Broken promises

Published November 19, 2021
Zubeida Mustafa
Zubeida Mustafa

THE current issue of the Journal of the Pakistan Medical Association carries a supplement sponsored by Pathfinder and titled ‘Keeping the FP promise alive’. This will no doubt be a formidable challenge. A look at the family planning data contained in the supplement gives rise to a sense of hopelessness about the promise ever being kept. In 2012, Pakistan had promised at the family planning conference in London to double the contraceptive prevalence rate to 55 per cent by 2020.We are nowhere close to it.

The supplement reminds me of the three MWRAs (married women of reproductive age) — to use a demographic term — who have been saddled with unintended pregnancies. I know them personally. They were all trying to prevent conception and were using one or the other contraceptive method. They have been let down and I don’t blame them. The eldest already had five children and now is the hassled mother of six. The next already had a toddler and is now expecting twins. The third was recently married and was on contraceptives. At the time of her marriage, she had planned to work for a few years before going in for motherhood. Evidently none of them was counselled which was their real need, as is also the need of four million other women in Pakistan who end up with unintended pregnancies every year. The irony of this situation is that none of these women had to be persuaded to practise family planning. They only needed counselling.

This is the reality of the sad story of population planning in Pakistan. It is a story of wrong priorities, lack of implementation of strategies at every level and a disconnect between the users and policymakers/staff who are supposed to provide the required services to the people. In most cases, the number of users is disproportionately high while the will of counsellors and healthcare providers to guide is low. And this is at a time when the political leadership is devoid of the commitment that is the need of the hour. Nor is sufficient attention paid to interpersonal communication which is so essential to mobilise people for demand generation for family planning.

Official family planning statistics show a dichotomy that is generally not explained. Pakistan’s population has jumped from 207.8m recorded in the 2017 census to 220m last year. Yet there are figures that show that progress has been made in some areas. But success eludes us as no impact has been made on the population scene on the ground. Pakistan’s population growth rate has dropped from 3.2pc per annum in the 1990s to 2.2pc today. Similarly, the total fertility rate has come down from 5.7 in the 1990s to 3.5 today. But these successes have come too late and too slowly. As a result, the baseline, from which the rates are calculated, has expanded rapidly. Hence in terms of absolute numbers we deal with massive figures and they constitute the reality that society has to deal with.

Women are deprived of counselling in family planning.

There is another issue for us to ponder over. The contraceptive prevalence rate has been stagnating. In 2007, it was 22pc for modern methods. In 2017, it had inched up to 25pc. That gives rise to the question of how population growth and fertility fell without more contraceptive coverage. The National Committee of Maternal and Neonatal Health (NCMNH) has the answer. Abortion — termination of pregnancy to use the medical term — is not illegal in Pakistan and this year 2.2m abortions were performed. This figure was 890,000 in 2002. Women have found their own way out of the burden of pregnancy.

According to the NCMNH, it is being used as a family planning method. This is a shameful reflection on the failure of our family planning programme as is the very high unmet need of 19pc of women who don’t want children but do not have access to contraceptive services.

It is not that funds are unavailable. Missing are the counsellors and providers who are supposed to give informed advice to the MWRAs and brief them about the pros and cons of various contraceptives of their choice and guide them on their use. Shocking is the disclosure in the supplement that only 4.9m women use government services while the majority depend on the private sector. The four provincial budgets collectively set aside Rs14.6bn for population welfare. One wonders how this money is being spent. This much is certain that all sectors of human development — mainly, women empowerment, health, education, employment and family planning — work holistically and in tandem.

Family planning is the weakest link in the chain of development. With millions of babies being added to the population every year the government is finding it difficult to build new schools, healthcare facilities and income generation projects to match the growing need while meeting the backlog.

Published in Dawn, November 19th, 2021


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