In Pakistan, contraceptive prevalence is increasing, but fertility remains high

In Pakistan, contraceptive prevalence is increasing, but fertility remains high

Moore, M

Contraceptive prevalence has reached 18% in Pakistan, an increase of 50% over the rate of use in 1991. The ideal family size has fallen from 4.9 to 3.4 children over the last decade; nevertheless, data from the 1994-1995 Pakistan Contraceptive Prevalence Survey (PCPS) indicate that, at current rates of childbearing, women will have an average of 5.6 births.1 Child mortality remains a common experience: At the time of the survey, women aged 35 or older had borne an average of 6.7 children, of whom one had died.

The sample for the PCPS consisted of 7,922 married women aged 15-49 years who were interviewed between November 1994 and March 1995. Almost 68% of the women surveyed lived in rural areas and 75% had no formal education.

Marriage Patterns

The mean age at marriage has risen steadily since the 1960s; in the decade between the 1984-1985 PCPS and the current survey, it increased from 20.7 to 22.0 years. Age at marriage was slightly lower for women in rural areas than for those in urban areas (21.8 vs. 22.7 years). Educational level is strongly associated with age at marriage: Women who had had no education married at an average age of 16.9 years, three years earlier than those with a secondary or higher education.

Contraceptive Knowledge and Use

Knowledge of contraceptives rose substantially over the decade between PCPS surveys. The proportion of respondents who knew of at least one method of family planning increased from 62% in 1984-1985 to 91% in 1994-1995. In 1994-1995, the bestknown methods of contraception were female sterilization (86%), the injectable (79%), the IUD and the pill (73% each).

Levels of knowledge varied somewhat by residence and by education. Some 95% of urban women could name at least one method of contraception, compared with 88% of rural women. Similarly, 98% of women with a secondary or higher education could name at least one method of contraception, compared with 88% of women with no formal education.

Overall, 81% of the respondents knew of a source for at least one modem method of contraception. Women were most likely to know of a source for female sterilization (88%) and least likely to know of a source for the pill (69%).

Twenty-eight percent of women had ever used a contraceptive method, and 23% had ever used a modem method. At the time of the survey, 18% of currently married women were practicing contraception, an increase of 50% over the level of 12% recorded in the 1990-1991 Pakistan Demographic and Health Survey Thirteen percent were using a modem method and 5% a traditional method. The most commonly used modern method was female sterilization (5%), followed by the condom (4%), the IUD (2%), the injectable and the pill (1% each).

Contraceptive use was almost three times as high in urban areas as in rural areas (32% vs. 11%). Urban women were most likely to rely on the condom, female sterilization or withdrawal, while rural users most often used female sterilization or withdrawal.

The proportion of women practicing contraception rose from 13% among those with no formal schooling to 44% among those with a secondary or higher education. Women with no schooling were most likely to rely on female sterilization, while those with a secondary or higher education most often used the condom.

Women who lived in homes with electricity were more than twice as likely to use contraceptives as were those who did not (20% vs. 8%), while women who lived in a brick or concrete house were three times as likely to use a method as were those who lived in a mud or thatch dwelling (26% vs. 8%). Women living in a nuclear family were more likely to use contraceptives than women who lived in an extended family (49% vs. 37%), and women who watched television regularly were almost twice as likely to use a method as were women who did not (69% vs. 37%).

About 10% of all married women had used a family planning method in the past but were not doing so at the time of the survey. The reasons given for the majority of discontinuations of the pill, the injectable and the IUD were side effects, whereas accidental pregnancy was the most common reason for discontinuation of the condom, withdrawal and periodic abstinence.

Of the women who had never used a method, 47% approved of family planning, 29% were uncertain and 21% disapproved. Those who approved of family planning generally gave economic reasons (82%), while the majority of those who disapproved cited religious objections (68%).

Thirty-three percent of all never-users said they intended to use family planning in the future. When asked what method they planned to use, 24% named female sterilization, 18% the pill, 16% the injectable and 5% the IUD, while 7% mentioned various other methods and 30% were uncertain.

According to the PCPS data, 37% of women have an unmet need for contraception. Fecund women were considered to have an unmet need if they did not want any more children or wanted to space their children by more than two years and were not using a method.* Unmet need was lower in large cities than in other urban areas or in rural areas (33% vs. 38% each). Women with a primary or higher education were less likely to have an unmet need for contraception than were those with less education or with no schooling (33% vs. 39%). The level of unmet need also rose with the number of living children and the number of living sons.

Fertility and Fertility Preferences In 1994-1995, the total fertility rate (TFR) in Pakistan was 5.6 live births per woman. Women aged 35 or older had borne an average of 6.8 children, of whom 5.7 were living at the time of the survey. The number of children ever born declined sharply with increasing education, from 7.1 among women with no formal schooling to 4.3 among those with secondary or higher education.

Fifty-three percent of respondents reported that they did not want any more children. Among women who wanted to continue childbearing, 44% wanted another child within two years,19% wanted one later and 37% deferred to God’s will. The mean ideal number of children for any family was thought to be 3.4, a lower number than the 1984-1985 average of 4.9. The number of children personally desired, however, averaged 5.0, 1.2 children more than the average number of living children.

Family Planning Services

Current users were most likely to obtain contraceptive supplies from hospitals or clinics (55%), followed by drugstores or general stores (31%) and family welfare centers (10%); small proportions received supplies from other sources. Current users in rural areas reported a median travel time of one hour to reach their source of supply, compared with 15 minutes for urban residents. Urban women most often made the trip by foot (45%), while rural women were most likely to go by bus (37%).

Seventeen percent of women in large urban areas and 11% of those in other cities and in rural areas had been visited by a family planning worker. Overall, 70% of ever– users who had been visited said the worker had mentioned more than one method, and 52% said she had explained how to use the methods; however, only 21% said the worker had described possible side effects, and just 19% said she had told them what to do if she experienced side effects.

About one in four ever-users had experienced side effects. Of those who said they had discussed the side effects with someone, 74% had consulted a doctor. Thirty percent of all women with side effects who had discussed the problem had been told to stop using the method, 10% had been advised to switch methods, 53% had been prescribed medication to manage the side effects and 13% had been told that the side effects would disappear with continued use. Overall, 65% of women who reported having experienced side effects said their problem had been resolved.

Women’s level of satisfaction with their family planning services provider varied moderately by residence. Eighteen percent of women living in urban areas were dissatisfied with the information provided and 14% felt they had to wait too long for service; those proportions were 26% and 19%, respectively, among women in rural areas. About a quarter of women in both urban (26%) and rural (27%) areas felt that services were too expensive.

*The PCPS presents calculations for unmet need both including and excluding pregnant women whose pregnancy was mistimed or unwanted. When pregnant women are excluded from the analysis, the level of unmet need is 29%.

Reference

1. Population Council, Ministry of Population Welfare and United Nations Population Fund, Pakistan Contraceptive Prevalence Survey 1994-95, Islamabad: Population Council, 1998.

Copyright Alan Guttmacher Institute Dec 1998

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