Sunday, December 10, 2006

A Lack of Cultural Understanding: the True Reason for Failed Family Planning Programs in Pakistan -- Sonya Khan

Pakistan is the seventh most populous country, and with UN projections, will be the fourth most populous by 2050 (1). With a decline in mortality, post-World War II, and the fertility rate continuously on the rise, Pakistan’s population growth is estimated at about three percent per annum (1). Despite specific attempts since the 1960’s to curb this exponential growth, the population continues to grow, and this growth will eventually drain the nation of resources and space. Family planning was intended to be instrumental in these attempts at slowing population growth; however, it has been to no avail. Looking at Contraception Prevalence Rates (CPR) in Pakistan, a measure of the percentage of married women using modern and traditional methods of contraception, there was no change in contraceptive prevalence from 1974 to 1990 (1). Apparently whatever attempts Pakistan was making at slowing population growth and reducing fertility rates were not making any headway. In fact, there wasn’t a marked decline in fertility until the mid-90’s.

How can a country that boasts the highest gross national product per capita in South Asia, besides Sri Lanka, have such a poor showing in terms of health indicators, especially those attributed to reproductive health. The health system is burdened by the growing population, and will be under an inordinate amount of pressure as the population continues to multiply. While the lack of progress on health indicators can be attributed to many different issues, including under investment, frequent changes in government, corruption, illiteracy, inadequate health infrastructure, the health system’s ability to deal with major health issues is heavily influenced by incessant population growth (2). Furthermore, the incessant population growth is further compounded by inadequate approaches to the family planning problem in Pakistan. Without addressing this issue, no reform made on any level both in policy and infrastructure will decrease the pressures felt by the health system. Pakistan must slow its growth through efficient and appropriate family planning approaches, which on the surface it seems to be doing. The question that needs to be asked is why is this still a problem? If family planning programs are being implemented and contraception is being made available to the masses, where are the very apparent failures coming from?

Promoting contraception as a response to the high fertility rate is not a new idea to Pakistan. The Family Planning Association of Pakistan (FPAP) was founded in 1953 and is currently the largest non-government organization in the social sector (3). Since 1953, the FPAP has been combating the monstrous issue of the insistently high fertility rate in Pakistan by introducing family welfare centers and reproductive health services, and creating social marketing campaigns to encourage use of contraceptives, (3). With all of these resources available, contraception still wasn’t catching on. The CPR was stagnant at twelve percent for almost 20 years (4). For 20 years the fertility rate of Pakistani women averaged 6 to 7 births per woman, with population growth at an astonishing rate of 3% per year (1). However, when one delves deeper, looking at the context of these numbers, there are a number of factors that can help explain why Pakistani people just won’t use contraception. These factors can be understood using social and behavioral approaches, looking at the cultural context of contraceptive use. Important weight should be, but isn’t, given to a religious misunderstanding of the idea of contraception, the lack of forms of elderly care other than children, and the lack of women’s autonomy over their own bodies. These three issues are again and again overlooked in the current family planning approaches because of a lack of cultural sensitivity in the implementation of family planning programs.

The predominant religion of Pakistan is Islam. An outsider learning about Islam has a very different perspective of the religion than a muslim living in Pakistan for example. The facts an outsider may learn come without the influence of a cultural and geographical context. Therefore an outsider may ask the question, is contraception permitted in Islam, and get the simple answer of yes. And that would be the end of the conversation. Perhaps further discussion may arise concerning early Islam’s role as the originator of contraceptive medicine, and Islam’s acceptance of any contraceptive method that does not induce permanent sterility (5). However, one cannot just leave it at that. Just because the religion allows for contraception does not mean that this an accepted fact among the target population of the family planning programs. In fact, 13% of women and 18% of men, according to the Pakistan Demographic and Health Survey of 1990-1991, name religion as their hesitation to use contraception (6). There is an obvious disconnect between the actual tenets of the religion and the cultural understanding of the religion. Current programs do not take this into account and therefore are not as effective. Even if a program provided people with the education and the means to practice responsible family planning, if they do not believe that they can actually do the behaviors, they won’t do the behaviors. Here, religion, more specifically misconceptions of religion, is the limiting factor that casts doubt on people’s belief that they can do the behaviors.

Another important cultural aspect that one must consider is the way Pakistani culture provides for the elderly population. It is part of the Pakistani culture for the sons to take care of their parents when they get old; therefore, parents will continue to have children to guarantee a son that will remain at home in their old age to take care of them. What steps have been taken to even determine whether worries about familial elderly care are founded? The answer is that no real attempt has been made to really examine the fear that surrounds this issue and what effects that has on behaviors (7). In fact, trend data that shows whether or not there are changes in elderly familial care is quite rare to find. The nature of gender relations in the family – with the men ruling the family – and the nature of generational relations within the family – with the elderly generation of a family ruling over the younger generation – are important aspects of traditional family systems to look at when evaluating the effectiveness of a behavioral intervention (7). In Pakistan, the traditional family structure is that of a patrilineal/patriarchal joint- and stem-family system. What this means is that the males have a life-long “membership” or obligation to the family into which they are born, where as the females only are a part of the family until they are married at which point they take up residence with their husbands’ families (7). This family system is characterized by a dominance of a senior male or males in decision making, and as a result of these characteristics of the family structure and system, it is the males that continue to care for the elderly relatives when they are in need of care, both financial and physical. Knowing this culturally specific fact makes it clear that an obvious motivation behind having many children is to not only guarantee a son, but also to guarantee a son that survives. One cannot forget the context of this particular problem, which is that of a developing country where maternal and child health is not at its prime. Therefore, there is not a guarantee that each child a woman has will survive to adulthood. All of these factors are taken into account, with the motivation of ensuring social security, when a woman makes a decision not to use contraception, despite her access, know how and ability to use it. By not addressing the motivations behind these decisions, a family planning program cannot hope to be successful in just providing the means for reducing fertility rates.

Looking at the general mindset of the female population of Pakistan, other aspects of the decision to use or not to use contraception are made clear. There are more gender specific reasons, including the fact that many women perceive disapproval on the part of their husbands. Women’s autonomy is absolutely a necessary aspect of the culture to examine when looking at reproductive decision making processes. Women in South Asia are taught “that their own interests are subordinate to those of the family group”(6). One study found a significant association between women’s contraceptive use and female mobility and decision making capability (6). Another aspect of the culture, called “purdah,” which is the seclusion of the female family members, makes it particularly difficult for a woman to access contraception services outside the home (6). Violence can also be seen as a barrier, in that abused women tend not to use family planning practices for fear of their husbands reaction (8). The legal climate in Pakistan in terms of violence against women does not support women’s autonomy either and in fact is “deeply biased against women” (8). Women living in fear of rape or honor killings without any hope of legal protection or justice are not going to be inclined to exercise their right to make reproductive decisions. Ignoring the fact that the legal culture is one that doesn’t allow much room for women’s autonomy would mean that any attempts to provide women with tools of exercising their autonomy would overlook the fact that these women are in an environment that doesn’t allow them to use these tools freely.

In current family planning programs, the larger religious and social contexts that Pakistani women live in are being ignored. Pakistani misconceptions of Islam fall into the religious context that must be considered, in that if a person thinks that the norm according to Islam is that contraception is forbidden, then they will not follow through with family planning. Using sons as a form of elderly care falls under the social context, in that the outcome of using contraception would not only reduce the number of children a couple had, but also reduce their social security for elderly care, a person may see his or her future security as a more important outcome to consider and choose not to use contraception. And finally women’s autonomy can also fit under a social context. The repercussions of choosing to use contraception could involve violence because of the legal environment in Pakistan, which is a negative health outcome. Women may not value having fewer children over their physical safety. Also, the social norm in Pakistan is for a woman to submit to her husband in decision-making, and a woman may not feel comfortable going against these social norms in order to use contraception. It is very clear that current family planning programs do not take these issues into consideration and that this is this reason that no improvement has been shown in controlling the population growth problem.


(1) Rehan, N. Contraception Perspective in Pakistan. JCPSP 2005; 15:381-382
(2) Abbasi, K. Focus on South Asia-II: India and Pakistan. BMJ 1999; 318: 1132-35
(3) IPPF Country Profiles: Pakistan. Profile.htm March 2006
(4) Pakistan Country Study: Health and Welfare. March 2006.
(5) Maguire, Daniel C. Sacred Rights: The Case for Contraception and Abortion in World Religions. New York: Oxford University Press 2003.
(6) Fikree, Fariyal F. What influences contraceptive use among young women in urban squatter settlements of Karachi, Pakistan? International Family Planning Perspectives 27(3): 130–136.
(7) Mason, Karen Oppenheim. 1992. Family change and support of the elderly in Asia: What do we know? Asia-Pacific Population Journal 7 (3): 13-32.
(8) Ending Violence against Women and Girls: A Human Rights and Health Priority. The State of the World Population 2000.
(9) Salazar, Mary Kathryn. Comparison of Four Behavioral Theories: a Literature Review. AAOHN Journal, 39 (3): 128-135.


Anonymous Anonymous said...

Sonya, I really enjoyed your paper. I didn't know much about the topic. It seems so obvious from an outside perspective that the factors you identified should be considered in developing interventions. Maybe someone will listen...Rodney

5:50 PM  

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