Adopción y modernidad

In Katcho villages, reproductive health education is provided at home as well as in the community. During home-visits, family planning counselling is provided to Katcho women by LHWs and FWWs. In every village, there is a separate room “called health house” which is used by the LHWs to deliver community-based awareness raising sessions on health and hygiene, exclusive breastfeeding for at least the first six months postpartum, contraceptive utilization, the importance of the childhood immunization and how to care for their infants and young children. For men, reproductive health education sessions were organised by male FWWs at the community level.

Challenges to implement home-based reproductive health counselling

In Katcho villages, the home-based reproductive health services are not offered by the female FWW. There is only one female FWW assigned to 50,000 people in Tando Jhark and Katcho villages. The public transport is scarce in Katcho villages, and the FWW is not provided with the transportation allowance or a vehicle to access the sparsely located, hard to reach communities. The only time an FWW is provided with transportation is when they organise reproductive health camps in Tando Jhark and on these occasions the FWWs are provided with official vehicles, so they can visit the geographically isolated villages and motivate people to attend the reproductive health camp.

The FWWs (female) visit the remote sites when we organise health camps when a vehicle is provided. It is not possible for one FWW to go to remote villages like Ali Malah on foot. These workers are not compensated for travel, so they only go on a needs basis. (Sajida, FWC)

100 The LHWs either live in the same village or reside to a closer geographic proximity and are therefore the most accessible health workers for rural women. Each LHW is assigned to a population of 1,500 to 3,000 people. In Katcho villages the LHWs are often women’s first source of information (apart from the family and peers) about reproductive health services. This means that a well-informed and trained LHW is vital to women’s utilisation of reproductive health services in Katcho villages. However, this was not in case in Katcho villages, as the LHWs possess limited knowledge of contraceptives to counsel women about family planning services. According to LHW Shaista, during home-visits, there were many occasions when she was unable to respond to women’s queries about the side effects of modern contraceptives. The existing in-service training program of LHWs placed great emphasis on polio training. On average, every year, the LHWs attend at least six to eight polio training sessions and hardly one training/refresher course on family planning. The lack of training results in LHWs being unprepared to counsel rural women to use modern contraceptives. Rural women have heard of many myths and side-effects associated with the use of modern contraceptive methods and the current LHW’s in-service program is unable to respond to such queries with culturally appropriate and medically correct answers.

We mostly get polio training; like almost every second or third month we have a session about polio vaccination. In this year [January 2014–October 2014], I think we attended six sessions about the polio campaign and none on family planning or other maternity care services. Women ask difficult questions about family planning methods and sometimes we are not able to answer them. (Shaista, LHW)

Male community mobilisers from the Population Welfare Department organise and conduct awareness-raising sessions about family planning with male adolescents as well as with married men in the community. In the awareness raising sessions, the mobilisers inform the men about the different methods of birth control, STI, and the benefits of birth spacing for their family. The male mobilisers also engage the religious leaders in the community in the sessions, so they have an opportunity to answer any concerns the men have about contraceptive use and religious beliefs associated with contraception.

101 Male workers play a significant role to raise contraceptive awareness

among men. For cultural reasons, our female workers cannot talk to men, especially on family planning matters. Male community mobilisers organise small or large sessions called ‘kachehri’, at local community spaces, where they inform men about different birth control methods. As you know that a lot of people think it’s religiously forbidden, the male mobilisers also invite Molvis [religious leaders] who explain birth spacing from religious point of view. (Key informant, Population Welfare Department)

During home-visits, FWWs and LHWs do not provide contraceptive methods to unmarried women, because it is culturally unacceptable. In Bashir Machi, the LHW Shazia said that it is shameful to talk to young girls about their sexual health, or engage them in reproductive health discourses; talking to unmarried women or girls about sexual health is prohibited. While this practice deprives unmarried women from having access to home-based reproductive health services, they are able to access confidential family planning in the Family Welfare Centres.

It is a conservative village; the elderly women say mother or grandmother wouldn’t allow you to talk to young girls or unmarried females about reproductive health services. (Shazia, LHW)

FWWs go house-to-house to distribute condoms and oral contraceptive methods to married women, very similar to LHW services for family planning. They cannot distribute them to unmarried females; it’s not culturally acceptable. Her safety can be at risk if her family finds out that she is using contraceptives. The unmarried females may come to the centre as that’s probably safer for them. (Sajida, FWC)

The LHWs and FWWs provide condoms and oral contraception to women during their home-visits. Women who wish to use an intrauterine device, Depo- Provera injections, or have a tubal ligation are referred to the nearest Family Welfare Centre or to the private health providers in TMK City. The closest Family Welfare Centre to the Katcho villages is at Tando Jhark, which is 20 to 25 kilometres away (see Figure 3.2). According to LHW Shaista, one of the reasons that Katcho women do not

102 visit the Family Welfare Centre is because they do not have enough money to travel to the Centre. Shaista said tubal ligation is popular among women with high parity or those who do not wish to have more children. Women who choose tubal ligation are paid a cash incentive for the procedure and they are provided with a transportation allowance to and from the health facility. Moreover, the LHW who refers women for a tubal ligation also receives a cash incentive and transportation allowance which motivates health workers to refer women to the services. To date, such incentives (cash and transportation allowance) are not offered if a woman chooses temporary or reversible contraceptive methods.

Facility-based reproductive health services

The Population Welfare Department established the Family Welfare Centres to provide women and men with access to counselling and services for most types of modern contraception, except the contraceptive surgeries (tubal ligation or vasectomy) which are carried out at a Family Health Centre at District hospital. The LHVs and midwives said that they do not provide contraceptive services to women, instead, the Woman Medical Officers (WMO) provide counselling to pregnant and lactating women about modern contraception and refer women to Family Welfare Centres or Family Health Clinics.

According to FWC Sajida, the poor contraceptive prevalence in Katcho villages is due to cultural beliefs and lack of access to the Family Welfare Centres. Physical access to FWCs is particularly challenging for women in the Katcho region, where public transport is scarce and women’s financial capacity to afford transportation is low. Sajida stated that there is a need for more Family Welfare Centres which are located within walking distance to Katcho villages. She also added that women were taking an interest in modern contraception, and with effective counselling and improved access contraception use can increase.