Abstract

This study was conducted to examine the challenges faced by midwives in providing postpartum contraceptive counseling services to women in the rural area of Lahore city of Punjab Province, Pakistan. A qualitative research method was used wherein twenty study participants (midwives) purposively selected in the targeted locale were interviewed using a Semi-Structured Interview (SSI). The collected data was secured in the form of field notes which were subsequently analyzed while extracting four themes including (i) involvement of the client's family (ii) misinterpretation about the use of contraception (iii) contraception availability (iv) religious perspective on contraception. This study concluded that midwives are facing challenges from family, culture, and community while providing postpartum contraceptive counseling to rural women. Furthermore, the study also concluded that the personal choices, values, and religious beliefs of women also pose a significant challenge for midwives in providing contraceptive counseling to rural women in Pakistan.

Key Words

Contraceptive, Counselling, Midwives, Challenges, Availability 

Introduction

Being a developing country, Pakistan has reported a higher maternal and child mortality (276 per 100000, every twenty minutes with the death of a mother during childbirth (PDHS, 2006-2007). Various factors are responsible for such an alarmingly high ratio of child and maternal mortality including lack of reproductive health services, poor infrastructure, illiteracy, lack of family planning especially planned pregnancies, contraceptive use, and unintended childbirth practices, especially among the rural population in the country. Studies have reported that birth attendants give only 39% of their service to clients having skills and specialized knowledge of the subject. Despite World Health Organization (WHO) recommendations, many developing countries including Pakistan have always struggled to make progress in mother health before and after pregnancy. Coumminuty-based health attendants and ladies' health workers were introduced by the Government of Pakistan to ensure the health of mothers and newborns, who have been tasked to provide reproductive-related guidance and information to women of childbearing age. Despite these meritorious measures of the government, no visible health outcomes have been achieved in the country. 

In pregnancy time reproductive health service is an essential need for women. The most significant time for counseling a childbearing woman is during the postpartum period and post-abortion cycles and these women are usually coming in contact with the midwives. Midwives provide facilities to all areas as health care experts during pregnancy. They also offer their services to newborn babies on the basis of cultural knowledge and awareness. In health care counseling and knowledge, midwives play a significant role for women, family, and community (Kolak et al., 2017; Höglund & Larsson, 2019). Pakistan has been trying to solve the issue of women before and after pregnancy like other developing countries with the help of a developing national health infrastructure network. 




Postpartum Contraceptive Counselling 

Contraceptive is a method of birth control. The contraception course Scheme introduced for Midwives is specific to pregnant women working in childcare centers. In this scheme midwives' provides an immersive day of scenario-based learning, demonstrations, discussion time, questions, and role-playing (Kolak et al., 2017; Skogsdal, 2018). In a time of one year after delivery women return to their previous condition of ovulation at that time, so those women who do not take postpartum contraceptive counseling and care may suffer from unexpected, untimed, and unintended pregnancy. In order to help women of childbearing age and control the maternal mortality ratio, the government has appointed ladies' health workers and midwives to assist women, especially in the rural areas of Pakistan. These midwives are usually confronted by various challenges including religious beliefs, traditional norms, and stereotypical knowledge during the provision of contraceptive counseling. The purpose of this study is to get information about the counseling methods given by midwives to rural women also their characteristics and challenges faced by midwives(dais) during postpartum contraceptive counseling. Furthermore, due to many factors, midwives are not able to provide guidelines on the use of modern contraceptive methods due to geographical, economic, traditional, and social factors. The major challenge faced by midwives related to healthcare problems is mainly linked to traditional beliefs and faith in rural areas (Kazi, 2009; Tabassum, 2014).

International evidence shows that 20% of childbirth-related deaths and 90% of abortion deaths could be prevented by routine use of contraceptives among women who wish to postpone or are unable to have another child (Cleland et al., 2006). Women have freedom through family planning in decision-making about another pregnancy, and space between pregnancy and their sexual health to save themselves from unwanted pregnancies. This suggestion shows that family planning is an important and beneficial health policy with effective results (not only for women's and child health but also for sex and reproductive health) (Vernon, 2009; Crowthe, 2018; Nigussie et al., 2021) moreover, family planning programs plays its main role by reducing the fertility from six births to almost three per women by taking modern contraceptive methods and services regularly mostly in low and middle-income countries (Cleland et al., 2006).




