The realization that you’re married has barely sunk in; you’re still in your honeymoon phase so it’s not his snoring that keeps you up nights; you haven’t yet decided whether you want to deal with NADRA and officially change your status on your CNIC card. But already, the chachis and the mamis, the parosans and the parlour wali are doing a better job of scanning you than any ultrasound machine, and the question “Kya tum pregnant ho?” is on everyone’s minds, if not their lips. You hope not, but all the tips from your three unmarried friends and the married one with a teenage son seem unreliable.
So, every time you feel slightly nauseous you wonder if it has less to do with the fact that you just caught sight of your saas and more because of a ‘nanna shehzada’.
All this could be so much easier if you just knew what to do, separate the superstitions from the science and take an informed decision. So here is the low-down on all the birth control methods that you may be too embarrassed to ask your mother about.
When planning a family, women should be aware that reproductive risks increase with the age of the woman. Like older men, older women have a higher chance of having a child with autism or Down syndrome, the chances of having multiple births increases, which cause further late-pregnancy risks, they have an increased chance of developing gestational, the need for a Caesarian section is greater, older women’s bodies are not as well-suited for delivering a baby. The risk of prolonged labour is higher. Older mothers have a higher risk of a long labor, putting the baby in distress.
Almost half of all pregnancies in Pakistan — around 4.2 million each year — are unplanned and around 54% of those end in termination, according to a report by US research firm Guttmacher Institute.
The oral contraceptive/ Birth control pill:
Despite all the bad rap the pill gets from your khalas and phuppos — weight gain, cancer, and scarier than both, nebulous ailments — it is the most reliable contraceptive and one of the most popular forms of birth control.
NGO Aware Girls counsels those who call its hotline on how such drugs should be used safely and when to seek emergency or professional treatment at a clinic.
“Most of us know women who have died of an abortion,” said Aware Girls co-founder Gulalai Ismail.
At the other end of the Aware Girls hotline, counselor Ayeesha reassured and advised her on what medicines to take and in which dosage.
They insist that women must never be alone when they attempt such procedures.
“My work saves women’s lives. When they call, they are willing to do anything to have an abortion,” explained the 26-year-old.
Ayesha estimated that she fields around 350 calls a month. Most women who contact the NGO know very little about contraception. Access to condoms, the most well-known option, is limited and even when they can be bought, it requires the man to agree.
According to official statistics, only around 35% of Pakistani women use any form of non-abortive birth control despite them being inexpensive. Birth control pills cost just Rs20 rupees, for example, while an IUD is available for Rs400 rupees.
But population control is a controversial issue in Pakistan, where large families are prized.
“Authorities have not been able to make this issue an emergency for Pakistan. It is all rhetoric and political gibberish,” says Dr Haroon Ibrahim of the family planning NGO Greenstar,
Zeba Sathar, a demographer in charge of another NGO, the Population Council, branded the nation’s negative attitude to contraception a “systemic failure”.
Prime Minister Imran Khan in December acknowledged the lack of political will on the issue and promised pro-contraception campaigns using the media, cell phones, schools and mosques.
“The mullahs have a key role to play,” he insisted.
But the Council of Pakistani Islamic Ideology, a religious body which advises the government, says otherwise, insisting that family planning is against Islam.
“The birth control campaign at the government level should be immediately stopped and the birth control program should be removed from the economic planning,” the council stated.
The charity Marie Stopes, whose clinics provide post-abortion care, has profiled a typical client in Pakistan: aged in her thirties, married at 18, she is poor, uneducated and already has three children.
Such women approach the agency when backstreet abortions go wrong.
“Women are just dying… for the lack of knowledge,” said Xaher Gul, an executive at Marie Stopes.
In 2012, the year of their last study, the Guttmacher Institute estimated there were 2.25 million abortions in Pakistan with 623,000 women treated for post-abortion complications.
“We have failed women in this country,” warned Hassan Mohtashami, former head of the United Nations Development Programme in Pakistan.
He added: “Abortion is not a family planning method.”
There are two main types of oral contraceptive pills available in the market. The combined pill contains synthetic versions of the female hormones oestrogen and progesterone and stops the ovaries from releasing an egg to be fertilized. The progestogen-only pill, which is commonly called the minipill or POP, does not have the hormone oestrogen and acts by thickening the mucus around the uterus so that sperm can’t pass through.
The combined pill, if taken regularly, has a 98% success rate. One hormone pill is taken each day at about the same time and most combination pills come in either a 21-day pack or a 28-day pack. This means that, depending on your pack, you will either stop taking birth control pills for 7 days or you will take a pill that contains no hormones (a placebo) for 7 days. Some women prefer the 28-day pack because it helps them stay in the habit of taking a pill every day.
