Identifying Geographic Inequities in Family Planning Service Uptake in Pakistan: A Comparative Study of PDHS 2006 to 2017 Using Cluster Hotspot Analysis

1. Introduction

Family planning (FP) has the potential to save over 30% of maternal and 10% of newborn deaths worldwide, making it one of the most important public health concerns as well as one of the most "health-promoting" and economical public health promotion initiatives [1]. It is an essential part of the healthcare given before conception, right after delivery, and in the first year following childbirth [2]. It includes all the goods, services, information, commodities, attitudes, and policies —including contraceptives — that encourage individuals, couples, women, men, and teenagers to choose when and whether to have a child and prevent unintended pregnancies [3,4]. Furthermore, FP permits controlled population growth that yields socioeconomic advantages such as decreased gender disparity, poverty, and increased access to education [5].

According to Starbird et al. [4], enhancing the accessibility of family planning services improves maternal and child health, and promotes gender parity and women’s empowerment. Also, FPS is necessary to avoid unintended pregnancies, reducing the risk of unsafe abortions, other pregnancy-associated issues, and economic burdens [1]. Despite these benefits, equal access to FP services is a challenge in Pakistan because of a lack of education, poor knowledge of FP, and low socio-economic status, ultimately affecting the utilization of FP services in Pakistan [6]. Additionally, several other health system-related factors such as inadequate health service delivery, low access to outreach services, and ineffectiveness of FP programs have been linked with the under-utilization of FP services in Pakistan [6,7,8].

Pakistan is experiencing exponential growth of population which poses major challenges, hence a need for enhanced uptake and continuation of FP services. Globally, Pakistan was rated the fifth most populated nation with about 225 million people. But, according to the estimations of PBS [9] & WPP [10], the population will grow to 310 million by 2050. In 2012, the Pakistani government promised to commit its efforts to address this challenge by increasing the nation’s contraceptive prevalence rate (CPR) to 55% by 2020, which was then modified to 50% by 2025 [11]. However, since 2007, Pakistan's CPR has been stagnant in the range of 30–35% despite the political efforts, allotted funds, and extensive FP programs [12,13,14,15]. Variation still occurs in the usage of FP services in different regions of Pakistan, especially in the rural areas. Although the government and several stakeholders in the FP domain have endeavored to promote FP, challenges still exist in increasing the optimal uptake of CPR [16,17]. Pakistan confronts difficulties in attaining sustainable development, lowering population growth, and enhancing maternal health [18].

Notably, Pakistani provinces show variations in the total fertility rate (TFR) and the CPR. The 2017 and 2018 PDHS reported that Gilgit-Baltistan province has the highest TRF of 4.7, Khyber Pakhtunkhwa has 4.0, and Balochistan has the lowest TFR of 3.0. However, CPR was the highest (35%) in Islamabad and the lowest (35%) in Balochistan [19]. These inequities are relatively higher at the district level; for example, the Multiple Indicator Cluster Survey (MICS) conducted between 2017 – 2018 shows that CPR varied from 49% in the Multan district to 17% in the Gujranwala district of the Punjab province [20]. Also, the same variations are found across the districts in other regions. This issue underlines the need for targeted or tailored approaches/interventions to reach the most marginalized and vulnerable women in Pakistan [21]. More so, despite the continuous efforts of the government, many potential barriers still exist to the use of contraceptives, especially among women of childbearing age in Pakistan because of social, cultural, and perceived religious unacceptability of contraception, lack of knowledge and awareness of contraception, cost of contraception, and access to contraceptive services [22,23,24,25].

Current research studies have highlighted the significance of spatial analysis techniques, like Cluster Hotspot Analysis, and Geographic Information Systems (GIS), in the identification of geographic inequities in family planning and reproductive health services uptake [26,27,28,29,30,31]. This study, however, aimed to add to the body of existing knowledge by investigating provincial or regional inequities in the use of FPS in Pakistan. It demonstrated the application of innovative techniques in the evaluation and planning of family planning programs that can strategically transform the family planning landscape in Pakistan. It maps geographic disparities in contraceptive prevalence rates, specif