Problem Statement and Aim of the Study 

The government of Pakistan is committed to controlling the major burden of mother health during pregnancy and child death ratio in the country by improving reproductive-related infrastructure, facilities, and other community outreach programs however these policy measures and programs have witnessed serious challenges at the gross root level. One of the significant policy measures was the induction of midwifery and lady's health workers who were being tasked with the provision of knowledge, guidance, and support to rural women regarding reproductive health, planned pregnancies, and appropriate childbirth spaces to avoid unplanned and mistimed pregnancies. It has been observed that these services have received unprecedented challenges at the community level and the program has witnessed minimal impact and outcomes. This study was planned to explore the community-based challenges and barriers faced by the programs and policy measures already introduced by the government for improving reproductive health and awareness among women. 

Literature Review

In developing countries, approximately 215 million women have unfulfilled desires for modern contraception (Singh et al., 2009). Studies have revealed that 22% of married women use modern methods of contraceptives whereas 17.7% use contraception methods in rural women in Pakistan. Further, 55% of married women report needing contraception, and 25% of married women currently have inadequate need (26.5% in remote urban areas, 31% in the lowest-income women, with the highest demand). Reasons for the unfulfilled wants are the service quality, cost barriers, and equity are cited here (Pakistan Demographic and Health Survey, 2006-2007). There is a need for proper family planning because approximately 27% of women are at risk of unwanted pregnancy (Pakistan Demographic Health Survey 2006; Tsui et al., 2010). 

In the context of developing countries such as Sri Lanka, India, Indonesia, and African countries reduce maternal mortality by introducing community-based programs and improving the condition of trained healthcare workers. The success of these measures depends on many factors such as the establishment of the health system, strong transmission and connection, transportation, and the existence of emergency services. Childcare programs have been successful in reducing maternal mortality by increasing the number of health service providers (Mavalankar, Vora & Prakasamma, 2008).15% obstetric complications and high levels of pregnancies are not managed by midwives because they are not enough qualified according to the State of World Midwifery Report (Ten Hoope-Bender et al., 2011). 

In order to fulfill the growing need for reproductive services, the government of Pakistan has introduced a variety of measures including the establishment of thousands of health centers and community health workers that provide maternal and child health services to rural communities. Bhutta, 2004; Tabbassam, 2014). The Ministry of Health also trained many traditional midwives to provide and improve maternal and child care. In 1994, another group of community health workers, Health Women (LHW), was formed to provide health education, child care, immunizations, referrals, family services, and primary health care. Furthermore, the government of Pakistan updated the program in 2006, related to mother and newborn health before and after pregnancy and introduced newly trained birth attendants to provide their services at the home-based level called (CMWs) community midwives (MNCH, 2006).

Despite policy measures on reproductive health and family planning in Pakistan, there is still a low level of use of adaptation of reproductive services including contraceptive methods during the postpartum period among rural women in Pakistan. The most prominent barriers to modern contraceptives in rural areas are structural, religious, traditional, and socio-economic factors. The high cost of contraceptives, growing doubts about side effects, and income inequality are the additional factors contributing to the lack of use of contraceptive counseling and uses. 

Another barrier to the use of contraceptive counseling is the social acceptance of the services of midwives in rural areas. Midwives face many barriers and challenges while providing postpartum contraceptive counseling because rural women lack knowledge about the use of contraceptives. So, there is a need for counseling in every health center in rural areas on a regular basis for all pregnant women in the time when they need the counseling. Rural women require knowledge and awareness regarding the appropriate and needed methods of contraceptives. Besides, it is necessary to increase the level of information about the use of contraceptive methods among rural women. It is also important to develop and implement postnatal family planning in rural areas by integrating it with those health services that are socially accepted. 

The literature shows that ineffective implementation of family planning policies due to low levels of funding and lack of political involvement in it (Grollman et al., 2018). Some studies in the literature link the poor performance of family planning indicators and lack of access to routine contraceptives with the lack of appropriate family planning methods. Literature shows many other factors in low-income countries like unskilled healthcare workers, lack of family planning, and low levels of contraceptive counseling and services (Cavallaro et al., 2019; Crowther et al., 2018). Three factors make a difference in family planning results; forbearing preferences and attitudes, health care factors, and patient-related factors (Dehlendorf et al., 2007). Contraceptive use varies according to culture, age, gender, schooling, profession, family characteristics, motivation, availability, and acceptance of contraceptives. Beyond any doubt, religion and culture have an impact on the traditional and social structure of society. Low level of knowledge, bad behavior, and treatment of side effects are barriers to the use of contraceptives. 

