While the contraceptive prevalence rate in the country has steadily increased from 18.8 percent in 1994 to 65.6 percent in 2010, health officials said that family planning services remained the same it started in the country.

A gynecologist with the national referral hospital in Thimphu, Dr Ugyen Tshomo, during an advocacy programme to the members of parliament on population and family planning services in Thimphu on July 24, said it is high time that more family planning choices are provided.

Dr Ugyen Tshomo said that since the family planning services started in 1970s, the family planning choices never increased.

“Except for the i-pill, an emergency contraceptive pill, nothing new has been offered,” she said. “Now it’s time we offer more choices especially the long acting reversible contraceptive which can be easily reversible when they want more children.”

Oral contraceptive pills, Depot Medroxyprogesterone Acetate (DMPA) injectable, intrauterine devises (IUD) and male condoms are the temporary contraceptive services available in the country. Tubal ligation (TL) and non-scapel vasectomy are the only two permanent methods of contraception.

DMPA remains the most availed contraceptive in the country with 47.7 percent of women availing it. Female sterilisation and male sterilisation follows with 13.3 and 13 percent respectively. About 12.6 percent of the women use oral pills and only 5.5 percent uses IUD (Copper – T).

The total fertility rate has reduced from 5.6 per woman in 1990 to 1.7 per woman in 2017.

The age specific fertility rate (ASFR) in Bhutan was found highest in women between 25 and 29 years and this has not changed since 2005. The ASFR is the number of live births in a year by mothers per 1000 women of reproductive age group.

The adolescent fertility rate of 15 to 19 years drastically declined from 120.2 percent in 1994 to 7.7 percent in 2017. Director of public health department, Dr Karma Lhazeen, said the decline could be because of education, awareness and socio-economic development.

Dr Karma Lhazeen said family planning is necessary because pregnancy is particularly risky to certain groups of women. There is risk to a child if proper birth spacing is not maintained between two pregnancies and risk to mothers if they undergo unsafe abortions in case of unwanted pregnancies.

Since 2013, more than 1,000 abortion cases are reported in the country every year. The country recorded the highest number of abortion cases in 2015 at 1,566. Last year, 1,343 abortion cases were reported.

Health secretary Dr Ugen Dophu, during a panel discussion at the event, said that the health ministry’s family planning programme’s objective is like in any other countries. “Our objective is to have healthy mother, healthy fetus and healthy child.”

He said that if family planning services are not implemented then there would be more births and maternal deaths.

An official with UNFPA, Dechen Chimmi, said that family planning prevents pregnancy-related health risks in women, reduce maternal and infant mortality, help prevent HIV/AIDS, empower people, enhance education and reduce adolescent pregnancies.

Dechen Chimmi said that increasing use of contraceptive methods has resulted in improved schooling and economic outcomes, especially for girls and women and family planning is key to slowing unsustainable population growth.

According to UNFPA data, in terms of demographic impact in Bhutan, about 9,039 unintended pregnancies and 4,248 abortions will be averted if unmet need for family planning is fulfilled.

About 5,017 healthy life years of women and children will be saved and USD 0.2 million direct healthcare costs will be saved. In terms of health impact, seven maternal and 54 child deaths will be averted.

In 1971, family planning was introduced in the health care system. The health ministry was asked to promote a small happy family and the ministry worked in line to this, Dr Ugen Dophu said.

The health ministry again received an order to promote families to have three children and the ministry also had a slogan, ‘delay the first, space the second and stop after third.’

Dr Ugen Dophu, in response to a question on if the health ministry had conveyed a wrong message to people on family planning, said that he joined the health service in 1988 and served in the districts until 2000. “I was one of the implementers of family planning services and as far my health colleagues and I are concerned, we never conveyed the wrong messages.”

But he said, there are about 4,800 health workers across the country and not all of them could have communicated well and educated the people on family planning well.

Health officials clarified that family planning is not only to stop giving birth.

Dr Ugen Dophu said that the ministry and health facilities never limited the number of children a couple could have. “But if couples have a child one after another then it is not healthy for the mother and the baby as well. There should be spacing of a minimum of two years between two pregnancies.”

Dr Ugyen Tshomo said creating awareness and correct education to the people is important.

She said Copper-T is a good contraceptive. Women can have the loop removed if they want to conceive. It doesn’t have side effects but many women don’t opt for it, she said.

Counselling could be a reason for influencing women to use the contraceptive method because in JDWNRH, Thimphu, copper-T is the most popular method availed, she said. “If we are able to counsel the women well then they opt for it.”

Dr Ugen Tshomo said many women started coming back for reversal of tubal ligation, which means they have not made informed decisions. “If they have been informed well they could have opted for copper-T because these women were very young when they underwent surgeries and were sterilised.”

She said some of them claimed that their parents and husband made them undergo the surgery.

“In health, you must make informed decision,” Dr Ugyen Tshomo said. “To insert copper T, women prefer female health worker but we don’t have enough in all the health centres and this could also be a reason why they don’t opt for this.”

According to the participants, lack of property such as land and resources to raise many children could also be the reasons for couples choosing to not have more children.

Lack of female health workers, babysitters, family planning choices, informed decisions on family planning services and impact of women’s education on starting a family early, are some of the underlying reasons for couples to have less children, according to the participants.

Dechen Tshomo