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Fertility Regulating Behaviour: A Study of Rural Punjab-Pakistan



M. Iqbal Zafar, M. Habib Ullah , Saif-ur-Rehman and Saif Abbasi
 
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ABSTRACT

The main objective of the study is to examine fertility regulation behaviour in terms of knowledge. Attitude and practice of contraception and to explore the socio-cultural obstacles in relation to acceptability and accessibility of birth control methods. Three hundred sixty women aged 25-45 years with at least one living child residing in the rural areas of three major districts of the Punjab province Lahore, Rawalpindi and Multan were interviewed. Findings demonstrate that cultural forces in terms of religious belief system, husband`s opposition, preference for large families and normative and psychic costs of contraception are vitally important in shaping fertility regulating behaviour. Organised efforts are required to provide contraceptive information, counselling and services about mother-child health, pregnancy complications and others reproductive health problems to reduce the health risks from mistimed and unwanted pregnancies. It is also argued that the contraceptives methods offered to couples should have minimum side effects and assistance should be readily available to those women or couples who find difficulty with a method and wishing to shift to another. The performance of the family planning programme can also be enhanced if it meet the multiple reproductive health needs of the Pakistani couples.

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  How to cite this article:

M. Iqbal Zafar, M. Habib Ullah , Saif-ur-Rehman and Saif Abbasi , 2003. Fertility Regulating Behaviour: A Study of Rural Punjab-Pakistan. Journal of Applied Sciences, 3: 376-384.

DOI: 10.3923/jas.2003.376.384

URL: https://scialert.net/abstract/?doi=jas.2003.376.384

Introduction

The public national family planning programme began in July 1965 with the start of the Third Five-Year Plan (1965-70). Its goal was to lower the crude birth rate from 50 to 40 per 1,000 by providing contraceptive protection to 25% of the 20 million fertile couples by 1970(Planning Commission, 1965). Similar targets have been the major focus of each of the five-year development plans. Several implementing organisations have changed or developed over this period to deliver these services and numerous strategies have been developed related to outreach, contraceptive methods and delivery systems.

It is generally agreed both with in Pakistan and outside that there has been insufficient demand created and inadequate provision of services, particularly in rural areas. The programme has a history of ambitious objectives that have not been met as the programme tried to increase services through the Family Welfare Centres, NGO's and supply distribution schemes (NIPS, 1992). These unrealised plans generally have been attributed to a "lack of consistent government commitment and social and cultural constraints" as well as financial, organisational and operational obstacles (Zafar, 1995).

The solution of the enormous population problem and action for the effective implementation of the family planning programme in Pakistan are linked with behavioural change. Organised efforts to provide contraceptive information, counselling and services to couples to limit pregnancies through well trained personnel have been recognised to enhance the effectiveness of the family planning programme and also help women to reduce the health risks from mistimed and unwanted pregnancies (Mauldin and Lapham, 1987; World Bank, 1998). The family planning programme should be so designed that couples who wanted to regulate their fertility can find assistance, information, services, guidance and counselling regarding ways of limiting pregnancies. Effectiveness of the family planning programme can be achieved through providing advice and services within the framework of the socio-cultural values prevailing in the society.

Materials and Methods

A well-structured interview schedule was constructed to investigate the reproductive history and fertility preferences. The present study is conducted in rural area of three major Districts –Lahore, Multan and Rawalpindi - of the Province Punjab to investigate the gender roles and relationships. These districts are among the most populated districts of the country. Lahore is 2nd and Rawalpindi is the 4th and Multan is the 5th district with respect to population size and these districts are situated far away from each other. Population situations of three districts present similar characteristics of size and development, making these areas suitable for this study. Significant differences are not expected in the cultural values regarding gender relationships because people's lifestyle of these districts is almost the same. Religion and language which are powerful forces influencing lifestyle of people (Hull, 1983) are the same in the areas. The main reason for the selection of three areas was to capture more variation and to increase the scope of the study from the viewpoint of generalization of the research findings. Although regional differences are not expected, but regional differences are investigated to verify the proposition that socio-demographic and cultural settings of the respondents of these districts are the same. Rural married fecund women of age 16-49 years with at least one living child were interviewed in this study.