Education and advocacy of rural midwives have the potential to meet women's unmet needs for these procedures. Midwives in rural settings understand the demands of rural women regarding contraceptives to fulfill their needs properly. It is possible that the greater use of contraceptive methods may be due to women's preferences, independent of the pregnant woman's financial support (Weaver et al., 2013). The latest study held in low and middle-income countries on the use of contraceptive decision-making, this study showed that a low level of male involvement in family planning programs and policies proved to be an important obstacle to women's reproductive rights in terms of their ability and freedom of choice and decide to adopt a modern contraceptive method. Due to a lack interest of in their partner, women also show a lack of interest in using or continuing these methods properly (Karra & Zhang, 2021).

Research Method

This paper is a part of our M.Phil research which deals 

with examining the challenges faced by midwives in providing postpartum contraceptive counseling services to women in rural areas of Lahore city of Punjab Province, Pakistan. We used Qualitative Method Research (QMR) where 20 midwives were purposively selected from the targeted area for in-depth interviewing. The data was collected from the rural areas of Lahore.




Study Participants

We purposively selected midwives who have a few years of counseling experience. Due to the diversity of rural areas, it is not possible to interview all midwives in one place. We informed the midwives about the timing and place of the interview. Interviews with all participants were conducted face to face in the local language Urdu, transcribed verbatim, and later analyzed.




Data Analysis

These questions were asked of almost all the participants, what is the procedure for counseling? Do you face barriers while giving contraceptive advice to rural women? About spousal reaction on the use of contraceptives? Is there any authoritative role of mother-in-law in rural areas in the use of these methods? The perspective of rural women on the side effects of these methods? Is there any relation between religion and contraceptive use that is more difficult than expected in rural areas?

Read the research participants' descriptions of the above-mentioned problems several times to familiarize yourself with the research data to analyze all descriptions and analyses of problems, problems, and solutions expressed by the research participants. After thoroughly reviewing participants' narratives, four themes emerged: (1) Involvement of the client's family (husband, mother-in-law), (2) Misinterpretation about the use of contraception (side effects), (3) Contraception availability, (4) Religious perspective on contraception). The themes are discussed with the help of a few selected narrations of some study participants in the discussion section. Because of the sensitive nature of the study especially when the participants are asked to tell personal stories regarding their personal views about family planning counseling, we decided not to use even pseudonyms rather we preferred to use the word "midwives' study participants while referring to their narratives in the discussion section.

Result and Discussion

The collected data through in-depth interviews with selected midwives was thematically analyzed because the chosen technique offers an opportunity for an in-depth and systematic examination of the topic under study. For the accuracy and interpretation of the results, the collected data was read multiple times, various texts, patterns, and text excerpts were grouped, and described and themes were being extracted. 




Family Involvement 

One of the most highlighted factors highlighted by midwives in providing postpartum contraceptives to women was the family system. In the targeted locale of the study, most childbearing women were in joint family networks thus getting little chances of reproductive choices, autonomy, and freedom. As revealed by the midwives, the reproductive decision was usually guided by mothers-in-law in a joint family network. Any idea, decision, and problem pertaining to reproductive health is predominantly spearheaded by the mother-in-law. They favor or disfavor the decision of contraceptive use of the daughter-in-law. However, educational status, financial conditions, and general awareness of women also played a significant role in reproductive decisions and autonomy. Furthermore, husbands in rural areas often dictate the reproductive decisions of their wives as a consequence midwives are facing challenges in the provision of counselling services. Most of the participants highlighted the situation of restrictions on women on the use of contraceptive methods in rural settings. One of the study participants talked about the dominant role of husband and family in the reproductive decisions of women. 

Women are not allowed to use and take contraceptive-related counseling and adopt means of contraceptives because their husband usually thinks that this disturbs their sexual lives. As a consequence, the husband doesn't allow their wife to use condoms or any other means of contraception. Moreover, husbands usually prefer a large number of babies therefore they don't allow their wives to use these birth control methods. 

Another participant has highlighted the potential involvement of mother-in-law in reproductive health, and birth spacing. 

Mothers-in-law in joint family systems are usually powerful and they exercise a lot of control and authority in manipulating the decision of reproductive health. Under the traditional economic system of the family, all resources are managed by these elder women. If any woman of childbearing age intends to seek a doctor or express her need for medicine, the mothers-in-law accompany them to see the doctor for a medical check-up. Under these circumstances, daughters-in-law cannot decide on their own for contraceptive use or adopt any other means of birth spacing or birth control.

Another participant narrated the influence of joint family networks and the use of contraceptives after postpartum treatment. 

Although traditions in rural areas are swiftly changing, however, a woman of childbearing age is still facing tremendous social pressure inside the joint family network. She is often asked, pressured, and intimidated by her husband, and in-laws for frequent pregnancies, and they are often discouraged when she demands for birth space or planned pregnancies. Living under immense pressure, some women do not express their free will and choice while compromising their health for repeated rapid childbirth.

