Family Planning Clinics May Not Be the Best Option for Serving Pakistan's Poor
The opening of a family planning clinic offering subsidized services and outreach in each of four urban slum areas of Pakistan contributed to an increase in local married women's knowledge of any modern contraceptive method over an 18-month evaluation period, but it had no impact on overall use and mixed effects on unmet need.1 Furthermore, although the clinics were intended to serve poor women, who often have many children and little access to services, they were used primarily by middle-income, low-parity women wishing to space births.
The clinics, opened in 1999-2000 by a major nongovernmental organization, were located in two communities in each of two provinces, Punjab and Sindh. To evaluate their impact after 18 months of operation, researchers compared selected outcomes in the clinic communities with those in a similar community in each province that had only the limited family planning services typical of poor urban areas. Using cluster and random sampling, they drew a sample of ever-married women aged 15-45 in each clinic and control community to participate in a baseline survey before the clinics opened and a second sample for an end line survey in 2001-2002. The interviewer-administered surveys covered women's socioeconomic characteristics; fertility; and contraceptive knowledge, use, needs and attitudes. Supplementary data were gathered in exit interviews with clinic clients at the time of the end line survey. In all, 5,338 women completed baseline surveys, 5,502 end line surveys and 92 exit interviews.
Women who completed baseline surveys were typical of Pakistan's urban poor. Substantial minorities were younger than 30 (42%), illiterate (38%) and uneducated (40%); half had a standard of living classified as basic or low, and fewer than one in five were employed. On average, respondents had married at age 18 and had had four births. Three-quarters of the women reported that their husbands had gone to school, and virtually all said that their husbands were employed. Reported levels of approval of contraception were high—78% among the women themselves and 69% among their husbands.
At baseline, 88% of women in clinic communities could name at least one modern contraceptive method without being prompted; at end line, this proportion had increased by eight percentage points, to 96%. In the control communities, the level of knowledge also was high at baseline and had increased by end line; however, the absolute change was only three points, from 89% to 92%. Using logistic regression analyses that controlled for differences in women's characteristics between communities and over time, and for differences between the clinic and control communities, the researchers determined that the net effect—the five-point difference between clinic and control communities in the amount of absolute change—was statistically significant and thus may be interpreted as a result of the clinics' influence. The change was driven mainly by greater knowledge of female sterilization and the IUD. Modest increases were seen for the pill and injectable; however, no significant change occurred in knowledge of condoms or male sterilization.
Overall, the proportion of women reporting current use of a contraceptive increased from 30% to 36% between surveys in the clinic communities, and from 21% to 27% in the control communities. Both increases were statistically significant, but because the absolute changes were identical, no net effect can be attributed to the clinics. However, in analyses of specific methods, the clinics appear to have contributed to a decline in condom use and an increase in reliance on female sterilization.
Findings regarding the clinics' impact on unmet need show no consistent pattern. In the two Punjab communities, about half of women had an unmet need for contraception before the clinics opened. The proportion fell by 14 percentage points in one community and by 10 points in the other; results of logistic regression analysis that controlled for respondents' characteristics show these declines to be statistically significant. In both communities, the change resulted mainly from a drop in unmet need among women who wished to have no more children; in one, the proportion of demand for family planning being met by contraceptive use increased significantly (from 30% to 45%).
By contrast, in Sindh, close to three in 10 women in each clinic community had an unmet need for contraception at baseline, and the proportion did not change during the evaluation period. However, both communities showed significant reductions in the proportion of demand being met; one registered a reduction in demand for limiting births and an increase in unmet need for spacing.
Data from the end line survey suggest that the clinics were serving only a subgroup of their target population: Larger proportions of new clinic clients than of women obtaining family planning services from other sources were younger than 30, had a medium or high standard of living, and used reversible contraceptives other than condoms. Information gathered in the exit interviews likewise suggests that local clinic users had a relatively high socioeconomic status and were seeking reversible methods because they had few children. In addition, data from the exit interviews show that about one-quarter of clinic clients were poor women from outside the clinics' catchment areas, who either were high-parity and wished to obtain a permanent method of contraception or were young and were seeking pregnancy termination.
The researchers suggest that their findings have several programmatic implications. For example, the clinics' impact on contraceptive knowledge may have resulted partly from their use of community outreach workers; therefore, outreach may be an important component of clinic services in slum areas of Pakistan. Additionally, the apparent interest in female sterilization and the IUD suggests that clinics should focus on providing permanent or long-term methods. Nevertheless, given the findings on the characteristics of clinic users, the researchers conclude that these clinics are not an effective strategy for providing family planning services to the poorest groups in the immediate clinic vicinity.—D. Hollander
1. Hennink M and Clements S, The impact of franchised family planning clinics in poor urban areas of Pakistan, Studies in Family Planning, 2005, 36(1):33-44.