We rank abysmally low in international development indicators, i.e., human development indicator (HDI), hunger index, close to African nations, which ordinary Pakistanis sneer at with disdain for any kind of comparison. One reason for such low ranking is high infant mortality rate which is partly associated with high birth rates or in other words, women who are already malnourished, when they have several pregnancies with no spacing, those children are likely to be underweight and have higher chance of dying.*
Coming back to population issue, several studies have shown that one of the major drivers that is keeping the demand for children steady in Pakistan is son preference, as they are considered investment for future and also bearer of family name. For example, families with four daughters and no son, would still go on to try to have a son, even if they do not have the resources to raise the existing children. Secondly, to some extent there is fatalistic attitude that things will work out by themselves as per God's well.
The foremost factor that has greatest impact on population size is use or non use of contraception. In Pakistan, since all births take place within marriage (the law and social norms both dictate that) hence, contraception use rate (CPR) is measured for married women (and their husbands). According to the last available demographic survey (PDHS)** only 35 percent married women are currently using any form of contraception. And, only around a quarter of all women use a modern method. Important to note since traditional methods have very high failure rates in preventing pregnancies.
It might be interesting to compare our CPR with that of India and Bangladesh, two countries of the region with socio-cultural similarity to Pakistan. In Bangladesh close to two thirds (62%) and in India more than one half (54%) married women are current users. Interestingly, pill is the most popular method in Bangladesh with 27 percent users and in India 36 percent of women are sterilized. In Pakistan 2 percent women are users of pill while 9 percent women have sought sterilization. Perhaps, in future, when Pakistan would be able to meet its family planning goals, we would have contraceptive usage pattern more similar to India. At present, 20 percent of Pakistani women have an unmet need for family planning. It would be interesting to see analysis of how Bangladesh has been able to popularize the pill which in Pakistan has a high discontinuation due to side effects.
It is important to note that, with increasing urbanization and change in lifestyles, demand for children is decreasing, and hence a significant proportion of women either did not want to have the last child they had or wanted it later. A large proportion of of such pregnancies end up in induced abortion.
While, it is clear that the family planning programme in Pakistan is still an unfinished agenda, it is time to reflect on why the programme has not produced the results it had set out to do, why the average number of children is still close to four, while the 2002 policy planned to bring it down to replacement level (2.1). Moreover, in my view, the programme activities, instead of planning for provinces/divisions, should focus on districts that need the services most. For that data is available through MICS survey of UNICEF and PSLM of Pakistan Statistic Bureau. A national or provincial level approach is not enough as ground realities differ by district to district, as one can observe from the data from these surveys.
*The latest PDHS was conduced in 2017-18.
*For example, see Dr Zulfiqar Bhutta's (the foremost expert on child health in Pakistan) comments here.