It is evident from the participant narratives that the challenges faced by midwives are mostly due to cultural factors. Family members including mothers-in-law are deeply involved in the reproductive health decisions of women in rural settings. The data indicate as revealed by midwives that because of the involvement of mother-in-laws and other family members, postpartum counseling to the women is very difficult and they usually visit and meet such rural women in the absence of their in-laws at their house. This study highlighted many challenges faced by midwives and these challenges are deeply embedded in religious beliefs, traditions, and social norms. Many rural families create fear in women's minds by giving them references to religion. Our study highlights while contextualizing the existing literature that the associated beliefs, traditions, and norms are drastically changing and women are slowly feeling the need for reproductive autonomy and decision-making with regard to their reproductive health. Consequently, families are now accepting the choices of women in the use of contraceptive methods to secure their position and status in society and allow their females to receive counseling from midwives.




Misconceptions in the Use of Contraceptives

Provision of reproductive health services is a difficult task because it is considered one of the socially and culturally sensitive topics. People usually avoid discussing such topics and the service providers, medical practitioners, and health professionals are looked upon with suspected eyes by the rural community. By and large, people view these services are doubtful and having serious health implications for mother and child. Some illiterate women, husbands, and family members considered this as a Western agenda and conspiracy to minimize the family size. Based on the narratives of this study's participants, due to the typical point of view of rural people midwives face many barriers. Under such circumstances, medical professionals such as ladies' health workers and midwives are often working under serious threat and intimidation. As one of the midwives narrated the story of her client as 

When my husband does not feel sexual pleasure, he immediately asks me to stop meeting with midwives otherwise it will have serious consequences. They often perceive contraceptives and means of birth control as seriously detrimental to health and children. They believe that these measures will undermine the fertility and childbearing capacity of women in the long run. 

Another respondent added that

One of my clients told me that the use of contraceptives has reduced my sexual desire as a result my husband has forcefully stopped me from the further use of these methods. He warned me to stop taking further advice from medical practitioners by saying that these methods are highly suspicious and have great health repercussions in the future. 

In rural areas, most women feel no hesitation while expressing their health concerns and are eager to take contraceptive counseling. The majority of the midwives stated in their interviews that the feeling of shyness was slightly higher among women with higher educational levels. They were reluctant to share their issues pertaining to reproductive health and pregnancies. The findings reveal that the method of contraceptives may have some side effects too like sexual disturbance, bleeding, and pain because of these issues rural women contact midwives to take medicine and advice from them. For better outcomes, midwives initially build rapport building with these women, take them into confidence, and ensure their confidentiality and anonymity. 

Availability of Contraceptive Methods

The government has made every possible effort to facilitate women of childbearing age by providing health services and contraceptive methods. Rural health centers and basic health units in rural areas are provided sufficient facilities for contraceptive methods to fulfill the needs of the population. There are no accessibility and scarcity problems at the level of medical settings. Women are properly educated, guided, and trained in the use of contraceptives, their timing, and care. Some of my participants responded: 

First of all, we consult with our customers and teach them how to use these methods, when to use them, what are the procedures for using these methods, and the protection methods they use. After the consultation, we provide them with these applications, but sometimes customers tell us which type they want to use. 

In rural areas, women have the availability of contraceptive methods by midwives. Some of my participants responded that;

Women have their own preferences. They tell us the details at the beginning and we provide guidance and support according to their needs and requirements. We provide detailed information about each method and then give them instructions to use the method they prefer. First, we show them the advantages and disadvantages of each method, and then the client chooses the type of model they want to use.

Some midwives talked about the emergency situation in rural settings;'' according to the demand of women we provide them these methods but in case of emergency we give them advice and refer them to hospital. Sadness on a face of some participants while told stories that:

We have these opportunities, but upper-class families in rural areas do not accept anything from midwives (us) due to hygiene problems and they are willing enough to insult us by asking us to wash our hands first. That's why women from the upper family went to the hospital to consult their doctors for us.

The interpretation shows that midwives face many problems during contraceptive counseling. it is very difficult to deal with all the obstructing factors of contraceptive counseling especially the personal values, beliefs, and social background of the users. Likewise, structural factors including poverty, lack of accessibility, awareness, education, and social inequality are the potential factors affecting the use of contraceptives among rural women. Furthermore, women belonging to affluent families with educational backgrounds often disregard the services and advice of the midwives while considering these as unhygienic, unsafe, and substandard. They usually do not trust the counseling provided by midwives and generally rely on seeking private medical services if needed.   These families always want to approach the doctor due to reliability and safety as compared to midwives for advice and treatment.

