Fertility decline must be the prime purpose of any family planning program besides preserving mother and child health which is of utmost importance for any country to keep health indicators in line with the targets of the Millennium Development Goals. This would only happen when long term contraceptives are promoted and made available to all eligible women looking for long term spacing, through quality family planning services, dedicated work force and state of the art service outlets[1]. Temporary contraceptive methods including condoms are very popular in many developing countries. A condom has a high failure rate (20% with typical use), therefore, it can result in an unwanted or untimely pregnancy. A number of such pregnancies result into multi parity or an unsafe termination of pregnancies and therefore, high maternal morbidity and mortality rates. This may be associated with low use of modern long term contraceptives which provide protection for 4–5 years. The modern Intrauterine contraceptive device (IUCD) is very effective (99%) and an inexpensive family planning method[2]. It is reversible, requires little effort on the part of the user once inserted, and offers 5–10 years of protection against pregnancy. IUCDs wider use would reduce the overall number of unintended pregnancies more than any other method[3].

Pakistan’s population is crossing 180 million whereby the contraceptive prevalence rate (CPR) has been stagnant (around 30%) in Pakistan for more than a decade now. People mostly rely on short term and temporary methods, of which condoms are the most popular one, but with high failure rate because of its incorrect use. Therefore, the number of children per woman in Pakistan is still above 4 with a high (25%) unmet need for contraceptives[4]. This latter may be a contributing factor towards the high maternal mortality ratio in the country as shown in Table 1.

Table 1 Comparison CPR & MMR amongst South-Asian countries Full size table

A majority of married Pakistani women are not using long term contraception despite the demand. The most common methods used by currently married women are the withdrawal and the rhythm method, condoms or female sterilization, as shown in Figure 1[4].

Figure 1 Current use of different contraceptives in Pakistan. Source: NIPS & Macro International. PDHS 06-07, Islamabad: 2008. Full size image

Family Planning programs have not succeeded in achieving their goals of controlling growth rate of population because they have targeted women who already have had 4–5 children. Temporary hormonal methods of contraception have their own side effects which have created fears among the users. Moreover, the lack of counseling skills among the health providers consulted by the women for child spacing has appeared to further aggravate the situation. To improve contraceptive prevalence rate (CPR) and to control the fertility rate in Pakistan, the reasons for low utilization of long term methods (LTMs) of contraception need to be explored. There might be numerous factors on both sides which may have led to this all time low use of IUCDs: users’ perceptions about the IUCDs and the providers’ bias or other service/supply related issues.

Study methodology

Qualitative research seeks to understand and interpret the information about the “human” side of an issue i.e. behaviors, beliefs, opinions, emotions and relationships[5]. We used a descriptive qualitative study design to explore and understand the perceptions of women regarding the utilization of IUCDs and to understand the challenges and issues faced by the service providers. This approach helped us to study the different perspectives, conflicting attitudes and experiences in relation to the research topic in depth.

This study was conducted in Tehsil Gujar Khan, one of the largest tehsils of Punjab, in District Rawalpindi, with approximately 73,000 inhabitants. It has one Tehsil Headquarters Hospital, 3 Rural Health centers, several Basic Health Units and many private clinics and maternity homes. The study participants were selected through purposive sampling in 2 Union Councils of the tehsil, one purely rural and the other near the main GT Road, relatively urban. The entire study was completed over a three month time period starting from May to July, 2012.

The study participants were divided into two groups: the permanently residing married women seeking family planning services, particularly those who have a need for long term family planning method; and the service providers providing family planning services in the study area. Pregnant women and women suffering from severe illness were excluded on health grounds.

Data was collected through in depth interviews with the family planning providers and focus group discussions with the community women. The probes for the in depth interviews and focus groups were developed with the help of available literature. Each FGD comprised 8–9 married women, and in all 6 FGDs was conducted. Twelve in depth interviews with family planning service providers were conducted in two Union Councils. Data collection was continued till saturation was reached, that is, when no new information was elicited from the FGD participants. Field notes were taken during or immediately after each interview and discussion session to describe the physical setting and non-verbal communication by the participants. The data was analyzed using Qualitative Content Analysis technique that is defined as “a research method for the subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns”[6].

Field notes were transcribed in Urdu and then translated into English. The transcribed data were analyzed using steps of content analysis. The transcribed data were read many times to explore and understand different perspectives and experiences of different participants. Analysis started by reducing transcribed text preserving the core meaning of the data. The meaning units identified were then condensed and coded. The codes were grouped into sub-categories and then into categories. The categories were then abstracted into sub-themes and leading to the main theme and that was used to support the conclusions of the study.

Ethical considerations

A written informed consent was taken from all the study participants. Confidentiality and anonymity was ensured. All the Focus group and interview transcripts were kept in a locked custody of the principal researcher. The study protocol including the written consent form was reviewed and approved by the Institutional Review Board of Health Services Academy, Islamabad, Pakistan.