After giving birth to her fourth child at the age of 29, Maral settled on a family plan: she wouldn't have any more kids, at least for now.
That was nearly seven years ago, and there have been no surprises. After making her decision, Maral consulted with a gynecologist who told her that she was eligible to receive birth control pills at her clinic in Kyrgyzstan's northwestern Talas Province. And there would be no charge, because the contraception was being provided as part of a program run by the UN Population Fund (UNFPA).
But now it is time for a new plan. Maral, who didn't want to give her full name, recently found out that her reliable supply of quality, cost-free contraceptives, has run out. If she wants to continue her course of contraceptives she must buy them from a pharmacy, and that is not a luxury she can afford.
"Many women in our villages use contraceptive pills, and I don't know what are we going to do," Maral says. "I'm now using the last remaining pack that I have, and it will finish by the end of the month."
While the UNFPA's involvement and presence in Kyrgyzstan will continue, including its efforts to foster family planning and improve maternal health, the nearly two-decade program through which it provided free birth control has ended.
As a result, according to Kyrgyz health officials, the last of the UNFPA-funded contraceptives are running low across and may not last long.
Experts say that women from less affluent families will be affected the most by the termination of the UN contraception program. (illustrative file photo)
According to the UNFPA office in Bishkek, over the past five years the agency has spent $3 million to provide free contraceptives in Kyrgyzstan.
Health groups warn that many Kyrgyzstan women of impoverished families -- the primary recipients of the aid -- will no longer have access to contraceptives because they will not be able to afford it on their own.
Earmarking funds for free contraceptives doesn't seem to be on the government's priority list, however.
"Unfortunately, the state budget doesn't provide any funds for [free contraceptives]," says Osmonbek Artykbaev, the head of the National Committee of Kyrgyzstan Parliamentarians for Population and Development.
Artykbaev acknowledges that after many years of "donor support, now it's time for self-financing" for Kyrgyzstan.
One Small Step
The government has taken a small step to replace the UN program by introducing a 50 percent discount for birth control tablets for medical insurance policy holders, but it doesn't apply to thousands of women in rural areas. This measure alone is not enough, Artykbaev says.
He says that Kyrgyz authorities "are trying to resolve many issues" regarding family planning and child and maternal health, but he says the country still is not where it wants to be.
Saltanat Akunova, the head of the Issyk Kul regional center for family planning, says that contraceptive pills are among most popular family planning methods with women preferring them as an effective and easy method of preventing unintended pregnancies.
While the Kyrgyz traditionally prefer to have large families, she says, women increasingly tend to "plan their pregnancies with at least three years between each birth."
In Issyk Kul nearly 40 percent of the women who employ family planning methods use contraceptive pills, Akunova says.
The office of the UNFPA in Bishkek says the agency has repeatedly warned the Kyrgyz government in recent years that the project was never meant to be open-ended and that Kyrgyzstan would eventually have to implement its own program.
"Kyrgyzstan should not just pin its hopes on international organizations, and should independently buy the medicines," the UNFPA office director in Bishkek, Meder Omurzakov, tells RFE/RL."The UNFPA funding for contraceptives for Kyrgyzstan ended in 2015 and we delivered the last supplies this year. But for several years we've been telling the Kyrgyz government that the project would end."
Reducing Birth Fatalities
The Kyrgyz government first introduced a national program to reduce maternal and infant mortality by promoting family planning in the early 1990s. However, due to high costs and an unreliable supply, the majority of women in Kyrgyzstan didn't have access to modern contraceptives like birth control pills.
Intrauterine devices and abortion were among the most common methods for family planning in the country, especially among poorer rural families, before the UNFPA launched its project to provide free birth control pills for Kyrgyz families from impoverished backgrounds in 2000.
According to the Kyrgyz government, maternal health and newborn health services have improved in recent years, with Prime Minister Sooronbai Zheenbekov saying in April that maternal mortality had decreased by nearly 30 percent since 2015.
As the use of contraceptives by women in Kyrgyzstan has increased, abortion rates have reportedly fallen since 1992.
The Central Asian country is among nearly 70 countries in the Family Planning 2020 global partnership project, which aims at increasing access to modern contraceptives for 120 million women around the world by 2020. The project is funded by several organizations, including the UNFPA, the Bill & Melinda Gates Foundation, and the U.S. and British governments' international development agencies, among others.
The UNFPA will maintain its presence in the country through a variety of programs.
Since 1992, UNFPA's projects in Kyrgyzstan have included helping health institutions provide quality maternal and newborn services; raising awareness about gender equality, family planning, and reproductive health; and offering sex education, among other issues.
But in her remote village in Talas, the end of the contraception program leaves Maral considering her options as the pills she had come to depend on run out.Paying for birth control pills is not an option for the family of six that survives on irregular farming income.
"In the past many women, who wanted to prevent pregnancy, would get fitted with an intrauterine device, but some had health problems with that," Maral says. "I might try it, but I'm still undecided."