Religious Reasons

The relationship between religion and contraceptive use in rural areas is more complex than expected. Religious rejection of birth control in rural areas often prevents the use of these contraceptive methods because most Islamic traditions and thoughts allow the use of birth control when the parents are involved or the health of the family may be affected. This study revealed that pregnant women face many problems while providing postnatal care to rural women due to many factors such as religious unacceptability of contraception. Pregnant women may find themselves in difficult cultural situations when providing contraceptive counseling across cultural and social contexts. In rural areas, culture and religion become the main reasons why these couples do not accept these birth control methods. In rural areas, different religious traditions exist and it is the choice of women and their partners whether to follow their religious teaching or not. Some of my participants highlighted some facts by the seriousness on their faces;

In rural areas, different communities have different religious points of view, some are flexible in their thoughts as compared to others we face restrictions on the Islamic point of view more in the Pathan community in villages rather than Punjabi community. Pathan community most of the time refuses to take counseling on contraceptive methods.

Pregnant women face many problems due to the influence of rural women's religious beliefs or religious practices, especially the actions of rural women. One of the participants said that the storyline

I have encountered many religious restrictions, but the advice I give them is that abortion is a sin, but a gap in a pregnancy is not a sin. Because sometimes many women may experience abnormal pregnancy due to multiple factors. But in rural areas, most women think the gap in pregnancy is a sin, so I encounter many problems when counseling them.

Islam opposes sterilization and abortion, emphasizing that childbearing is a religious duty in the family, and is of the opinion that midwives have a problem during counseling. Some participants responded with seriousness on their faces;

When we advise them with the help of Islamic quotes, we use religious perspectives so that they can easily relate to everyone, just as we often say quotes from Surah Al-Imran, the advice to us is: You will marry when you are able to provide for yourself rather than family.

Due to a lack of education among rural women, midwives face many problems in providing contraceptive counseling in rural areas, resulting in delays in seeking counseling for them (rural women). They are also being challenged by rural communities and religious sentiments. Despite personal beliefs against the use of antibiotics, there is disagreement among experts on the recommendation to prevent infection. The study reveals that midwives counter a variety of challenges in the provision of contraceptive counseling to women in the rural communities of Pakistan. It is revealed that the personal values and religious convictions of any particular individual may obstruct the process of counseling at any given point. Structural barriers also play a negative role in the propagation of reproductive health information and cultural sensitivities surrounding the matter may hamper the progress and development in this regard. Some people are challenged and oppressed under familial norms of obedience which are potentially guiding women's reproductive choices, decisions, and autonomy. Considering all the barriers and challenges in the way of post-partum contraceptive counseling is still considered a challenging task by midwives despite spending years in the rural community in Pakistan. Policymakers, legislators, administrators, relevant stakeholders, and health professionals need to develop socially viable and culturally acceptable measures to address the complexities involved in the reproductive health of women in Pakistan. 

Conclusion

This study shows that midwives face many problems when providing postpartum counseling to rural women: the nature of the participant, the personal values of the client, the involvement of the client's family, misunderstanding regarding the use of contraceptives, religious rejection of contraceptive use and contraception to prevent unwanted pregnancy. Midwives may find themselves in difficult cultural situations when providing contraceptive counseling across communities with diverse social and cultural backgrounds. Rural midwives face many challenges while addressing socially and culturally sensitive services. Because of the diverse social, religious, and cultural backgrounds, communities are difficult to convince through a pre-packaged message regarding reproductive services. For instance, people disregard proper childbirth space and plan pregnancy on religious grounds thus making it difficult for the health professional to change their personal notions and religiosity. The biggest challenge that midwives in rural areas face when providing contraceptive counseling is the 'bad faith' associated with contraceptive use. Our research suggests that midwives' experiences of rural women's religious endeavors or religious practices may influence rural mothers' lifestyles, including pregnancy or contraceptive use. According to some schools of thought, Islam has emphasized the religious duty of reproduction in the family and is therefore united against sterilization and abortion. Because of this perception, midwives encounter problems when providing consultancy. Besides, health professionals especially midwives are challenged by family elders under the pretext of family honor, control, and norms of obedience thus making it difficult for them to challenge strong family bonding and the social disfavor of reproductive health counseling. Another important factor in postpartum contraceptive counseling is the socioeconomic status and cultural subordination of women by husbands and families in Pakistan. This study provides deeper insights into the barriers and challenges in the dispensation of reproductive health services through the standpoint of midwives who are deeply associated with women of childbearing age in the rural areas of Pakistan. 

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