Appropriate sample size is necessary to ensure the validity and reliability of the research findings. Keeping in view limited resources 120 respondents – married fecund women from each district were interviewed. Altogether 360 respondents were interviewed from the selected three districts to explore the objectives. From district Multan two tehsils – Shujabad and Multan were selected randomly and from each tehsil three villages were selected randomly to interview 120 respondents- 20 respondents from each village. The selected villages from tehsil Multan were BastiBosan Mithar Billiwala and Joke Muhammad Khan Weins from Multan tehsil and Shahpur, Sikanderabad and Khaki Punjabi from Shujabad tehsil. From district Lahore the selected six villages were Ramkot, Sultankey, Mohniwal, Wara Gujranda, Nathokey and Atary and from Rawalpindi district the villages were Saroa, Chakry, hoha Khalsa, Sohra and Takhat Parri were selected.

The village list published by Population Census Organisation based on the 1981 Population Census was taken as sampling frame for drawing the sample 360 respondents from the study area. Twenty eligible respondents from each village were identified through systematic random sampling. Where the eligible respondent was not found in the selected household, the next household was investigated for the identification of the eligible respondent. In the next section of this article the findings about contraceptive use, side effects of birth control methods as perceived by the respondents, reasons for using contraception, intention for using fertility regulating methods are presented..

Results and Discussion

Knowledge of contraception
The association between knowledge and use of fertility regulation methods has been advocated in many demographic studies in different parts of the world. Of course, the knowledge of an innovation (contraception) is the first stage of the adoption process which leads to the stage of acceptance and confirmation. In this study a wide gap between knowledge and use of family planning methods has been found. A vast majority of the respondents (91.4%) reported their awareness about the methods of birth aversion while the proportion of women who were using contraception was quite low. In the in-depth interview it is also observed that the respondents had misconception about the family planning methods as being a mean of stopping the reproductive process (Table 1).

Knowledge about the place of availability
Availability and accessibility of fertility regulation methods are very important components to enhance the effectiveness of family planning programme. It generally realised that in some form of family planning methods are available at the service delivery point but people do not know where the service delivery point are located. The majority of respondents perceived that the birth control methods are available in hospitals. Although the hospitals are the right places as service delivery point but many hospitals are situated out of majority of the respondents’ reach and socio-cultural constraints further limit their access to these hospitals. No doubt through the Government’s social marketing approach the specific form of contraception such as condoms are widely available in the rural as well urban areas but people are not properly utilising these facilities. For example the condoms are available at shops in the rural areas but only a small percentage of the respondents knew that the shops as service delivery point for condoms. Table 2 indicates that 39.2% of the respondents reported nurse/dai as a source of contraception supply whereas the dais (traditional birth attendants) do not provide contraceptives in Pakistan. The Government’s effort to provide contraception through dais could not increase contraceptive use in rural areas. They primarily assist in delivering babies and which is a major source of their income. Through this profession the traditional birth attendants earn considerable amount. In Pakistan, dais want that every woman get pregnant many times to ensure their earnings.

Table 1: Distribution of the respondents according to their knowledge about family planning

Table 2: Distribution of the respondents according to their knowledge about the place of availability

Table 3: Distribution of respondents according to specific methods of contraceptive use

Table 4: Distribution of respondents according to specific methods of contraceptive use

Table 5: After which birth the couples first use family planning methods

Table 6: Who decided to use the family planning method

Table 7: Reasons for not using the family planning methods

Table 8: Distribution of respondents according to their intention to use contraception

Table 9: Distribution of the respondents according to their intended methods to use

Table 10: Who should go and get information

Ever use of contraception
Respondents were also asked weather they or their husbands have used or using any method for birth aversion and if they or their husbands used and are using then which was/is that method. The responses to these questions, presented in Table 3 and 4 indicate 28.3% of respondents were acceptors of the family planning methods while 71.7% respondents were not using any fertility regulation methods. The finding on ever use is similar to the Pakistan fertility and family planning survey (PFFPS, 1997). The information on specific methods indicates that the majority of respondents were using the pills, IUD, condom and injection. The barrier methods had not used by any one of the respondents. The method which used majority of the contraceptive users (45.1%) was condom followed by the traditional methods such as withdrawal, rhythm and period abstinence. The percentage of users of IUD and female sterilisation was the same i.e. 13.7%. It is interesting to note that no one respondent reported the adoption of sterilisation method by their husbands while a substantial number of the respondents had gone through the operation of sterilisation for birth aversion reflecting husbands’ domination on their wives contraceptive decisions. Table 3 Distribution of the respondents according to their ever use of family planning methods.

