Factors Affecting Contraceptive Use in Pakistan

Please download to get full document.

View again

of 19
All materials on our website are shared by users. If you have any questions about copyright issues, please report us to resolve them. We are always happy to assist you.
Information Report

Internet & Web


Views: 0 | Pages: 19

Extension: PDF | Download: 0

Related documents
The Pakistan Development Review 35:1 (Spring 1996) pp Factors Affecting Contraceptive Use in Pakistan NAUSHIN MAHMOOD and KARIN RINGHEIM Using data from the Pakistan Demographic and Health Survey
The Pakistan Development Review 35:1 (Spring 1996) pp Factors Affecting Contraceptive Use in Pakistan NAUSHIN MAHMOOD and KARIN RINGHEIM Using data from the Pakistan Demographic and Health Survey of , this study examines the effect of selected socio-cultural and supply factors on contraceptive use as reported by married women of reproductive ages. In addition to the expected positive relationship of woman s age, number of living children, education, and place of residence with contraceptive use, it is theorised that there are five factors potentially affecting fertility regulation in the socio-structural context of Pakistan. These include the extend of communication between husbands and wives, religious beliefs, female autonomy, son preference, and the family planning service and supply variables. Using logistic regression analysis, the results of the study indicate that the explanatory power of these five factors is significant in affecting the use of contraception in both urban and rural areas. While knowledge of a source for family planning is the strongest predictor of contraceptive use, husband-wife communication and religious attitudes are also significant. The fact that the inclusion of the theoretical variables dampens the predictive effect of the primary and secondary education for women leads to the speculation that while the extremely low levels of literacy among women must be addressed through government commitment to universal education, scarce family planning programme resources can be focused more effectively on promoting spousal communication, about family size and contraceptive use, and on soliciting the support of religious leaders to counteract the misperceptions about Islamic teachings on family planning and reliance on fate. With high quality and accessible services, these measures could go a long way towards providing couples with the means to meet their reproductive goals. INTRODUCTION The high rate of population growth in Pakistan and its adverse impact on the successful implementation of development strategies have long been recognised. In Naushin Mahmood is Senior Research Demographer at the Pakistan Institute of Development Economics, Islamabad. Karin Ringheim is a Social Scientist affiliated with the USAID, Department of Population Research, Washington, D. C. Authors Note: The above is a revised version of a paper presented at the 22nd Population Conference of the International Union for the Scientific Study of Population (IUSSP), held in Montreal, August 24 September 1, Permission for the use of the PDHS data was granted by the National Institute of Population Studies, Islamabad. The authors wish to thank Dr Mohammad Irfan and Mr Ghulam Yasin Soomro for their valuable comments and suggestions on an earlier draft of the paper. The comments of the anonymous referees are gratefully acknowledged. However, the views expressed in this paper are entirely those of the authors themselves. 2 Mahmood and Ringheim view of this, the government initiated a national family planning programme in the early sixties to reduce fertility levels. After nearly three decades of family planning activities and numerous small-scale non-governmental family planning projects, the contraceptive prevalence rate rose from 5 percent in [Pakistan Population Planning Council (1976)] to 18.7 percent in [Ministry of Population Welfare (1995)]. The total fertility rate has shown only a gradual decline from 6.3 lifetime births per woman in to 5.4 births in [National Institute of Population Studies (1992); Afzal et al. (1993)]. There is, however, evidence that a significant proportion of women do not want to have more children. Yet a majority of these women do not use contraception to avoid future births [Mahmood (1992)]. 1 This apparently poor performance of the programme poses a challenge: How to increase contraceptive use levels and accelerate fertility decline? The challenge is even more serious when we consider that other Muslim countries with similar socio-economic conditions, like Bangladesh and Indonesia, and neighbouring India, have been successful in achieving distinctly higher levels of contraceptive prevalence and thereby lowering fertility rates in the last decade. Given this situation, it becomes crucial to determine what policy prescriptions would be more effective in changing the fertility behaviour of Pakistani couples. On the one hand, it is argued that the social and cultural conditions which constrain the use of family planning must be evaluated and changed to generate more than a marginal decline in fertility. On the other hand, the emphasis on