Globally, over 257 million women wishing to avoid pregnancy have an unmet need for family planning and resort to unsafe methods of contraception. As a result, the number of unintended pregnancies averages 121 million per year, or a staggering 331,000 pregnancies per day. Termed as a “neglected crisis” by the United Nations Population Fund, these realities not only have lifelong implications on women, but also impact the human development index, have significant costs in healthcare, and contribute to rise in unsafe abortions.[1]
Emergency contraceptive pills (ECPs) are a form of post-coital contraception that works to delay ovulation or prevent implantation thus reducing the chances of pregnancy.[2] Although the efficacy of ECPs varies depending on the exact formulation and regimen, they are effective for up to 5 days after unprotected intercourse, with a reported < 1–2 pregnancies per 100 women.[1] Furthermore, ECPs have almost no medical contraindications and are generally considered more convenient than intrauterine copper devices (IUCDs) despite the latter being regarded as the most effective form of emergency contraception.[2] However, as the name suggests, ECPs should only be used in the event of an emergency owing to their short-term contraceptive action and their inability to protect from sexually transmitted infections (STI).[3]
Despite the expected appeal for ECPs, it is a severely underutilized method and has had minimal impact at a public health level.[4] A 2014 multi-country analysis of the use of ECPs found that in 36 out of 45 countries, less than 3% of sexually active women had used ECPs. The reasons for this are multifactorial such as social, cultural, and religious barriers that influence its reach, but ultimately stem down to the extreme lack of awareness regarding ECPs, especially amongst those of a lower socioeconomic status and those living in rural areas.[4]
Just like other methods of contraception, the use of emergency oral contraception has remained historically low in Pakistan. One study revealed that 88% of Pakistani women, predominantly homemakers, lacked awareness of the existence, usage and access of emergency contraception.[5] This can be attributed to a multitude of factors, such as the low literacy rates in Pakistan, the various barriers to access, and more importantly, the cultural, and religious taboos around their use.[5] A review of current literature evaluating barriers to family planning in Pakistan also identified physical inaccessibility, clinical concerns, cultural norms, and familial restrictions as pertinent barriers to contraceptive usage among married couples in Pakistan.[6] Moreover, the review also suggested that addressing attitudes toward family planning requires targeting household males in behavioral change campaigns aimed at enhancing contraceptive awareness. This is also consistent with previous evidence from Pakistan, Kenya, Nepal, and Ethiopia which articulated that joint decision-making regarding family planning may potentially increase contraceptive usage.[7–13]
Furthermore, amongst the limited number of women utilizing ECPs, as many as 84% have acknowledged having acquired them from Lady Health Workers (LHWs). The same study shows that approximately 6% of LHWs had provided ECPs to women living in their catchment areas prior to an emergency, whereas the overriding majority of LHWs (74%) only provided the pills after an event of an emergency, such as unsafe intercourse.[14] This is in stark contrast to the Western population where sexual health clinics and primary healthcare centers remain the mainstay for seeking knowledge and guidance regarding adequate contraception in cases of emergency.
Pakistan has encountered a plateau in its efforts to increase the usage of contraceptives since the 1990s, as only a mere 30–35% of the population uses them.[15] In comparison to the average of 53% usage of contraceptive methods in South Asia, Pakistan ranks the lowest amongst its neighboring countries.[16] Nearly one-quarter of women in Pakistan have an unmet need for family planning, with significantly higher rates in provinces such as Balochistan.[15] As Pakistan’s population rises at a rate of 1.9% annually, the failure to improve contraceptive utilization will have lasting repercussions years into the future.[16]
For a country where the rate of long-term contraception usage in the general population is dismally stagnated and termination of unwanted pregnancies is hampered by legal, cultural, and religious barriers, the use of Emergency Contraceptive Pills (ECPs) appears to be of prime importance in the fight against overpopulation. However, there is a complete absence of awareness regarding ECPs in significant proportions of the population, and where awareness does exist, it is permeated with myths and religious misconceptions. Additionally, where the knowledge of the usage is adequate, the availability and cost of ECPs pose undeniable uncertainties.[17]
Scarce literature exists on the knowledge, practices, and most importantly, the barriers to ECP usage in Pakistan. Most previous studies are aimed at investigating the awareness in specific communities, without looking at attitudes, sexual behavior, and use of other methods of contraception in women. Furthermore, with Pakistan primarily being a male-dominated society where men play a significant role in the use of contraception and reproductive decision-making, it is of utmost importance to further investigate and compare the gaps in knowledge and attitudes of both men and women regarding ECPs.