In Pakistan, women do not take decision to be sterilised if they have few children. Women only take decision for sterilisation when they have already had many children or due to ill health and almost all these women are in forties and close to age of menopause. So this proportion of the contraceptive users does not have any contribution in the national efforts of fertility reduction. The findings of the present study are in accordance with the findings of Pakistan fertility and family planning survey (NIPS, 1997). In this survey, the majority of contraceptive users had chosen condoms and female sterilisation for birth aversion. The higher level of condom use is really a good change because condoms are easily available in urban as well rural areas at almost all shops in Pakistan. However, a choice of methods which is normally not available at the family planning clinics should be available. Studies indicate that both the choice of methods and the effective delivery of methods enhance the effectiveness of the family planning programme (Simmons and Lapham, 1987).

Number of children at first use of contraception
Table 5 identifies when the respondents during their reproductive life span became motivated to initiate contraceptive use. The information given in Table 5 indicates that the majority of respondents started contraception when they had two living children. It is also clear from the table that 20.6% of the contraceptive users initiated contraceptive use when they had only one living child. Overall, 62.8% of the users of the modern methods started contraception for birth control when they had fewer than three living children. It emerged from the findings that the younger women at lower parities had more positive attitudes towards family planning than the older women as the percentage of users is sharply decreasing with the increasing number of children. This finding reflects that younger women are more inclined towards contraceptive use than older women with more than three living children. From the policy point of view the programme managers should motivate the young couples who had at least two living children and to make aware all women particularly the women who have more three children about health risks for having many children.

Who decided on contraceptive use
The majority of respondents (82.4%) reported, as is clear from Table 6 that the decision regarding contraceptive use is taken by both partners (husband and wife). It can be said that husband and wife relationships are of paramount importance regarding the fertility and contraceptive decision-making process. The positive attitude of husbands in traditional societies is very important for the initiation of contraception by couples because in these societies women cannot take the decision to use contraception without their husband's consent (Beckman, 1983). As the table reveals only 14.7% of the respondents reported that their husbands took the decision about contraceptive use. It is indicated in many studies (Beckman, 1983; Hull, 1983) that in husband dominated societies the husbands have more negative attitudes towards contraceptive use than their wives. It was also found in the study of Punjabi Men and Women (Population Council, 1997) a large majority of the non-users’ husbands did not intend to use contraception at any time in the future. Further study also reveals that husbands are more likely in favour of sooner births than their wives. The wives were more in favour of spacing than their partners. Efforts to develop positive attitudes among husbands towards contraceptive use through different channels of mass media would be a very useful approach for enhancing family planning activities in Pakistan.

Reasons for not-using contraception
Non-users were asked 'what is the particular reason for not using contraception'. The percentage distribution of the respondents according to different reasons for not using contraception given in Table 7 indicates that husband's opposition, not allowed in Islam, fear of side effects and need for more children were the prime reasons for not using contraception. 22.9% of the respondents said that they were not using contraception since they wanted more children. Husband’s opposition was mentioned by the next largest group of respondents (21.7%) for not using contraception followed by the religious belief (14.0%). 10.5% of the non-users also reported that they are not using contraception due to health concerns (fear of side effects) (Table 8). The findings reflect that social conservatism and cultural restrictions in terms of religious belief system, husband's opposition, preference for large families are prime forces opposing the idea of small family norms and of contraceptive use in Pakistan (Zafar et al., 2002).

Intention of using contraception
The intention of using contraception in the future was also obtained in the study. 32.3% of non-users of fertility regulation methods have showed their intention of using contraception in the future while 14.4% non-users were unsure about their thinking regarding contraceptive use. The remainder majority of the non-users reported that they have no such intentions of using contraception. The respondents who showed their desire in favour of contraception were also asked which method they preferred to use in the future. A huge majority of the respondents (91.4%) preferred to use the condom, IUD, injection, female sterilisation (Table 9). The female sterilization was the most preferred method reported by the potentials users. This finding has great significance for policy makers and urges the provision of female sterilization facilities in the rural health centres to prevent unwanted pregnancies which are more likely to occur to women at higher parities because in Pakistan women only take decision to be sterilised when they have had many children. Among the other methods the IUD, condom and injection were the most liked methods. Theoretically in Pakistan all methods are provided at service delivery points, practically only a few methods are available (Hashmi, 1990). As mentioned earlier choice of methods and effective delivery of methods contribute to programme effectiveness (Simmons and Lapham, 1987 ; Foreit, 1991).

