMWs have shown that many areas have no CMW coverage and some overlap in terms of outreach and proximity with another CMW zone. Furthermore, awareness about availability of CMWs in the area was very low. Combined with paucity of skills and capacity of CMWs to tackle issues of maternity care in remote rural setting, it means that the services of CMWs were not used. Thus, the report recommends that there is a need to involve community representatives in selection of women for CMW trainings. This will help build ownership of community. The training of CMWs also needs revision and must be made more practical and skill based rather than theoretical.
http://r4d.dfid.gov.uk/pdf/outputs/raf/RAF_Report_final_CF.pdf

Dobson, S., &Lalji, N. (2011). Are community midwives competent to practice? Lessons from Pakistan.Technical Resource Facility.
The Technical Resource Facility conducted this assessment, on community midwives with support from HLSP. Using Pakistan as a case study, this paper considers whether the cadres of birth attendants being trained are adequately skilled to perform the services they are expected to deliver in the context of the training of Community Midwives (CMWs). Pakistan is facing challenges as it aims to achieve high training targets with limited resources. The paper examines these challenges and suggests approaches to help overcome them. One of the challenges is regarding finding suitable candidates, particularly in remote rural areas such as Baluchistan where education achievement is low. Furthermore, many tutors require more thorough training in helping students develop analytical skills and the ability to synthesize and apply knowledge. More broadly, CMWs are hindered in their work by the fact that efforts to strengthen the district health system are lagging behind the implementation of the training programme. Thus, the paper recommends that there is need to build capacity to ensure effective implementation of the midwifery curriculum to improve training. There is also need to stop focusing on the numberof CMWs without due attention to their specific role within the overall health system.
http://www.hlsp.org/LinkClick.aspx?fileticket=U8Qwkd2XqCw{5fae829be7f2ac2fe240ef3893666b371329fe804754bc76382cc5045395a053}3d&tabid=2439&mid=4674

Douthwaite, M., & Ward, P. (2005). Increasing contraceptive use in rural Pakistan: an evaluation of the Lady Health Worker Programme. Health Policy and Planning, 20(2), 117-123.
This paper assesses the impact of the Lady Health Worker Programme (LHWP) on the uptake of modern contraceptive methods using data from a national evaluation of the LHWP, completed in 2002. Because a major aim of the Programme was to increase access to services in rural areas, this paper focuses specifically on the impact of the Programme on rural women. Using logistic regression, this paper finds that the current use of reversible, modern contraceptive methods is significantly higher in rural areas served by the LHWP compared with control areas, even after controlling for a range of socio-economic factors. Despite some inherent design limitations, this study provides strong evidence that the LHWP has succeeded in integrating family planning into the doorstep provision of preventive health care and in increasing the use of modern reversible methods in rural areas. In a country like Pakistan, where women’s mobility is severely limited and female modesty highly valued, the provision of doorstep services through community-based female workers appears to be one model of service delivery that will help to achieve universal access to family planning.
http://heapol.oxfordjournals.org/content/20/2/117.long