Exploring reasons for low uptake of widely available modern contraceptive methods in Karachi, Pakistan: a mixed-methods study

Background: Despite increased investment in family planning (FP) programs, Pakistan’s modern contraceptive prevalence rate (mCPR) has not increased in recent years. A better understanding of women’s method preferences and FP decision making in urban contexts may help to inform program and policy development. Methods: We apply a mixed methods design to explore current contraceptive use and reasons for use/non-use of particular methods in urban Karachi, Pakistan. We triangulate findings from a cross-sectional household survey with married women, and qualitative interviews with 22 community informants. We report on the concordance and discordance identified in the qualitative and quantitative components to illustrate the nuance underlying contraceptive decision making and method choice. Results: Despite widespread awareness of modern methods among women surveyed, mCPR was low (32.3%). Condoms and withdrawal were the most common methods (18% each), and few women reported using long-acting methods. Covert contraceptive use appears to be common within extended families and social circles but not within couples. Couples consider a range of potential trade-offs associated with modern method use, weighing perceived social, personal, and health considerations before deciding on a particular method. Although many women wish to delay or space future pregnancies, health concerns and fear of side effects remain deterrents from modern contraception use. Conclusion: While preferred methods such as condom and withdrawal are less effective in preventing unintended pregnancy at the population level, they may be best suited to address individual needs and preferences. FP service providers should focus on what women perceive to be most appropriate for their unique situation. Opportunities for repeated counseling with trusted medical sources for both men and women may address concerns related to modern methods and improve uptake of FP in this context.