Failure in maintaining the pill cycle, excessive vomiting, diarrhea and intake of other drugs can increase the chances of pregnancy.
The progestin-only pill is recommended over regular birth control pills for women who are breastfeeding because the mini-pill does not affect milk production (oestrogen reduces the amount of breast milk). Gynaecologist Dr Saadia Pal considers the mini-pill the “safest contraceptive pill because it has low levels of hormones” and can be taken on a regular basis without any breaks between packets. The latest formulations even stop you ovulating, just like the regular pill, reducing your chances of pregnancy even more.
“The mini-pill can be taken while breastfeeding while regular combinations pills can be taken after 6 months of breastfeeding,” recommends consultant obstetrician and gynaecologist Dr Azra Ahsan.
The advantage of taking the mini-pill is that by omitting the hormone oestrogen in the formulation, it avoids the rare but dangerous side effects of the regular pill. It is particularly recommended for women who are breastfeeding, diabetics, smokers and those over 35.
While you may be scared off taking pills by aunties willing to exaggerate its disadvantages, it is important to know what its side effects are. Nausea, weight gain and mood changes are common and WebMD warns that more serious disadvantages which require immediate medical attention include stomach pain, chest pain, severe headaches, blurred vision and swelling or aching legs. You also need to be careful of pills containing drospirenone, a man-made version of the hormone progesterone, since they appear to increase the risk for blood clots.
With Pakistani women, the main gripe with pills seems to be weight gain. Dr Pal thinks this has more to do with our post-shaadi dietary habits than with the pill. “A lot of women start binging on food right after their marriage because they assume that their mission has been accomplished and they don’t need to look good anymore. They then blame the weight gain on pills,” she says.
The good news is that the pill comes with a host of advantages: it can make your cycle more regular and even solve your hair and skin problems. “Women who are on contraceptive pills have less risk of exposure to ovarian cancer and polycystic ovaries,” says Dr Ahsan. “However, the occurrence of breast cancer is high if you start taking the pill before your first baby.”
Failure rate: The risk of pregnancy is 1-3% for both the pills even if the user takes them regularly and on time.
What you should know
Some drugs, including antibiotics, can reduce the effectiveness of birth control pills. Keep condoms (a pack of three costs less than Rs100) on hand in case you forget to take a pill. The severity of weight gain, nausea and vomiting varies and trying out different brands can ease symptoms.
Commonly made of latex or polyurethane, condoms are the most easily accessible and handy contraceptives. Not only do they prevent conception, they provide a host of other benefits, including protection from sexually transmitted diseases. They are the safest contraceptive since they provide a physical barrier and have no side effect.
The main reason condoms fail — other than plain old male unwillingness to put them on in the first place — is that they may break or tear due to pressure during intercourse. Unfortunately, according to Dr. Ahsan, “People in Pakistan shy away from discussing this topic which is why more than half the couples don’t even know the correct method of using a condom.”
According to Health.com, condoms are 98% effective if used correctly and only 83% effective if you don’t put them on correctly. Though female gynecologists often call couples for counseling, Dr Ahsan explains that mostly it is just the woman who shows up, while the guy remains oblivious. This helps explain why men prefer not to use condoms and are often irresponsible in wearing them. Dr Pal blames lack of education for this irresponsible behavior towards family planning. “To date, people in Pakistan consider sex education vulgar, which is why many couples who come in for counseling don’t even know the right way of procreating,” says Dr Pal, articulating a frustration many doctors feel.
Failure rate: Dr Pal however believes that the failure rate of condoms could be as low as 4% and as high as 40%.
What you should know: If the condom ruptures or slips off during intercourse, you should immediately take an Emergency Contraceptive Pill (available for as little as Rs 10) to avoid conception. Dr Ahsan says, “While using condoms, a couple should always have a stock of ECP at home. In case of an accident, the pill can be the back-up plan.”
The IUD is a long-term contraceptive with a high success rate that can easily be reversed and removed whenever you wish. The modern intrauterine device (IUD) is a small T-shaped device, that is placed in the uterus to prevent pregnancy and has a string hanging down to check its position or to remove it. There are two types. The hormonal IUD prevents fertilization by damaging sperm and thickening cervical mucus, so sperm can’t get to the uterus. It keeps the lining of the uterus from growing thick so that it’s harder for a fertilised egg to implant and grow. The copper IUD makes the uterus and Fallopian tubes produce fluid that kills sperm, since copper is toxic to sperm.
IDr Pal considers IUDs “As good and effective as a permanent birth control method. It has the added benefit of being reversible.” The doctor recommends using this method before the age of 30. This is because she has seen women who have gotten the IUD removed after crossing 35 and have then faced trouble conceiving and ended up blaming the technology for hampering their fertility. “A woman’s biological clock slows down after the age of 30. Women should plan the insertion and removal of IUD properly to avoid disappointment,” says Dr. Pal.
