Special report on family planning

Fatima Shameem Akhtar is a mother of five and a volunteer at a family planning clinic in the Pakistani city of Rawalpindi. She told IRIN if it had not been for the clinic in the People's Colony area, she would now have been a mother of 15, having been completely ignorant of contraception when she first visited it. "I had an IUCD [Intrauterine Contraceptive Device] fitted," she said. "Without this clinic I don't know what I would have done. We simply cannot afford any more children," she said, adding that she wanted the best for her children, but feared that she and her husband would not be able to provide for them with a monthly income of US $60. The clinic is one of 400 established across the country by the nongovernmental Family Planning Association of Pakistan (FPAP). In addition to these, some 50 mobile clinics are operating. With a population set to nearly double in just 20, the need for family planning in Pakistan has become greater than ever. There are 25 volunteers from the local community working at this centre, which charges patients minimal fees of up to 10 rupees (US $0.18). Although the clinic is always busy, getting women to attend it is an uphill struggle, according to Dr Tasleem Akhtar. "One of the main problems in educating women is actually getting them out of the house, as their husbands are wary about what we are trying to do here and stop them from coming here for advice," she told IRIN at the clinic. With an average family size of seven in the Rawalpindi area, she added, there needed to be much more motivation and public awareness of family planning. Abortion is illegal in Pakistan unless a woman's life is threatened, so women often resort to dangerous methods of terminating an unwanted pregnancy. A Karachi-based women's rights NGO called Shirkat Gah has recorded many cases where women with no information on family planning have done just this by resorting to action based on old wives tales. "Just because abortion is illegal, other methods of family planning are automatically seen as being wrong in this society," Akhtar said. "The women are so desperate and they will do anything." In one incident, she said, a 20-year-old woman from Attock, a district in the Punjab Province, some 80 km west of the capital, Islamabad, had been so determined to stop her sixth pregnancy that she drank a concoction of chilli powder, clarified butter, sugar and paracetamol. It made her very sick, but did not terminate the pregnancy. POPULATION GROWTH At current rates, the population of Pakistan is expected to grow to almost 300 million people in 20 years, whereby a huge strain will be brought to bear on resources and infrastructure in a country that is already one of the poorest in Asia. In many ways the country is already overpopulated, there are just over 140 million people living in the country, according to government statistics, ranking it as the seventh most populous in the world and the fourth in Asia. With six live births every minute, the average number of children per household country-wide is 5.5, according to analysts. "I believe that population growth is a major threat to stability in Pakistan in the forthcoming decades," the United Nations Population Fund's country representative for Pakistan, Olivier Brasseur, told IRIN in Islamabad. "There will be a massive group of young people who will require education health, employment and, given the current level of literacy rate and employment, we can think it will be very hard to accommodate these needs," he added. He said although the government had been responding to the alarming growth rate, there were still many problems in terms of delivering services. "Family planning is no longer a taboo subject here, but more work needs to be done." "As far as Pakistan's population is concerned... if you look at the demographic profile, about 60 percent of the profile is under the age of 24 years, which means they are at the active reproductive age, so education for these people is crucial," the head of the FPAP, Kanwal Bokhari, told IRIN from the Punjabi city of Lahore. "We desperately need to reduce population growth and manage those people who are already here," he stressed, adding that education and poverty alleviation were the keys to success. The government of Pakistan has pledged to reduce the official growth rate from the national official figure of 2.1 percent per year to 1.9 percent by 2004. "Even if the growth rate is reduced to 1.8 by 2015, the population will reach nearly 300 million, and this is going to be a huge strain," he said. However, government officials remain optimistic. "We are hopeful that with the declining trend we have seen already that the growth rate will continue to fall," the secretary of the Population Welfare Division, Abdur Rashid Khan, told IRIN in Islamabad. He maintained that Pakistan had come a long way since family planning started in the 1950s. "We have a fairly large established network from where we provide family planning services. We have a strong arm of advocacy, communication and education on family planning," he said. Another major step, according to the health official, was the transfer of family planning services to the provincial level, which would eventually filter down to the district level this year. "We have created awareness in Pakistan, which is universal at this stage," Khan said, adding that the challenge now was to provide quality services. He praised the government of President Pervez Musharraf, saying that it was only under him that a proper, workable population policy had been formulated. According to Khan, the involvement of men in family planning had been neglected in the past, but was crucial for future development. "It has now been realised that it's important to target men in our programmes, which is what we are concentrating on now." Dr Zakir Hussain at the People's Colony clinic told IRIN that, despite tradition in this conservative, religious society, male patients had been very responsive. "We give them advice on male sterilisation and point them in the right direction if they opt to have a vasectomy." "Men are coming forward and are seeking advice every day. I am also encouraging people to come here, and I'm putting out messages in the local mosque," a volunteer at the clinic, Mohammad Hanif, told IRIN. In the rural areas, government radio campaigns and local health authorities are providing information on family planning. "There are 60,000 female health workers - to be increased to 100,000 - working in rural areas on primary health care and family planning," Bokhari said. However, changing old attitudes in this country remains one of the biggest obstacles to universal acceptance of family planning. "In many areas in all provinces, people are pushing for their children to get married at an early age, without knowledge of contraception," he observed. RELIGION According to health experts, one of the main reasons why contraception is frowned upon is pure misunderstanding and confusion over how it is viewed under Islam. The FPAP is trying to use Islam by incorporating verses from the holy Koran which appear to be promoting family planning. "As far as Islam is concerned, there is no contradiction. We have been able to extract these Islamic verses with the help of religious scholars to educate people," Tasleem Akhtar said. She said working with religious leaders - very influential people in Pakistan - was often the most effective way to get the message across. The NGO has arranged for religious leaders to spread the message following Friday prayers. But one of the most difficult parts of the country to engage in this kind of advocacy is in the North West Frontier Province (NWFP), where Pakistan meets Afghanistan. Dr Muhammad Farooq Khan, an Islamic academic in Mardan in the NWFP has been working with the religious community to try and promote family planning. "I would say it is compulsory in Islam to have family planning," he told IRIN from Mardan. He pointed out that there were many misconceptions in the rural areas about forms of family planning. "This topic has to be handled very gently and without provocative language. For example we do not use the words 'sex' or 'abortion'. These words cannot be used at all so we use phrases such as 'when a child enters the world'," he explained. Khan said the prevalent view remained that family planning went against religion. "We have held several workshops with religious leaders in the NWFP, and it was very difficult for them to accept what we had to say," he added. However, the response from religious leaders in other parts of the country had been more progressive. One recent workshop organised by the FPAP and Khan with 100 religious leaders in Islamabad proved to be very successful. The government maintains that it has been very cautious not to propose policies that challenge religious beliefs. "We show due respect to religious beliefs and the practices permitted by our religion. We hold them very dear to our heart," Khan said. Back at the family planning clinic in Rawalpindi, a volunteer, Rubina Akhtar, told IRIN that she already had six children and could not afford any more. "We've been told how to use condoms and have been told about different forms of contraception," she said. And in an indication that attitudes are slowly changing, she added: "My husband wasn't happy about me coming here at first, but now he's fine."