the provision and improvement of supply-side activities of family planning is considered important for an increased and sustained use of contraceptives even with low levels of socio-economic development and casual attitudes towards fertility control. The social set-up and the developing nature of Pakistan s economy, together with a high desired family size, provide the traditional scenario where it becomes difficult to motivate couples to adopt contraception. As many of the family planning activities are concentrated in urban localities, the access to the family planning services is inadequate for a majority of the rural population. It has been argued that the lack of success of the population programme in Pakistan has largely been due to limited and inefficient supply of services [Robinson et al. (1981); Rukanudin and Hardee- Cleaveland (1992)]. The official family planning programme has been subjected to frequent changes in management strategies, without the earlier activities having been fully implemented. 2 Improving the coverage and supply strategies further and increasing the use of effective contraceptives are, therefore, viewed as a policy priority. In dealing with the question of raising the level of contraceptive use in Pakistan, it is worthwhile to understand what factors are significant in promoting the practice of 1 Changes in selected indicators of fertility and family planning, as estimated from various surveys in Pakistan, are given in the Appendix Table 1. 2 A detailed review of the history of the family planning programme in Pakistan, its management, and implementation is given in Robinson et al. (1981) and Rukanudin and Hardee-Cleaveland (1992). Contraceptive Use in Pakistan 3 family planning. The apparent unmet need among a substantial proportion of women provides us the basis for identifying factors affecting the demand for contraception and, ultimately, for selecting programme and policy interventions that would better assist couples to meet their reproductive goals. The key question, therefore, is to investigate how various measures of social, cultural, and supply factors affect the use of contraception in the socio-structural context of Pakistan. These concerns need to be analysed both for urban and rural areas separately as women residing in the two types of area differ with respect to their background characteristics, reproductive attitudes, and family planning behaviour. THEORETICAL CONTEXT There is an evidence for high desired family size and strong son preference among Pakistani couples [Khan and Sirageldin (1977); Mahmood (1992); Ali and Rukanudin (1992)]. These types of preferences could be associated with the predominantly agricultural economy where children are valued highly for their contribution to farm work. As the majority of the population in Pakistan resides in rural areas characterised by inadequate basic infrastructure and social services, the low level of education and literacy, particularly in the case of women, perpetuates the gender inequality through differential access to education for boys and girls. The relatively less favourable position of women in the economic and decision-making spheres inhibits them from making choices about family size and the use of family planning methods. Under these circumstances, typically associated with low contraceptive use and high fertility, a clearer understanding of the role of social and cultural forces, jointly with the provision of family planning supply services, provides an important basis to judge the variations in contraceptive use across different population groups. In this context, we theorise that there are five factors potentially affecting contraceptive use, in addition to the expected positive relationship of age of women, number of living children, urban residence, and education. Deriving from both the sociological and cultural perspectives [Coale and Watkins (1986)], these five factors include the extent of communication between spouses, son preference, religious beliefs, female autonomy, and family planning service supply variables. The rationale and the theoretical relationships for each factor are discussed below which would be tested empirically in the data. 3 3 It may be borne in mind that the data available in the Pakistan Demographic and Health Survey (PDHS) used in the analysis is not the most ideal and comprehensive to test our hypothesis in terms of the contextual or socio-cultural effects. However, it is not only the current best source of data for analysing the determinants of contraceptive use but also for information on certain theorised variables that have not been utilised and tested before. We attempt to maximise the information that the PDHS does offer to address our research question and to demonstrate that, despite its limitations, the data do signify useful findings for policy-makers and service providers. 