Failure rate: With a failure rate of only 0.001% , this is as good as 100% protection but according to Dr Pal, “We should still keep a small window of failure in mind.”
What you should know: While IUDs are great if you’re looking for a method of birth control that requires little effort and is reversible, you should continue to see your doctor for periodical check ups. The copper IUD is approved for use for up to 10 years and hormonal IUD for up to 5 years. Insertion of an IUD can also lead to heavy periods and you should check the string of your IUD after every period. Rarely, the IUD can perforate the uterus during insertion. Also, there is the risk of hormonal IUDs causing ovarian cysts, which usually go away on their own.
The Emergency Contraceptive Pill:
The Emergency contraception pill (ECP) is usually taken after your normal birth control method fails or you’ve accidentally had unprotected sex. These tablets are most effective if you take them within 72-120 hours (3-5 days) of having unprotected sex but women are generally advised to take the pill immediately after sex, especially if they feel the chances of conceiving are high (such as during ovulation).
There is a general misconception in Pakistan that these pills are not easily available. In fact ECPs are available at almost all medical stores, can be bought without a prescription, and are quite cheap. It is a good idea to have ECPs handy, in case your normal birth control method fails.
“Unfortunately,” says Dr Pal, “a lot of couples even in the modern world don’t know about ECPs.” The doctor laments that the lack of sex education at the basic level and the indifference of the government has resulted in an utter lack of awareness about these crucial health issues. “There’s no need to shy away from these issues. If you can show sanitary napkin ads, then you can talk about this too,” says Dr Pal.
The chances of pregnancy are higher because “A lot of people don’t even know what ECPs are, let alone knowing that they must have an ECP in case the condom fails to perform,” adds Dr Pal.
Failure rate: Depends on the gap between the time of intercourse and the time of taking the pill but according to Dr Pal, “the failure rate of ECPs is somewhere around 000.1%.”
What you need to know: While a very good back up, ECPs are not a substitute for regular birth control, and reliance on them will reduce efficacy and can result in pregnancy.
This article is not a substitute for professional medical advice. Make sure you consult your doctor before deciding on the birth control method suitable for you.
6 myths about contraceptives
- Breastfeeding prevents pregnancy
Breastfeeding tends to postpone ovulation but that doesn’t mean it can be used as a contraceptive. You can actually get pregnant without ever getting a period while you’re breastfeeding so make sure you have your birth control plan in place.
- Using contraceptives is equivalent to abortion
Contraceptives stop the sperm from fertilising the egg. Abortion comes into question when the fertilised egg comes in the lining of a woman’s uterus.
- Birth control pills are the most effective form of contraception
Even though many doctors vouch for the effectiveness of ECP, combination pill and the mini pill, they still believe that all these pills have a 000.1%-3% failure rate.
- Your body needs a break from birth control pills
Progesterone Only Pill (POP or minipill) can be taken regularly without breaks. The pill also proves effective in solving acne, facial hair and menstrual problems and can be taken while breastfeeding.
- IUDs make women sterile forever
IUDs are said to be as effective as a permanent contraception but they can be reversed in case the user changes their mind about children. Dr Pal suggests it’s better if women get it reversed before they hit their 40s.
- ECPs are a form of abortion
Most ECPs start working before the pregnancy even begins. A woman can’t abort something that wasn’t even conceived in the first place.
How pregnancy occurs
In order to become pregnant, the female egg (released from the ovary during ovulation) must be fertilized. This phenomenon of fertilization takes place when the sperm ejaculated during intercourse, travels up the cervix of the female and combines with the released egg to form a single cell. The fertilized egg then needs to attach to a woman’s uterus lining and grow, a process known as implantation. Once the implanted embryo starts releasing hormones that prevent menstruation, pregnancy is confirmed.
Pakistan is one of the most populous nations in the world, with an annual growth rate of 2.8 and high total fertility rate, even among developing nations. The Pakistan Reproductive Health and Family Planning Survey highlighted the wide gap between knowledge (97%) and use of contraceptives (28%) among currently married women.
In order to improve contraceptive use in Pakistan we need to use multiple media sources to educate couples and their parents regarding contraceptive services, strengthen the perceptions that religion not only allows but also recommends family planning and to create awareness among women to have their rights and opinions about the size of family. The concept of differentiation between sons and daughters should be discouraged.
In addition, government and non-governmental organisations (NGOs) should organize groups to provide counselling and promotion of contraceptive services at the doorstep. We must act as a team to control our growth rate for economic stabilization of the country and to raise the living standards of our people.