Who will get information
Although the inception of the family planning programme can be traced from the last four decades but the issue of family planning is still very sensitive in Pakistan. People still feel hesitation and embarrass to talk on family planning methods and reproductive health issues. Even many people are reluctant to discuss reproductive health related issues with doctors and health personals. Majority Pakistanis perceive that these issues are concerning with once private life and open discussion about these issues spoils once respect and honour. As it is clear from Table 10 that the majority of respondents (67.9) viewed that the both husband and wife should go for counselling about family planning methods. They also expressed that women are not independent to take such important decisions without the husband’s consent and agreement. How it is possible for a woman to get information on family planning issues which is quite sensitive. They also said that in the husband dominated society if a woman take decision in her own for obtaining information on family planning methods without consulting her husband then she has to face the family and the husband’s criticism which makes her family life miserable. That’s why the majority of respondents viewed and favoured that the joint communication between husband and wife is of vital important for family development.

A wide gap between contraceptive knowledge and its use in this study indicates that the family planning programme has been failed to create sufficient demand and adequate provision of services in Pakistan. Presence of social and cultural constraints as well as financial, organisational and operational obstacles reflects the government’s lack of consistent commitment. Findings of the study reveal that cultural forces in terms of religious belief system, husband's opposition, preference for large families and normative and psychic costs for fertility regulation are the prime components opposing the idea of small family norms and of contraceptive use in Pakistan. Organised efforts to provide contraceptive information, counselling and services which fulfil the multiple reproductive health needs of couples for improving their reproductive health status have been recognised to enhance the effectiveness of the family planning programme and also help women to reduce the health risks from mistimed and unwanted pregnancies.

REFERENCES
1:  Zafar, M.I., 1995. Significance of beliefs and values in predicting fertility and contraceptive behaviour in Pakistan. J. Biosocial Sci., 27: 301-318.
Direct Link  |  

2:  Iqbal Zafar, M., F. Asif, M. Imran Khan and M. Shahbaz Bajwa, 2002. Investigation of reproductive history and fertility preferences: A study of rural Punjab: Pakistan. J. Applied Sci., 2: 1115-1118.
CrossRef  |  Direct Link  |  

3:  Beckman, L., 1983. Communication power and the influence of social networks in couple decisions on fertility. Determinants Fert. Dev. Countries, 1: 415-443.

4:  Foreit, J.R., 1991. More Methods, More Outlets More Promotion. In: Operations Research Helping Family Planning Programmes Work Better, Seidman, M. and M.C. Horn (Eds.). Wiley, UK., pp: 215-232.

5:  Hull, T.H., 1983. Cultural influences on fertility decisions styles. Determinants Fert. Dev. Countries, 1: 381-414.

6:  Hashmi, S.S., 1990. Population Welfare Programme Growth of Population and Social and Economic Development in Pakistan an Occasional for Reassessment. National Institute of Population Studies, Islamabad, Pakistan.

7:  Mauldin, W.P. and R.J. Lapham, 1987. The Measurements of Family Planning Inputs. In: Organizing for Effective Family Planning Programs, Lapham, R.J. and G.B. Simmons (Eds.). National Academy Press, Washington, DC., pp: 545-582.

8:  National Institute of Population Studies, 1992. Pakistan Demographic and Health Survey, 1990/1991. National Institute of Population Studies, Islamabad, Pakistan.

9:  National Institute of Population Studies, 1997. Pakistan Fertility and Family Planning Survey. National Institute of Population Studies, Islamabad, Pakistan.

10:  Planning Commission, 1965. The 3rd Five-Year Plan, 1965-1970. Government of Pakistan, Islamabad, Pakistan.

11:  Population Council, 1997. The Gap Between Reproductive Intentions and Behaviour: A Study of Punjabi Men and Women. National Institute of Population Studies, Islamabad, Pakistan.

12:  Simmons, G.B. and R.J. Lapham, 1987. The Determinants of Family Planning Effectiveness. In: Organizing for Effective Family Planning Programs, Lapham, R.J. and G.B. Simmons (Eds.). National Academy Press, Washington, DC., pp: 683-706.

13:  World Bank, 1998. Improving Women Health in Pakistan, Health, Nutrition and Population. World Bank Publications, Washington, DC.

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