4 Mahmood and Ringheim Level of Husband-wife Communication Interspousal communication has been found to be associated with favouring a fewer number of children and with enhancing the practice of contraception. If couples can openly discuss their desires and aspirations for children with each other, a smaller family norm may emerge. But communication between husband and wife may be hampered by social norms of modesty and privacy concerning sexuality, as well as by the subordinate status of women. In countries where the fertility transition has already been completed, husbandwife communication about family planning and desired family size is the norm. A national survey in Korea found that 78 percent of currently married women had discussed family size with their husbands [Oh (1988)]. Mutual influence occurring through two-way communication has been identified as the most important source of agreement in desired fertility among U.S. couples [Thomson (1986)]. It has also been demonstrated that where husband and wife are in disagreement about desired family size, the husband has greater influence in fertility outcomes [Mitchell (1972); Thomson, McDonald and Bumpass (1988)]. In contrast, the level of spousal communication about family planning in developing countries has been found to be very low. The evidence indicates that lack of communication between wife and husband is a major factor constraining contraceptive use [Mukerjee (1975); Bertrand et al. (1982); Pineda et al. (1981); Raju (1987)]. A Turkish study [Olson (1976)] found that husband-wife communication was more essential to contraceptive use in the rural than in the urban areas. This is due to the difficulty of obtaining contraceptives in the rural areas which required more cooperation between the couples in order to do so. Although some women attempt to use contraception without their husband s knowledge, many forms of contraception require partner s participation or concurrence. Eighty percent of women in a Sri Lankan study of the potential demand for Norplant stated that they would need to discuss their interest with their husbands and the extent of communication was positively related to the wife s level of education [Thapa, Lampe and Abeykoon (1992)]. The limited evidence for Pakistan indicates that the use of contraception is strongly related to communication between spouses [Shah (1974)]. Past research also shows that the role of husbands in household and reproductive decision-making is significant [Mahmood and Ringheim (1993)], and women often mention their husband s disapproval of family planning as one of the reasons for non-use of contraception [National Institute of Population Studies (1992)]. Using the available information on husband-wife communication about family planning matters, an empirical examination of the question whether interspousal communication promotes mutual agreement in family size desires and the use of contraception among couples would be of special significance for Pakistan s demographic concerns. Contraceptive Use in Pakistan 5 Son Preference Although the influence of a preference for sons has not been shown to have a pronounced effect on contraceptive use or fertility in most countries, Pakistan is one of the few where son preference is still evident in excess female mortality among female infants and children both historically and in the present [Arnold (1992)]. In a review of the survey data on sex preference, Nag (1991) found that a preference for sons was higher in Pakistan than in neighbouring India and Bangladesh, based on the evidence that the number desiring no more children was higher for those with more sons, as well as the higher mortality for female than male children of 1 to 4 years old. As for the role of son mortality in influencing contraceptive use behaviour, the limited evidence for Pakistan suggests that the two variables are negatively related. The effect, however, is not significant when controlled for socio-economic factors [Shreeniwas and Mahmood (1995)]. The results of a study in Bangladesh showed that the mortality of sons, and not daughters, was associated with a lower rate of female contraceptive use and a higher rate of discontinuation [Johnson and Sufian (1992)]. Sex preference has influence on birth outcomes in a natural fertility regime, but in a society still near the onset of fertility transition, it may influence whether and at what parity contraceptive use is initiated [Niraula and Morgan (1994); Rahman and DaVanzo (1993)]. Early contraceptive adopters are likely to be those of relatively high parity who believe they have a sufficient number of sons, as would be the case in Pakistan. Given the low level of contraceptive use among women, our expectation is that the impact of the number of living sons on contraceptive use will be relatively small, but will be greater than that of living daughters. Religious Beliefs/Values It is argued that religious beliefs in Pakistan are not favourable to the practice of family planning and contribute to a lack of self-efficacy in limiting family size. Based on the information from the Pakistan Demographic and Health Survey of , about 13 percent of women cite religion as a reason for not intending to use contraception in the future, while the percentage among husbands is higher, (18 percent generally and 22 percent for husbands over 30 of age). In terms of the ideal number of children, about 60 percent of both husbands and wives give up to God as a response; this percentage is unprecedented in both previous national surveys and among the 30 other DHS country surveys that have been completed thus far [Ali and Rukanuddin (1992)]. 