Providers' perspectives on family planning services in karachi, Pakistan: A mixed-methods study

Background: South-central Asia, including Pakistan, accounts for over half of the world's unsafe abortions. In Pakistan, where only 30% of reproductive aged women use contraception, there are religious, cultural, legal and informational barriers to safe family planning services (FPS), including legal therapeutic abortion (TAB). Exploration of these barriers could inform interventions to improve health outcomes. Methods: We conducted a mixed-methods study with Gynecologists practicing in Karachi, Pakistan. Following IRB approval, structured surveys and in-depth interviews addressing care delivery, training, and perceived knowledge regarding legal restrictions and personal religious beliefs about family planning, including TAB, were assessed. Results: Surveys were completed by 150 respondents along with 6 qualitative interviews. 92% of respondents indicated they routinely counsel and provide FPS to patients, but only 44% - 58% reported being trained to provide all FPS. Although 50% of respondents indicated awareness of laws allowing TAB, 80% of physicians do not provide this procedure and 48% cited religious reasons for not doing so. Four themes emerged from the qualitative analysis: 1) Knowledge of legality of TAB varied; 2) Personal religious objections to TAB overrode legality; 3) Provision of FPS was considered crucial but training inadequate; 4) Paternalism and myths about FPS were described as barriers. Conclusion: Religious beliefs were the primary reason cited by doctors for not providing TAB, even though most were aware that doing so was legal. Provision of FPS broadly were considered essential, however inadequate training, combined with societal and cultural factors were the major barriers to delivery of these services.