For Nusrat Bibi, short-term contraception methods had been the preferred choice, which she used to get from the healthcare centre near her village close to Renala Khurd in the Punjab. But as the Covid-19 pandemic struck, the resulting overload of information, misinformation and conspiracy theories made her choice difficult. “People say that if we go to hospitals, doctors will inject us with coronavirus. Also, I cannot go repeatedly to get condoms or pills. My only option now is to go for a method that provides me protection for a longer period,” says the 33-years old mother of six. She turned to Abeeda Shehbaz, a community midwife (CMW) in her neighbourhood, who has set up a makeshift clinic at her home as women in the village are now unable to go out for their medical needs, due to fear of contracting the virus and also due to a lack of mobility and finances. Nusrat now has a contraceptive implant that is placed under her skin in the upper arm, releasing the hormone progesterone into the blood stream, and providing safe prevention of pregnancy for the next three years.

While the pandemic has affected every aspect of healthcare ecosystems globally, it is relevant to observe on World Population Day how it is affecting family planning (FP) efforts, particularly in populous nations where the healthcare systems are already buckling under pressure. Population experts predict that by 2030, Pakistan’s population will swell up to 245 million, making it the fourth most populous nation in the world. According to the latest Pakistan Demographic and Health Survey (DHS) only 34 percent of currently married women are using a contraceptive method. In the year 2019 the modern contraception prevalence rate (mCPR) in Pakistan was recorded to be just 17.7 percent, according to FP2020. It is estimated that some 3,522,000 unintended pregnancies, 1,409,700 unsafe abortions, and 3,830 maternal deaths were averted due to this mCPR. A 1.5 percent decline in the number of women using modern contraceptives during Covid-19 may negatively impact some 1,263,000 women.

Dr Azra Ahsan, a gynecologist and obstetrician with a special focus on family planning and maternal health, confirms that women are avoiding visiting healthcare facilities and hospitals for deliveries or FP as they are scared of contracting Covid. “Many helplines have emerged as there are very few patients coming to outpatient departments (OPDs). This also might be due to lockdown and lack of public transport,” she says. With less than usual women coming to hospitals for deliveries, the opportunity of post-partum family planning (PPFP) is also lost.

“It is true that due to the pandemic, all healthcare facilities have been impacted adversely, including antenatal, postnatal, and FP initiatives,” says Dr Muhammad Imran, the Okara district coordinator for the Government of Punjab’s Integrated Reproductive, Maternal, Newborn & Child Health and Nutrition Programme (IRMNCHNP). Not just FP, even the nutritional status of would-be or new mothers has suffered due to the financial crunch people are going though, adds Dr Imran.

This is why the work of lady health workers (LHWs) and CMWs like Abeeda is critical. To tackle this challenge, government departments and organisations are going the extra mile and providing special trainings to them. “We are training LHWs and concerned healthcare persons about the SOPs regarding how to stay safe themselves, create awareness among communities, and simultaneously ensure continuity of activities related to FP and maternal health,” says Dr Imran.

“Now we mostly counsel them or follow up on their progress via phone or WhatsApp messages. If someone is in need of an examination physically or needs to have a procedure done, we call them to the small facilities in our homes,” says Abeeda, a Lady Health Worker (LHW).

According to Abeeda, service providers like her were initially confused, as a lot of their work is centred on one-on-one counselling as well as conducting awareness sessions in communities. “However, virtual training by Naya Qadam helped us, as did the personal protective equipment (PPE) like masks, protective gear and sanitisers they provided to us. Now we mostly counsel them or follow up on their progress via phone or WhatsApp messages. If someone is in need of an examination physically or needs to have a procedure done, we call them to the small facilities in our homes,” says Abeeda. Naya Qadam is a project led by Pathfinder International with five partners aimed at high-quality FP programming, working in three districts of the Punjab and seven districts of Sindh. During the pandemic, organisations like these, working hand in hand with the government, are critical.

One of the concerns is the protection and safety of the healthcare staff. This, along with addressing the fast-growing stigma around Covid-19, is a key challenge, according to Dr Tabinda Sarosh, Pathfinder’s country director in Pakistan. “Communities might lose faith in health facilities and are afraid that they might end up acquiring the infection from the facility. Providers are also in a state of insecurity, as well as inundated with work. This is bound to reflect on the quality of their work, and also take away time and energies from FP counselling and services,” she says, adding that FP services are still not declared as essential health services by the provincial governments. “A policy-level assertion is much needed to motivate and set up compliance frameworks for the time to come. While some FP-RH Covid-19 framework has been developed by the governments, implementation and monitoring is a long way to go,” she says.

Another obstacle is that supply of commodities essential for continuity of FP services has been hampered due to the pandemic. “Our biggest problem is the shortage of medicines and products we need for FP,” says Haseena Soomro, a lady health supervisor (LHS) from Shaikh Zaid Colony, Larkana. “Our work has decreased by 50 percent due to this pandemic. I have to convince both LHWs and the communities that if the SOPs are in place, we can still do the needful.”

Dr Sarosh echoes the concern, saying that long acting methods that women were using could soon go out of stock if expedited procurement plans are not put in place. For this, her organisation, along with the public sector, has expedited the response for commodity security to ensure continuity in FP services in the areas where they work.

Judging by the importance of LHWs and CMWs in this scenario, the need of the hour is a gender-equitable response to Covid-19, especially in the sphere of FP. As Dr Sarosh says, “Women, as it is, are a marginalised community in Pakistan, and FP as per DHS is in a stagnant state. Add to that the emergence of the pandemic and the disruption of services. This scenario calls for ensuring that women are at the centre of the policies that are being developed or implemented and their growing needs need to be responded to.”