RAISING eight children is not easy. Nasreen spends every day juggling menial household chores with looking after them — and yet she is only 38 years old, married off at the age of 15. For her, time flew by too fast.

“I love each one of them,” she says, smiling at the brown faces looking up at her. “But if I could change anything about my past, I would have stopped at three,” she adds in a lowered voice.

Nasreen lives in a decrepit old house, with an ailing husband who is around 50 years old. The children are too young to be sent off to work, and paying for education and health is secondary because the household’s primary concern remains food. “I work in two houses and that gets us by as my husband is usually without work,” she says. “But more than often we go to bed hungry. How would we pay school fees?”

The only way Nasreen was able to end recurrent pregnancies was to get a tubal ligation. “I had to end it somewhere,” she says. Her husband Masood still does not know — but he also does not ask. Persistent coughing from the other room proves that he is not well, and of course the financial situation is difficult.

Nasreen is only one of thousands of women in the country who face an unmet need of controlling pregnancies and taking decisions regarding reproductive health into their own hands. According to a report by the Rahnuma Family Planning Association of Pakistan (FPAP), about 25 per cent Pakistani women would prefer to stop having children or wait two or more years between successive pregnancies. But they are not using any family planning methods. As a result, one of every three pregnancies is unwanted.

A rapid population growth is not the only result, and women like Nasreen still fare better than some others. Unplanned pregnancies can also lead to attempts at abortion, which are usually unsafe, as in the case of Sajida.

Sajida was only 20 when she conceived immediately after marriage — but she was not ready to have a child. Being a mother would close off all chances of studying, and she wanted that very much. So she confided in her community’s midwife, who convinced her to come by her house the next day. What ensued was one of the most painful processes Sajida had ever experienced. No real anaesthesia was given, and the midwife crudely terminated the pregnancy using the dilation and curettage (D&C) method. This resulted in inflammation of the uterus, and infection. Except for her sister, no one knew of the abortion. By the time her sister got her to hospital, the infection had grown so bad that it ended up taking her life.

“There are 900,000 abortions every year in Pakistan,” says Nabila Maalik of the FPAP. “We must look at the unmet needs that women — and even men — have in order to discourage abortions. Because they are not legal, women resort to back-alley procedures that can harm them for life. Some may never conceive again. Most of these women are above 30 and married. They wish for some kind of birth control.”

“After I went through this procedure [tubal ligation], many things dawned upon me,” says Nasreen. “It hurts to realise that women don’t know about contraceptive methods.” Once she stepped out of her house and started working, Nasreen took the initiative and asked a lady health worker in a basic health unit about the issue. “I know now that it is dangerous if men and women do not use contraceptives. Diseases can be passed on too.”

“So many young girls are married off by their families and end up bearing children at extremely young ages,” adds Nabila. “They can also end up suffering immensely because of broken pelvic bones, resulting in incontinence. In the latter case, these young girls are then shunned by their families. Imagine the trauma of living like that, and the psychological issues these young girls and women face.”

For Dr Faiza Rabbani, who previously worked with the Population Welfare Department, and is currently associated with the National Health Services (NHS), reproductive health became her true calling after she saw the dire need for it amongst women in slum areas. “Our contraceptive prevalence rate (CPR) is only 35pc,” she says, including traditional methods that are not reliable. The CPR should at least have been 50pc this year, and increasing, according to the Sustainable Development Goals.

“Unfortunately, the government lacks the will to work on reproductive health issues because it is the common person who is most affected,” says Rabbani. “Leave aside fulfilling unmet needs, the government does not even research or understand the issue. Its strategies are not realistic. Even lady health workers have little knowledge about reproductive health and need intensive training.”

“Today there is a little more talk about birth control than when I was young,” says Nasreen. “But even now, I would say most women don’t know about it. How many more of us have to suffer without this information? Is it not our right to know?”

Published in Dawn, June 2nd, 2017