4 4 The possible explanations for a higher percentage of responses to the question on the ideal family size could be associated with the high level of illiteracy, cultural conservatism, among older people in particular, and a general apathetic attitude among couples to give numeric answers to family size questions. Moreover, women with larger number of children are more likely to give the up to God responses, as has been found in the preliminary data analysis. 6 Mahmood and Ringheim Preconditions to contraceptive use stipulated by Coale indicate that unless the concept of fertility control has been entertained and perceived to be advantageous, contraceptive-seeking behaviour cannot occur. For individuals who consider that fertility is controlled by fate, the ideal of preferences for family size or the approval and use of family planning may be meaningless [Kane and Larson (1982)]. Given that a substantial proportion of women have cited religion as a reason for not using contraceptives, and consider fertility as being controlled by fate, we test the hypothesis whether religious attitudes are significant in reducing the likelihood of contraceptive use. Female Autonomy The status of women in Pakistan, as measured by the educational level and participation in the paid labour force, is inarguably low. Based on the Pakistan Demographic and Health Survey of , nearly 80 percent of ever-married women of ages 15 to 49 years report having no formal education at all. Only 9 percent of women have secondary or higher levels of education, inevitably linked to a very small percentage of women in professional employment. Illiteracy not only greatly constrains the modes of communication available to reach women but also prohibits women s access to a world of ideas, and allows them access to information only as filtered through their husbands and other relatives/friends. Moreover, family structure in Pakistan is patriarchal and patrilocal, with strong family ties and kinship values. Marriages are mostly contracted between relatives and families and women are likely to have less autonomy in the extended than in a nuclear households. Those women who are exposed to the outside world and are able to go out independently have greater awareness and may have a greater say in family decisionmaking. Acknowledging the limitations of the indicator variable to represent autonomy, 5 we propose that self-sufficiency to negotiate in the public realm and exposure to places outside the home is one aspect of female autonomy, and that such exposure or autonomy will increase the probability of use of contraception. Family Planning Services From a global perspective, Pakistan is clearly on the low end of the programme effort. Although 60 percent of Pakistani women either desire no more children or want to delay their next birth, only 20 percent have access to family planning services [National Institute of Population Studies (1992)]. In general, quicker and easy access can be expected to lead to greater contraceptive use [Bulatao (1993)]. The shortage of family planning service outlets is especially severe in the rural areas of Pakistan, where the great majority of the population lives. 5 The only measure of autonomy in the Pakistan DHS is whether a woman would be able to go to a hospital or clinic alone or would need to be accompanied. This, therefore, is our sole measure of female autonomy. Contraceptive Use in Pakistan 7 Personal contact is perhaps the most effective mechanism for conveying family planning information, but the media has also been a successful channel for reaching large numbers of people. Contact either with a programme worker or exposure to the family planning massage through media have been found to be critical factors in increasing contraceptive use among a sample of Pakistani women who want no additional children [Mahmood (1992a)]. Where people s attitudes towards family planning need to be changed, as they do in Pakistan, a logical first step of a media campaign would be to increase public approval [Bulatao (1993)]. In El Salvador, when contraceptive prevalence was 35 percent, over 90 percent of reproductive-aged women reported having heard a media message concerning family planning [Bertrand et al. (1982)]. In Pakistan, by contrast, with current usage at 14 percent, only 21 percent of the women have reported having heard a media message in the past month [National Institute of Population Studies (1992)]. The role of family planning service supply variables, measured in terms of the knowledge of and ease of access to a service outlet, as well as exposure to a media message about family planning, is expected to promote the use of contraception. DATA AND METHODS The data for the p
View more...
We Need Your Support
Thank you for visiting our website and your interest in our free products and services. We are nonprofit website to share and download documents. To the running of this website, we need your help to support us.

Thanks to everyone for your continued support.

No, Thanks