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The population welfare efforts were initiated in mid-fifties by a national level NGO “the Family Planning Association of Pakistan”. There-after the Government started institutionalized efforts for population planning. The main objective of Population Welfare Program is to reduce the level of fertility by motivating people for child spacing and for a small family norm. It was estimated in 2005 that Pakistan’s population totaled 151 million; a number which grows 1.9 percent annually, equaling a 2.9 million population growth per year. The rapid increase reflects a decrease in death rate, low literacy, low female labor force participation rate and low status of women.
Even though there is considerable demand for family planning in Pakistan, the adoption of family planning has been hampered by government neglect, lack of services and misconceptions. Demographics play a large role in Pakistan’s development and security since the recent change from military rule to civilian leadership. Challenges to Pakistani’s well-being, opportunities for education and employment, and access to health care are escalated due to the country’s continuously-growing population. The simplest solution will be to set up effective family planning centers, but even the simplest solution in Pakistan comes with its own obstacles. Family planning in Pakistan faces a lot of skepticism by the general public. The government would have to raise awareness for the benefits of family planning to dispel the skepticism. The best way to achieve this would be to present people with hard facts. The government has set up family planning centers but unfortunately these are few in number as compared to the population that needs these services.
Religious influence and the role of women is another factor which prevents Pakistani population from family planning methods and contraceptive use. In Pakistan, extremely conservative Islamic beliefs predominate in many parts of the country, in which purdah restricts women to their homes unless accompanied by a male relative. Additionally, levels of schooling are very low in Pakistan, allowing men to have more power in decision-making. Some religious demonstrators use the slogan “Family planning, for those who want free sex!” in attempt to disregard family planning because it is considered “un-Islamic”. Though Pakistani couples commonly cite religious reasons for avoiding birth control, there is not one definitive agreement about family planning and contraception in Islam. In Pakistan, many local religious figures are now supportive of family planning and have begun discussions in their communities in order to promote the health of women and children.
Historically, political strife and cultural restrictions on women constraining their empowerment have hampered implementation of family planning strategies throughout the country. Most women who say they do not want any more children or would like to wait a period of time before their next pregnancy do not have the contraceptive resources available to them in order to do so. One-fourth of married women are estimated to have an unmet need. In the 1990s, women increasingly reported to wanting fewer children, and 24 percent of recent births were reported to be unwanted or mistimed. The rate of unwanted pregnancies is higher for women living in poor or rural environments; this is especially important since two-thirds of women live in rural areas. While only 22 percent of pregnant married women report to be currently using a modern method of birth control and 8 percent reported to be using a traditional method, lack of widespread contraceptive use could be due to the lack breadth of the current family planning program. The most commonly reported reasons for married women electing not to use family planning methods include the belief that fertility should be determined by God (28 percent); opposition to use by the woman, her husband, others or a perceived religious prohibition (23 percent); infertility (15 percent); and concerns about health, side effects or the cost of family planning (12 percent).The first abortion penal code (Article 312) of this region dates back to 1860, during British colonial rule which stipulated that unless an abortion was to “save a woman’s life,” it was expressly illegal and punishable by law, and the same applied for (self) induced miscarriages. In 1990, the penal code was provisionally adapted in order to better reflect Islamic Law, and finally was made permanent in 1997.
According to this change in the abortion law, preservation of “the physical and mental health” of a woman, early on in the pregnancy, also became legal grounds for a permissible abortion. Unfortunately, however the interpretation of necessary treatment required by a woman for an abortion to be performed is vague, and despite the legality, health professionals in Pakistan felt abortion was “immoral, contrary to religion and illegal,” especially according to female paramedics when compared to doctors and gynecologists. When a comparison of the private sector and public sector was made with regards to abortion and post-abortion care provided, it was noted that the private sector performed more abortions and took on double the case-load of post-abortion care, as opposed to the public sector. Therefore, it currently plays an important role in the provision of care of patients undergoing abortions. Due to a lack of access (especially in the rural areas), no clarity (dearth of awareness, understanding and education), fear of legal persecution (especially in the public sector), an inability of health care professionals to interpret the law, as well as a form of FP, women are often forced to seek abortion by untrained providers.
According to an indirect estimation method, applied to the 2002 national data on abortions and its related complications in Pakistan, 1 in every 7 pregnancy terminates in an abortion. Extending beyond the reach of family planning and contraceptive methods is the issue of women’s sexual and reproductive health. According to the World Health Organization and Population Action International, as of 2007, “only 16 percent of women receive at least four antenatal care visits during pregnancy, fewer than one-third of births are attended by skilled health personnel, and the maternal mortality ratio, at 320 maternal deaths per 100,000 live births, remains high.
Dating from 2002, Pakistan’s current family planning policy reflects the government’s concern with rising population trends and poverty. The policy’s goals include reducing population growth (from 2.1 percent in 2002 to 1.3 by 2020), reducing fertility through voluntary family planning (from 4 births per woman in 2004 to 2.1 births per woman by 2020), and as a signatory to the Programme of Action developed at the International Conference on Population and Development in Cairo in 1994, Pakistan pledged to provide universal access to family planning by 2010. Also in Pakistan’s Poverty Reduction Strategy Paper is the objective of increasing contraceptive use 57 percent by 2012. At present there is no federal ministry of health or population welfare and therefore no population policy. However, at the time of writing, Khyber Pakhtunkhwa, Sindh and Punjab are working on individual Health and Population strategies. An analysis of this policy showed that while the Government of Pakistan spent USD 652 million funds under this policy between 2000 and 2009 (UNFPA), there was hardly any change in CPR which was 30% in 2000 and remained unchanged in 2006. It is also important to note that other elements of population development such as education, capacity building, economic development, climate etc. were notably absent from this policy.
In 2009 the Ministry of Population sought to revise the Population Policy. However, under the 18th Amendment to the Constitution, the Ministry was devolved and its responsibilities were shifted to Provincial Population Welfare Departments. In 2013 some of the provinces – notably Punjab – reported that they were developing their own population policies. In the 1990s, two agencies in Pakistan started village-based community health worker programs in Pakistan. The Ministry of Population Welfare started planning a program in 1992 based on a similar program in Bangladesh. This program recruited married women, with at least 10 years of schooling that lived in rural areas, and trained them to provide family planning services to their communities. The aim of these services was to reduce the fertility rate and slow population growth. The Ministry of Health (Pakistan) started a similar program in 1994 called “lady health workers.” This program emphasized maternal and child health, and also delivered family planning services. Both groups of women provide door to door health and family planning services, supplied with oral and injectable contraceptives and condoms to distribute to their communities. One study in 2002 showed that in areas with 2 or more community based workers there was a 7% increase in the use of modern, reversible contraceptive methods. An evaluation of the lady health worker program showed only a marginal improvement in FP among health indicators the populations served of around 5-6%. In 2006 there were 96,000 lady health workers.
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