Closing the counselling gap: a qualitative study to strengthen rights-based family planning in Pakistan.

Abstract

To identify client and provider perspectives on contraceptive counselling in Pakistan and inform the development of an effective, rights-based counselling intervention package. A formative, multimethod qualitative study was conducted using in-depth interviews, non-participant observations of counselling encounters and thematic analysis. The study was embedded within a WHO-led multiphase complex intervention. Primary care-level family planning facilities (public and private) in the urban and peri-urban districts of Islamabad and Rawalpindi. The analysis reported in this paper includes 72 married family planning clients (36 women and 36 men), 15 frontline healthcare providers and 72 observed counselling sessions across three facilities. Broader stakeholder interviews with programme managers, public-sector officials and donor/development partners were collected for the wider multiphase study but are not analysed in this paper. Three overarching themes were identified: (1) counselling was often understood as basic method-related information rather than a structured, rights-based decision-making process; (2) public and private facilities differed in counselling depth, method choice, privacy and use of visual/couple-centred approaches; and (3) system constraints, including time pressure, commodity limitations, limited follow-up mechanisms, weak privacy arrangements and inconsistent training, shaped the quality of counselling. Observation data supported interview findings by showing variation in privacy, side-effect discussion, client engagement and follow-up advice across facilities. Findings from participating facilities suggest that the current counselling model in these settings inadequately supports informed, autonomous reproductive choices. A redesigned, context-sensitive counselling package is needed to address these gaps. This should be supported by improved training, supportive supervision, inclusive tools, systemic reforms and enhanced follow-up mechanisms that are essential to increase decision-making autonomy and contraceptive continuation. NCT06081842.