KARACHI, Pakistan (WOMENSENEWS)--Late last year, after the birth of their fourth child in six years, Zohail and Salma Bangash decided to start using contraceptives.
It seemed like a bold step when, 10 months ago--after much soul searching and several visits to medical clinics--Salma began taking birth control pills.
"If our parents knew, they'd probably die ofshame," says the 25-year-old Salma. "Children are gifts from God and they would never dream of interfering with the process."
But for the Bangashs, who survive on a joint income of just over 2,700 rupees (about $55) a month, another child would mean even less food, clothing and education for the four they already have. A month's supply of the pill, at about 7 rupees (about $0.15) fits into their meager budget.
Salma, who works part-time as a cleaning lady in Karachi, suffers from chronic fatigue and back aches. "A friend of mine had an operation done, but it seemed too final," she says. "This way we can still change our minds."
Population Boom and High Mortality
Despite the willingness of a growing number of younger Pakistanis like the Bangashs to use contraceptives--use has jumped to 23 percent of the population from 14 percent in the last 10 years--an ongoing population boom threatens to crumble the country's existing infrastructure.
With eight babies delivered every minute, the population has catapulted to 149 million in 2001 from 84 million in 1981. At this rate, the population is expected to double in 33 years.
Meanwhile, the country's status as South Asian laggard in preventive health care and education feeds into the problem. With poverty, illiteracy and lack of proper health care virtually ensuring the high mortality rates, many Pakistan couples have as many children as possible. The average family size is 7.3 with over 66 percent of the population living on less than $2 a day.
"Husbands and wives rarely spoke of these issues; wives quietly giving birth to children year after year with little attention paid to her health or what effect that might be having on the children," says Dr. Mohsina Bilgrami, managing director of the Pakistan chapter of Marie Stopes Society, the London-based nongovernmental organization
Program Targets Population, Rural Infrastructure
That may be about to change.
To stem the boom, the government unveiled this autumn a six-year plan to reduce the population growth rate from 2.1 percent to 1.8 percent, reducing infant mortality and increasing rural health capabilities by 70 percent. Over $11 million dollars has been earmarked to jumpstart the project, which will include building more health care facilities in rural areas, public awareness campaigns and training seminars for clinicians on reproductive health issues.
Health practitioners say the program could not come soon enough.
"Three women die and 40 are permanently disabled during childbirth every hour in Pakistan," says Dr. Talat Rizvi, a long-time Karachi-based independent women's health advocate, who serves as an advisor to the United Nations Children's Fund. While the last decade has brought some improvement in rural health care infrastructure, especially in the Punjab province, Rizvi says most rural women receive treatment in "horrid conditions."
One woman in 38 dies during pregnancy or childbirth in Pakistan, compared with a regional average of 1 in 230. One in 2,400 women dies during pregnancy or childbirth in Europe.
Access for Pakistan's rural people--about 70 percent of the population--remains sporadic at best. Women in rural areas are often either housebound by the dictates of their families or reluctant to buy contraceptives from the few local pharmacies that stock the items lest someone see them.
Tuning in to Global Change
With the 1990s introduction of the Internet and satellite television into their households, an increasing number of middle- and upper-class Pakistanis understand--and want to close--the lifestyle gap with those of comparable socio-economic status in more developed countries such as the United Kingdom or the United States.
"Things have changed in the last six or seven years," says Bilgrami, who has been working in the reproductive-health field for 22 years. "People want healthy children, educated children who can go beyond what they themselves were able to achieve . . . and that has opened up more discussion on issues that are rarely discussed even inside the family."
Bilgrami's organization, the Marie Stopes Society, is one of an estimated 200 nongovernmental organizations working on the issue in Pakistan. It operates 30 district centers, two dozens mobile clinics and employs 550 counselors, doctors and nurses, who provide pre- and post-natal care and gynecological exams and dispense contraceptives.
"In a historically conservative society, reproductive issues must be dealt with sensitively and there is no better way than to employ local people," says Bilgrami. "Sending local volunteers door-to-door has been our most effective way to reach housebound women."
Ignorance the Big Risk
Ignorance, says the activist Rizvi, is the single biggest obstacle. While many young women think kissing or holding hands will get them pregnant, others think pregnancy can only occur after marriage. Many youngsters get their information--often hopelessly incorrect--from their peers.
"There simply aren't enough outlets for young women to learn about their bodies and how they work," Rizvi says.
Health practitioners say that, contrary to popular perception outside Pakistan, religious authorities do not oppose family-planning outreach efforts.
"As a practice, the first people we approach in a new area are the clerics," Bilgrami says, "and never once have I had any one of them argue with me. They too realize the importance of quality healthcare for child bearers."
Sterilization remains the most preferred method of contraception, Bilgrami says, and usually only after a couple has had as many children as they desire.
Men, in fact, play a large role in the ongoing efforts to educate people in this male-dominated society. With the literacy rate for women at only 26 percent, compared with 50 percent for men, health workers reaching out to husbands as well as wives. Marie Stopes Society clinics regularly treat male patients and run educational seminars.
"We get men riding up on bicycles, donkey carts and on horses demanding to see our doctors," Bilgrami says. "Once word gets out about what we're doing, they even come in big groups to discuss their concerns. It's truly an amazing sight to see."
Juliette Terzieff is a free-lance journalist currently based in Pakistan, who has worked for the San Francisco Chronicle, Newsweek, CNN International, and the London Sunday Times.
For more information:
Pakistan: Population Planning Policies and Problems:
Jamaat -e- Islami--
Muslim Society, Family Planning, and Economic Development:
Country by Country: Pakistan: