She leads the way
Profile of a Lady Health Worker in the remote Upper Dir district of NWFP
By Delawar Jan
Chaman Bahar, 26, works in the remote Upper Dir district of NWFP as a Lady Health Worker (LHW). She is not married but her influence on the newly wed couples in the area as well as among her relatives is such that a lot of them have started following the 'family planning' regime she prescribes.

Man to man
The job of the male mobiliser is no less difficult
By Waqar Gillani
As part of the understanding that the male head has the most important say in a family system, the government of Pakistan launched the male mobilisation project, initially with the help of the Asian Development Bank (ADB). The main function of a male mobiliser is to reach out to the menfolk and teach them the merits of family planning.

barriers
Family matters
Age-old issues -- male dominance, monstrous mothers-in-law, lack of acceptance, opposition from religious factions, inaccessibility to services etc -- still plague women in our society
By Naila Inayat
Growing up in the early 1990s' Pakistan, I couldn't have escaped the impact of the very many, meaningful dramas they showed on PTV. I distinctly remember one such serial. Titled Nijaat, it was produced by the Ministry of Population Welfare and highlighted the travails of a family in a rural setting. The female protagonist, played by the very beautiful Atiqa Odho, was shown to be badly anaemic because she had given birth to a baby every year in the hope that she would be blessed with a boy.

Non-government vs government
Foreign aid has been consistently flowing for both NGOs and government without much success
By Aoun Sahi
Pakistan is among those few countries which have a separate ministry for population welfare. The rest only have a health ministry.
The concept of family planning was introduced in Pakistan in 1953, when the Family Planning Association of Pakistan (FPAP), an NGO, initiated efforts to contain population growth. The role of NGOs in creating awareness has always been significant in Pakistan since then. Hundreds of local and international NGOs have been working on the subject since early 1950s.

Where a woman needs to be heard, too
Family planning services in the country must be linked with maternal health services to reflect positive trends in the future
By Aroosa Masroor
In a country that largely comprises people from the rural areas where the literacy rate is quite low, it is not surprising that Pakistan has one of the highest population growth rates in the region. Part of this, say observers, has to do with the government's failure to deliver family planning services where they are most needed and reduce the Marital Fertility Rate (MFR) that currently stands at 6.6.

There isn't much in the public sector that works in this country; neither education nor health. So how could population planning, which has largely remained in the hands of governments?

Cynics would say we don't do anything substantive in any field because we want to remain qualified to beg for more aid. Cynics' views aside, there has been no dearth of aid for Pakistan's population programmes which have been formally and consistently followed, at least on paper, since the 1960s, or even before.

Yet we have failed in making any sort of headway to stall our population growth rate and the figures before us, in 2009, are stupefying, to say the least. The consistent family planning programmes have only yielded consistent rates. Our population growth rate is the fastest in the region hovering between 2 and 3 and so is the fertility rate that hovers around 4.1.

Another Special Report on population planning will perhaps only add to the printed material available on the subject, some more data, most of it recycled, almost all of it done to death. And yet we decide to do it as July 11, the World Population Day approaches.

We list the barriers to birth control, talk about the Millennium Development Goals, compare the performance of the government and the non-government sector, interview male and female health workers to know what it's like in the field. Basically, we try to review the public policy on population growth.

Our findings are not new. Our conclusions aren't startling either.

After we are through with the expected awareness, male dominance, religious barrier, frequent policy change issues, we find interesting cultural and social patterns that may have more to do with this staggering growth.

We don't know if this has been adequately prioritised in the government's list but the preference for son matters in this society and this is a major cause of the bigger size of the family.

As stated earlier, this is a subject that has mostly been handled by governments. So, imitating the government teacher who absents himself from the school without any accountability, the health workers find it easy to not go to the health centre and still get paid. This attitude puts paid to the accessibility -- of advice and contraceptives -- claims while we marvel at the unchanging growth rates despite everything we did.

As stated earlier that government did not deliver in the field of education or health or population control. What we did not state was that the government failure in the first two fields has a direct bearing on the last. Without literacy and health, the issue of birth control is impossible to handle. The status of women, the availability of choice, the high infant mortality, are all parts of a big puzzle. We can't see the complete picture till all of them fall in place.

So the strategists and the donors who sit and think and change the approach -- from the earlier slogan of a smaller family to safe spacing and health of mother and child -- should better rethink. This country needs education and health first. Population control will follow.

The Minister for Population Welfare, Firdous Ashiq Awan has given the issue of population explosion a new dimension. While admitting the government's failure in controlling the population of the country in the National Assembly session on June 29, she said that population is linked with terrorism. To control the population (or terrorism, as the minister implies), she suggested that tax be imposed on those who have many children; and that it should be started by members of the parliament.

What perhaps must be operating in the minister's mind was the current instable political situation: mainly the war against the jehadi militants and the recruitment of the poverty-stricken young people as jehadists in Fata and elsewhere in the country.

One wonders if the population experts would be sympathetic to Awan's view as they have struggled for decades to advocate a very different approach -- initially, that Pakistan's economic growth rates are swallowed up by the many new mouths which need to be fed, and the millions of youngsters that need jobs. So, the number of newborns must be controlled. Since this failed to bring about satisfactory results, a new policy was evolved in recent years that focused on the wellbeing of the mother and her child by promoting child spacing and fewer babies.

Pakistan's population growth has been the most serious and difficult problem. According to Population Census Organisation, on July 2009, our total population is 166800500, making it the sixth most populous country in the world. According to the United Nations projections, Pakistan's population will grow to over 380 million by the year 2050, surpassing the United States, Indonesia, Brazil, and Russia to become the world's third largest country behind India and China.

More than 50 years have passed since the family planning programme was launched by a group of women. Some argue that it is one of the world's oldest programmes. Since then millions of dollars have been pumped in, multiple resources have been exhausted and Pakistan still adds more than three million people to its population each year.

Still, the history of family planning in Pakistan is the history of failures.

The statistics are shocking primarily because, as the proponents of family planning agree, it has received an inconsistent political support. It was further hampered by frequent changes in leadership, weak implementation, contraceptive-centred approach not supported by an adequate supply system, low literacy rate, resistance from religious element in the society, desire to have more children especially boys, and the exclusion or neglect of the male member of the family. Additionally, "Population programmes lack adequate geographical coverage and community outreach," says Shahida Azfar, Chief of Party FALAH (Family Advancement for Life and Health), Population Council, Islamabad.

Above all, she says, "There is a missing link between the Ministry of Health and the Ministry of Population Welfare in providing birth spacing and family planning counseling and services through the health infrastructure at the union council and the village level. Remember, health infrastructures are four times bigger than the population welfare facilities in the country. Using health facilities for such a cause can benefit individuals who visit these facilities for some health issue or the other every day."

Despite these failures some changes, if not revolutionary, are reflected in the Demographic and Health Survey 2006-07 (PDHS). For one, it shows a reduced total fertility rate (the average number of children per woman) has decreased from 6.0 in 1984 to 4.1 on average at present. The survey further states that urban women have 3.3 children on average whereas women residing in rural regions have 4.5 children.

The PDHS says that despite the decline in fertility rate, women in Pakistan have more children than those in the neighbouring countries like India where TFR is 2.7, Bangladesh 3.0 and Nepal 3.1.

Also, nearly all Pakistani women are aware of at least one method of contraception. About 85 per cent of married women know of pills, injectables and female sterilisation. Condoms and IUDs are known to them too. Women were better aware of the modern methods of contraception than the traditional ones. It also suggests that the median age of first marriage is now 19.1 years, which reflects a slight improvement over the previous years.

The results of the survey, opines Azfar, "means that Pakistan is a 'late starter' in the demographic transition process and that it will be one of the last to complete it, thus finishing much later than other Asian countries, such as Korea and Thailand".

She adds, "The PDHS 2006-7 shows absolute stagnancy in reducing neonatal mortality and the high levels of maternal mortality, and above all the high level of unwanted and mistimed pregnancies. According to a national study in 2002, the estimated number of induced abortions number is as high as 890,000 a year, and post-abortion complications mainly among married women with more than three children are a further reflection of a huge gap between demand and supply for fertility regulation."

Although, the changes shown in the PDHS may appear positive, says Kamal Shah, CEO Rahnuma-FPAP, "the studies conducted after 2000 clearly indicate stagnation in fertility decline at 4.2-4.1. PDHS data is a positive reflection only when you compare it with data from the 90s. The fact is that population is growing at the same rate since 2000."

So, in the past years, family planning approach to limit the childbirth -- often communicated through messages such as "do bachay khushal gharana" or "Bachchay do hi achhay" played with catchy jingles -- only backfired. Experts maintain that limiting the family size through the khandani mansuba bandi programme was not approved by Islamic and other influential leaders. Therefore, in recent years, the safe spacing approach was considered more pertinent in the Muslim context -- as preventing fertility is not perceived against religion beliefs.

"Delaying and spacing births by three to five years helps women bear children during their healthiest years and enables them to have their desired number of children. International health experts now believe that the healthiest interval between a woman's previous birth and her new pregnancy is at least two years," informs Azfar. "Alternately, short intervals also affect mothers' energy and weight."

Shah says that family planning worker faced a lot of pressure from religious factions that "family planners are 'child stoppers'. Now when we talk about women's health, safe spacing and healthy growth of children, it does not invite any opposition from any ideology."

To ensure that the message of wellbeing does not simply go straight over peoples' heads "and the Ministry of Health recognises the challenges it faces in the path to achieving the Millennium Development Goals (MDGs) 4 and 5, it needs to recognise the fact that the reduction of unwanted fertility may be the key to reducing maternal and child mortality," urges Azfar.

She feels that the safe spacing approach will show results only if family planning and birth spacing become part of the health policy. Services and staff must be trained and well-equipped and family planning must be made part of primary health care package. At the same time, antenatal visits and immunisation must be encouraged.

"We also need to work on education, breast feeding promotion, higher age at marriage, women's decision-making in reproductive matters and promotion of good image of small family. Although we cannot restrict or impose reproductive choices by saying that 'only two children per couple are desirable for population stabilisation', through clever social engineering programmes, we can create such an environment where it becomes people's own choice to have smaller families. For that matter, we have to cover the gap of huge unmet need for family planning: currently about one third of couples want to use family planning but these services are not accessible to them."

And Shah couldn't agree more. He says that population and reproductive health must be approached from the rights perspective. "We cannot impose choice or restrict anyone's right to have as many children as one wants; we only promote safe choices, better health and wellbeing."

Chaman Bahar, 26, works in the remote Upper Dir district of NWFP as a Lady Health Worker (LHW). She is not married but her influence on the newly wed couples in the area as well as among her relatives is such that a lot of them have started following the 'family planning' regime she prescribes.

"My brother has only two children," she tells TNS, with a hint of pride, as if trying to claim the credit for it.

At such a young age, Chaman has already got an experience of 13 years of work in the field. She has basically covered Kandaogay (a village) in Dir town, the district headquarters of Upper Dir. She says that she has been assigned the task to campaign for the population of 800 to 1,000 people.

A Health Department employee, Chaman works on the mother-child health project in her area of operation. It's a "tough job", she declares, adding that it is "hard to try to convince the women, most of whom are illiterate, to practice family planning; it's a highly conservative society."

Despite the odds, Chaman sounds quite upbeat about the future of the population planning programme in the district. "Initially, we had issues but now the situation has improved and the women are listening to us," she says.

Covered from head to toe -- it's only her eyes that are not veiled -- Chaman commonly does not carry any medicine bag or something; rather it's a "a family child" she likes to accompany her every time she is visiting places. Her daily routine is four to seven houses a day. "We meet couples, have follow-ups and also take care of their newborns."

In the first place, the female spouses are asked to relate their family health history and show the EPI (Emergency Patient Information) cards for recording details such as those about a child's vaccinations. Later the women are told about the right diet for kids below age 3.

The second step, Chaman says, concerns 'family planning'. This involves persuading the women to follow the advice in order that they can avoid a lot of health issues later.

"We tell them to give a gap of at least three years between two children. This is for the betterment of the health of the mother as well as the child."

The pregnant women are given other related advice, such as the benefits of vaccination. As an LHW, Chaman says she has to be very tactful about the way she offers advice so that no one involved is displeased. "Though our target is population control, we don't bluntly tell the women to limit themselves to two children. We try to convince them with arguments."

She laments the fact that whereas more and more families are showing interest in family planning, there is a glaring absence of proper facilities such as the required injections. "Come to think of it, some women haven't even cotton and bandages!"

She also criticises the staff at a local hospital that is largely inattentive towards the indoor patients. "The result is that the patients often lose faith in our advice and would not listen to us again."

On the personal front, Chaman says she hasn't received her dues (salary) for the past three months now. A lot of her colleagues in the business are living from hand to mouth.

TNS was shocked to learn that the salary of an LHW in the area is only Rs 3,090 per month. It also transpired that the people in certain areas were trying to stop the LHWs from visiting homes. The health workers had to engage the local Health Committee of Women, in addition to elders and their own relatives, to solve the problem.

barriers

Growing up in the early 1990s' Pakistan, I couldn't have escaped the impact of the very many, meaningful dramas they showed on PTV. I distinctly remember one such serial. Titled Nijaat, it was produced by the Ministry of Population Welfare and highlighted the travails of a family in a rural setting. The female protagonist, played by the very beautiful Atiqa Odho, was shown to be badly anaemic because she had given birth to a baby every year in the hope that she would be blessed with a boy.

The serial that notched the highest TRPs of the time presented the illiterate village girl's suffering in contrast with that of an educated, issueless urban woman, the wife of a CSP officer placed in the same district. Years later, as I get down to write on population planning and the barriers that the women in our society face, I am instinctively reminded of the Sahira-Kazmi-directed serial. And, for once, I am forced to wonder if we have moved on from the Nijaat days.

No, we haven't. The women in our strictly male-dominated society still face age-old issues like the monstrous mothers-in-law, lack of acceptance in the family in particular and the society in general; rigid religion-based opposition; inaccessibility to contraceptives as well as the myriad services supposed to be given to them in public hospitals; the imminent role of the Lady Health Workers, et al.

Lahore-based Shehla, a housewife and a mother of four, says, "My in-laws consider this family planning thing as cheap and obscene; especially my mother-in-law strongly opposes the idea. And even if I want to end my family, I'm helpless."

She adds that her mother-in-law is trying to control her family life, albeit unnecessarily.

Maheen Arshad, a young entrepreneur from Karachi, has a similar tale to tell. "I've been married for the past three years now. My husband and I don't want to start a family just yet. But our decision doesn't matter. What matters is the opinion of the society at large. The people will make your life miserable with their weird inquiries -- why not now? And so on. Sure you don't want to answer them or even listen to them. But do you have a choice?"

Living in a patriarchal society, the women -- irrespective of their social and educational status -- have to face more or less the same kind of issues. Family planning is a mini battle they have to fight at home. It is not easy for most of them.

Lack of awareness is one major obstacle in the way. The women with no education or no exposure to radio and television usually end up with a huge line of offspring and a failing health.

Restricted personal mobility is another reason why most women are not able to educate themselves. Take the example of Saeeda Khalid in Quetta Cantonment. She has 13 children (and still counting): eight girls, five boys.

"If I had a baby boy early on, we wouldn't have expanded our family," Saeeda tells TNS. "The first boy came after we had six girls." She seems to have no issues with raising so many children.

God knows, Saeeda is not the only one. A huge majority of women don't seem to realise that their own children can be a source of suffering for them because -- well -- they cannot be fed as well as raised properly.

Most religious groups strongly decry the family planning programme and the use of contraceptives, chiefly on two grounds. First, they equate any practice that prevents pregnancy with 'infanticide' -- something they warn is prohibited in the Holy Quran. Second, they believe the higher their population growth rate, the greater their power.

Fehmida Aslam, an Islamiyat teacher based in Peshawar, says: "The local khateebs who are no experts on the subject misguide the couples. As long as I know, Allah wills no hardships for you."

Those women who have the required level of 'enlightenment', so to say, often find the services -- be it contraceptives such as condoms, IUDs (intrauterine device), pills, spermicides; or surgery -- difficult to access. Inefficient staff and lack of proper facilities in public hospitals can be attributed to a lack of coordination between the governmental departments (the health ministry and the population welfare department).

Aslam and his wife Fariha say they have been visiting a local hospital for over two weeks now but they have not been able to meet the family planning consultant. "Today, finally we met her but all she had to tell us was a long list of the merits and demerits of having a small family.

"When we asked for the contraceptive products (which we heard were available for free), the staff told us that they were short," Aslam tells TNS.

The Lady Health Worker Scheme, launched in 1994, with an aim to reach out to remote, rural communities and act as a primary healthcare provider has not yielded positive results either. The job of an LHW is to inform the clients about the side effects of the methods adopted. According to the PDHS Survey 2007, only one-third of users were informed about the possible side effects of the methods they adopted.

Women also complain about a communication gap that exists between the LHW and the clients. The need of the hour is to train these workers properly.

Where a woman needs to be heard, too

In a country that largely comprises people from the rural areas where the literacy rate is quite low, it is not surprising that Pakistan has one of the highest population growth rates in the region. Part of this, say observers, has to do with the government's failure to deliver family planning services where they are most needed and reduce the Marital Fertility Rate (MFR) that currently stands at 6.6.

According to Dr Mehar F Hansotia, Chairperson, Department of Community Medicine, at Aga Khan University Hospital, Karachi, the MFR can only be reduced through coordinated efforts between clinical services and preventive services. Presenting the findings of Pakistan Demographic and Health Survey 2006-07 that was carried out with the help of the National Institute for Population Studies and USAID, Dr Hansotia said the family planning services in the country should be linked with maternal health services.

"Our maternal mortality ratio (MMR) stands at 276 maternal deaths per 100,000 births nationwide, with a much higher ratio in rural areas, whereas Pakistan's Millennium Development MMR goal is to reach less than 140 per 100,000 births by the year 2015. But considering the lack of coordination between the maternal health services and family planning services, we won't be able to achieve even half the target in the next six years," he says.

PDHS which provides an accurate picture of mother and children's health in Pakistan, also reveals that contraceptive prevalence in rural areas stood at only 24 percent as opposed to 41 percent in urban areas in 2006-07. "Moreover, once women in the rural areas conceive, they avoid antenatal visits to doctors owing to poverty, distance of basic health units and lack of transport and in some cases because their husbands or in-laws do not permit them to do so," reveals the study.

As a result, women in these areas remain uneducated about the importance of family planning that in turn, affects their health. "In such a scenario, is an added burden on the country's healthcare services," says Prof Dr Subhana Tayyab, Chairperson Department of Gynaecology Dow University of Health Sciences. "73 percent of women in rural areas of the country feel going to visit a doctor during pregnancy is unnecessary. If they do not visit a doctor at all, how can we educate them about the use of contraceptives?" she questions.

The situation in urban areas is not any better, where 65 per cent of births take place at home with the assistance of a traditional birth attendant. This is basically done to cut down on the expenses of a hospital. Also, most women who make up this 65 percent are mostly those who have migrated to the urban parts of the country from the rural areas and are unwilling to give up their traditional practices. "My mothers and grandmothers have been giving birth at home for centuries and nothing ever happened to them, then why should I go to a hospital? Instead of spending on hospital bills, I would rather use that money to buy food for my children," is Roshan's response when questioned by TNS. Roshan is a domestic worker who migrated to Karachi from Sukkur seven years ago.

There are others who feel that apart from tradition, religion has a strong role to play in the decision-making process between couples. And in the case of a patriarchal society like ours women have little say in the use of contraceptives. This is particularly common among the tribal community in Pakistan who have large families by the "grace of God". "Every soul that enters this world is due to God's will. We humans have no right to control what He has planned for us. It's a sin," is Gul Zaman's belief, who is a rickshaw driver. He also believes that God will provide for every child He sends into this world so he need not worry.

However, he remains unaware of the impact of a huge population on the country's economy. Although the government has the support of the private sector and NGOs in delivering family planning services, some feel it is about time the government sought the support of religious scholars as well. In Dr Naveed Ahmed's opinion, who is associated with Marie Stopes Society, providing reproductive healthcare services across Pakistan for a population that largely looks up to religious scholars for advice on social issues, this relationship between the government and local imams can prove to be beneficial.

"We have the successful model of Bangladesh in this regard that managed to reduce its population growth rate largely by engaging clerics at local mosques. They were used to educate people and clear certain misinterpretations about the use of contraceptives in Islam." Everything boils down to right kind of education, he believes.

His view is seconded by a social activist who adds that if the government is committed and serious about reducing its MFR it should invest in educating the female population first. "Women have been ignored for too long. They need to be taught that from homemakers they now need to move a step ahead and become decision-makers and plan their families according to their will. They have the most important role to play in controlling the population growth."