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 Governments 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 Governments 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.
|| Distribution of the respondents according to their knowledge
about family planning
||Distribution of the respondents according to their knowledge
about the place of availability
||Distribution of respondents according to specific methods
of contraceptive use
||Distribution of respondents according to specific methods
of contraceptive use
|| After which birth the couples first use family planning methods
|| Who decided to use the family planning method
||Reasons for not using the family planning methods
||Distribution of respondents according to their intention to
||Distribution of the respondents according to their intended
methods to use
||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. Husbands 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 husbands 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
husbands criticism which makes her family life miserable. Thats
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 governments 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.