Open Access Research BMJ Open: first published as 10.1136/bmjopen-2013-003279 on 1 August 2013. Downloaded from Objects of temporary contraception: an exploratory study of women’s perspectives in Karachi, Pakistan Kamyla Marvi,1 Natasha Howard2 To cite: Marvi K, Howard N. ABSTRACT ARTICLE SUMMARY Objects of temporary Objectives: To explore perspectives of three modern contraception: an exploratory contraceptive objects, using an emic approach, among study of women’s Article focus women in a low-income community in Karachi, perspectives in Karachi, ▪ To explore women’s understanding and interpre- Pakistan. BMJ Open 2013;3: Pakistan. tations of three modern contraceptives. e003279. doi:10.1136/ Design: A qualitative interview study design was bmjopen-2013-003279 employed, using qualitative content analysis with an Key messages inductive approach and manual thematic coding. ▪ Women were knowledgeable about family plan- ning and relied on modern contraceptives. ▸ Prepublication history for Setting: Shah Faisal Colony, Karachi. ▪ Contraceptive potency and effects were inter- this paper is available online. Participants: 20 women, potential contraceptive preted using the hot–cold idiom of traditional To view these files please users of reproductive age and living within a health medicine. visit the journal online centre catchment, were purposively selected to provide ▪ Consideration of women’s interpretive idioms (http://dx.doi.org/10.1136/ a similar number of non-users (n=5), contraceptive could help providers improve health messages bmjopen-2013-003279). injection users (n=7), pill users (n=4), and intrauterine and family planning counselling. device users (n=4). One interview was excluded Received 22 May 2013 Revised 4 July 2013 because it was not recorded. No other exclusion Strengths and limitations of this study Accepted 5 July 2013 criteria were used. ▪ Use of qualitative methods provided rich insight Primary and secondary outcome measures: The into women’s interpretations and decision- primary outcome was interpretation of potency and making regarding contraceptives. effects of selected family planning objects. Secondary ▪ Available time and funding constrained the http://bmjopen.bmj.com/ outcome measures were knowledge of family planning sample size, limiting the inclusion of a poten- and description of therapeutic approaches used and tially broader range of perspectives. preferred. Results: Awareness of family planning was high. Women described different therapeutic approaches, 2.1% resulted in the population quadrupling stating they generally preferred modern medicine for in the past 50 years with 41% below age contraception as it was fastest and most powerful. 15.13Potential reasons are both demand- They reported that fear of some contraceptive objects, side (eg, female autonomy, religious beliefs, – particularly injections and intrauterine contraceptive on September 29, 2021 by guest. Protected copyright. son preference4 7) and supply-side (eg, cost, devices, influenced their choices. Women explained poor distribution and limited coverage of their perceptions of how the heating effects of 8–10 contraceptives could cause unwanted side effects contraceptives ). A rise in political and including menstrual irregularities, weight gain and religious extremism since the dictatorship of weakness, leading to disease. Zia-ul-Haq (1977–1988), Pakistan’s subse- Conclusions: Most women wanted family planning, quent involvement in the international ‘war but remained dissatisfied with the available on terror’, poor governance and corruption 1Leadership Development for contraceptives and their effects. While women reported have weakened the economy, worsening the 11 Mobilising Reproductive that they relied on modern medicine for contraception, social indicators. High population growth Health (LDM), Institute of their descriptions of how contraceptives affected their strains Pakistan’s limited resources, affecting – International Education, health relied on the hot cold explanatory idiom of the health indicators. For example, with Karachi, Pakistan traditional medicine. 