The 'Avon ladies' of Pakistan

From 8am to 4pm, 25-year-old Samina Khaskheli travels door-to-door in rural Pakistan handing out free samples of condoms, birth control pills, and intrauterine devices.
“I was told ‘This is sinful’,” Samina says about the initial opposition to her selling birth control. She took the job warily. Her off-the-map village, Allah Bachayo Khaskheli, is home to roughly 1,500 people in the country’s south-eastern Sindh province. The flatlands are covered by livestock, and economic desperation leaves women toiling alongside men as farmhands, livestock breeders and cotton pickers.
Samina is a worker for the Marginalised Area Reproductive Health Viable Initiative – Marvi – once a popular emblem of female independence in Sindhi folklore. Today, Marvi refers to a network of literate or semi-literate village women aged 18 to 40 who travel door-to-door selling contraceptives. “In our village, there was no information about family planning. Many women died during childbirth,” says Samina about what inspired her to join.
Trained by the Karachi-based Health and Nutrition Development Society (HANDS), roughly 1,600 Marvis are dispersed throughout Pakistan’s remotest villages, where government healthcare facilities are scant or nonexistent. In the Sanghar district where Samina’s village is located, at least 400 Marvis fill a gap left by a lack of government funded lady health workers (LHWs).
After Afghanistan and Timor-Leste, Pakistan has Asia’shighest maternal mortality rate. In 1994, the LHW programme was established to bring urgent healthcare services to rural Pakistani women and lower the birth rate inthe world’s sixth most populous country. However, approximately 30% percent of Pakistan is not covered by the LHW programme, says Rubina Jaffri from Hands.
Pakistan’s contraceptive prevalence rate is low – out of a population of more than 190 million, only 35% of women aged 15-49 use contraception. Nevertheless, demand is high in rural areas, where women give birth to an average of 4.2 children, compared to 3.2 children in cities. “In villages, electricity is not there and health facilities are not there, but the need for contraceptives certainly is,” says Dr Talat Abro, the deputy secretary of reproductive health service for Sindh’s population welfare department.
Marvi workers receive a six-day initial training by Hands and have their sessions in the field supervised by LHWs. Marvis emerge from the underserved populations they work with, so understand how family planning is best presented to the women they target.
“I wish I had learned about birth control 15 years ago,” says Azima Khaskheli, a 45-year-old livestock breeder in Allah Bachayo Khaskheli village, her black bangles clinking together as goats bleat nearby.

When a Marvi worker visited her household to teach about birth control pills, Azima’s husband agreed that limiting future births would be a good choice. Not only would it save the family another trip to a hospital – the last one charged Azima 2,500 rupees (£16) per visit and was located more than half a day away by road – but it might increase Azima’s productivity in the field, which was already flagging thanks to the weight of childcare. She hefts her youngest child on her back while tending to a pack of cows and goats each morning.
“I tell the women ‘If you have a large family, how will you manage the family’s needs and food expenses?’,” says Marvi worker Bhagbhari Babar, who is required to make 50 home visits a month and usually visits a home five or six times before a couple agrees to buy any contraception.
The most popular contraceptives are the injectable contraceptive and birth control pills, says Babar. Ease of use makes them particularly attractive for women labouring in the field. Almost every contraceptive method is sold for five Pakistani rupees (£0.03) apiece to a family, allowing Marvis to generate an income from the sale of the products, which Marvis obtain at a government-subsidised rate of 3 rupees per piece.
“Now [the women] have knowledge about the procedures, and they pursue contraception out of their own choice,” says Ambreen Khaskheli, a LHW.
In addition to birth control options, Marvi workers also teach women about birth spacing, or providing a gap between pregnancies to protect the health of a mother.
“We are not trying to limit the number of children – a woman or a family has a right to choose as many number of children as they want, but they must keep in mind the pregnancy period is important for a woman’s health,” says Anjum Fatima, the general manager for health at Hands.
Opposition to birth control in Pakistan often takes on a religious hue, so Marvis are trained to sensitise local religious leaders on the health benefits of family planning. The Marvi programme relies on community mobilisers – ranging from religious leaders to influential landlords – to communicate the benefits of contraceptives. In 2014, approximately 40 Islamic religious leaders approvedbirth spacing for women in Pakistan. Samina adds that she enjoys the support of the village’s maulvis, or religious authorities, who endorse her door-to-door campaign, and never issue anti-contraceptive messaging over the mosque’s loudspeakers.
“Before the culture was rigid, but now they’ve gradually accepted family planning,” says Samina, the Marvi worker, motioning to the group huddled around her. “I am proud I can teach women about both the Qur’an and birth control.”