2 reproductive-age women constituting almost Department of Global Health ’ and Development, London one-quarter of Pakistan s total population, a School of Hygiene and low contraceptive prevalence rate (CPR) of Tropical Medicine (LSHTM), 29.6%, with much lower rates among poor London, UK INTRODUCTION and rural populations, contributes to a high ’ — Correspondence to Pakistan, the world s sixth most populous maternal mortality ratio of 260/100 000 Dr Natasha Howard; country, has an estimated population of 176 mostly preventable haemorrhage, eclampsia [email protected] million.12The annual population growth of and sepsis.1 5 12 13 Marvi K, Howard N. BMJ Open 2013;3:e003279. doi:10.1136/bmjopen-2013-003279 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2013-003279 on 1 August 2013. Downloaded from Pakistan has had a population programme since the problems (eg, obesity, body aches, high blood pressure, 1960s and family planning awareness is nearly universal, nausea, irregular bleeding and infertility) with contra- with 96% of women surveyed identifying at least one ceptive usage. modern contraceptive method.114While modern con- Most studies approach contraceptive behaviour from traceptives comprise 73% of Pakistan’s CPR, temporary medical or behavioural perspectives, with minimal con- methods allowing birth spacing (eg, pills, intrauterine sideration of the contraceptive objects used.28 Such contraceptive device (IUDs), injectables, implants, approaches can result in women’s perspectives being condoms) comprise 13.6% of current usage, of which minimised as misconceptions.29 30 Little research has half (6.8%) are condoms.1 Thus, only a small propor- explored the explanatory models Pakistani women apply tion of Pakistani couples use temporary methods, with to their contraceptive beliefs.29 The term ‘misconcep- evidence suggesting a significant unmet need for contra- tion’ already implies that these beliefs are flawed and ception (table 1).11516 that the alternative medical model provides the correct Pakistan is a predominantly Muslim society with explanation. However, these beliefs are entrenched in formal, informal and popular healthcare approaches age-old belief systems and experiences that are real and coexisting. Pakistan’s formal medical system includes personal to women and those around them. Nishtar modern (ie, Western) medicine, westernised homoeop- found these beliefs to be based on societal perceptions, athy, and traditional hikmat. Hikmat or unani tibb is trad- which women considered must have some basis in truth itional Greco-Arab medicine, widely practiced in to be so widespread.29 Multiple sources of perception Pakistan, with similarities to Indian Ayurvedic medicine. create the basis on which each woman makes deci- Modern medicine is the most common approach in sions.31 The objects used for temporary contraception urban settings and government facilities, but overlaps have their own potency to affect the body’s functioning, with traditional and folk approaches.17 18 Shaikh et al17 the perceptions of which influence usage decisions (eg, found that health providers often presented false qualifi- whether, which, how long?). Little emic data, showing cations or interpreted modern medicine to suit patient behaviour or beliefs in culturally meaningful terms, beliefs. While contraceptives are modern medicine, connect popular perceptions of contraception to popular perceptions and practices are influenced by reli- usage.32 33 gion and other therapeutic approaches.12 18 Nichter19 This study examined perceptions of modern contra- noted that multiple therapy systems coexist in most ceptive objects, using an emic perspective, among women countries, despite the regulatory efforts of government in a low-income community of Karachi, Pakistan.34 The or vested interests of dominant therapy systems. research question was ‘What are these women’s beliefs Kleinman classified the professional, traditional, and about contraceptive objects and do those beliefs affect popular as three overlapping systems, while Nichter usage decisions?’ It contributes to the literature on http://bmjopen.bmj.com/ found providers underappreciated the ways popular unmet need by describing how popular perceptions ideas about medicine influenced healthcare seeking and affect usage. Study objectives were to: – compliance.19 21 ▸ Describe women’s perceptions of three temporary Women’s perceptions of contraceptives significantly contraceptives as objects (ie, injections, pills and influence their decisions to start or continue family IUDs); planning in Pakistan, supporting recent global discourse ▸ Consider how women’s perceptions of contraceptive – on the influences of side effects on usage.22 26 Bhatti usage and potency within their own therapeutic para- et al27 found that 12.1% of non-users cited digms affected usage decisions. on September 29, 2021 by guest. Protected copyright. method-related reasons, including fear of side effects and interference with normal bodily processes.1 Sultana et al24 found that a 29% discontinuation rate for female METHODS methods in Punjab was primarily due to side effects, as Ethics approval was granted by the LSHTM research contraceptive users associated all subsequent health ethics committee in the UK and the Institutional Review Table 1 Percentage method usage among married women aged 15–49 years in Pakistan1 Residence Education Wealth Quintile Current Ever