Fifteen-year-old Nasreen Qutubuddin beams happily at her mother, Haseena Bibi, and says: "Now that she is well all I want is to get some good uninterrupted sleep."

Belonging to Alipur village in Muzaffargarh, they made a 24-hour bus journey to reach Koohi Goth Women’s Hospital in Karachi to get the mother treated for a serious child-birth injury she suffered and which left her incontinent.

Termed obstetric fistula, in the world of medicine, it is caused by long and stressful labour. In its fight to come out and unable to, the baby’s head puts undue pressure on the lining of the woman’s birth canal causing the wall of the rectum or bladder to tear resulting in urinary or fecal incontinence.

Nasreen says she had not slept fitfully in the last three years after her mother developed this condition while giving birth to her eighth child, who did not survive.

Being the eldest and a daughter, she'd have to get up every two hours in the night to change and wash her mother's clothes, she explained.

But not anymore as Bibi is dry now. She is as happy as Nasreen but for a different reason. "As soon as I am up and about, I will get her married off. We had to delay it for too long because she was taking care of me, the house and her siblings," she explains.

According to United Nations Population Fund (UNFPA), obstructed labour, that Bibi suffered from, is especially common among young, physically immature women giving birth for the first time. Her own injury should make Haseena wary of marrying off her daughter, but Haseena says: "The custom is that a girl must be married off as soon as she gets her period."

Fortunately for Nasreen, once married, she does not plan to have as many kids. "I think I will have three or four," she said shyly.

However, she does not know how and from the looks of it neither does her mother. In public healthcare parlance, this is called unmet need. "It means either the couple does not want anymore children or wants to space the pregnancy but don't know how," explains Dr Farid Midhet, a demographer heading Jhpiego, which is an international, non-profit health organisation affiliated with The Johns Hopkins University.

In Pakistan, six million married women say they don't want more children or want to space births, but are unable to do so," says Dr Zeba Sathar, country director of the Population Council of Pakistan. This comes to one in four women with an unmet need. And like Nasreen, most married Pakistani women (and men) want not more than four children on an average.

Pakistani women have about one child more than their wanted number. — Photo by author

While, on one hand, there is a high unmet need (24 per cent), on the other, the contraceptive prevalence rate (CPR) or the percentage of couples using both traditional and modern contraception methods is very low at just 35pc.

Between 2006 and 2013, there was no increase in the use of the modern Female Planning (FP) method, with the exception of tubaligation (female sterlisation).

Pakistani women have about one child more than their wanted number. This implies that the total fertility rate of 3.8 children per woman is 31pc higher than it would be if all unwanted births were avoided. (PDHS 2013)

This is quite a paradox. So women want to have fewer or no children but are not doing anything about it.

But experts say there are many reasons for that: from being completely unaware of all the modern methods of family planning that exist to not having all the options available to chose from; at times women don't know where to go to get contraceptives from or the health centres are not functional.

Safety and reliability of the various methods is also a big question mark. If they use the pill, they don't have the discipline it requires. There is no proper counseling to prepare women in advance for the minor discomfort they may face at the start of a hormone-based method and how to deal with it. As a consequence, women often stop using the pill after experiencing the first sign of discomfort, instead of switching to another.

"Unless these issues are addressed in parallel with the availability of the product and which can only be done through media as well as by trained health practitioners and FP counsellors, we cannot hope to make a difference," says Midhet.

With just 35pc of couples using any method of contraception in Pakistan, it is the lowest in the region (except for Afghanistan).

Midhet blames the country's burgeoning population which is weighing down its socio-economic development. "The population is enormous," he says and if unchecked, by 2030, the population will be 245 million.

"It's a nightmare traversing main arteries in Karachi now; imagine what it will be like 15 years from now when Sindh's urban population will reach 50pc!" he exclaims.

Pakistan's population is growing by around 1.8pc a year but the economy has failed to keep pace with the population growth. At this pace and if the population growth does not slow down, it will outpace Indonesia by 2030 as the country with the largest Muslim population.

Midhet blames the country's burgeoning population which is weighing down its socio-economic development. — Photo by author

Earlier this month, State Minister for National Health Services, Regulations and Coordination, Saira Afzal Tarar, addressing the media ahead of a population conference, said the issue should be declared a "national priority" with an "emergency" plan not unlike polio.

Take a look: ‘Population growth problem as critical as polio’

She blamed the past governments' "wavering of political commitment and unsustained support" as reasons for Pakistan failure in making the demographic transition or improving its women's reproductive health indicators.

"Rapid population growth was an emergency twenty years ago; now the country should be in the disaster management mode, and doing something on a war footing," says Midhet who smells the same lack of "political will" in the present government towards arresting population that Tarar had blamed previous governments for after attending the National Population Summit in Islamabad on Nov 5 and 6.

"Nothing tangible was said and the lack of political commitment could be clearly understood from the fact that neither the prime minister nor any provincial chief ministers showed up.

Midhet further says the provincial political representation was conspicuous by its absence with many important ministers missing.

"The few who did come including senior bureaucrats, brought nothing spectacular to the conference and their level of engagement was low."

"Let's see if they walk the talk," says Dr Yasmeen Qazi, senior technical advisor to the Bill & Melinda Gates Foundation, hoping the political posturing was not merely to please the global community.

But in Midhet's opinion, any consolidated effort towards population control now would probably minimise, but not completely avert the "imminent major disaster that is looming upon" the country.

For that he blamed the stagnating FP programme for the sorry state Pakistan finds itself in today.

So where did we go wrong and when?

Looking at Pakistan's woeful population graph through a medley of failed FP programmes, Dr Inayat Thaver, a health and population advisor at Mustashaar — a group of experts specialising in health and population issues — says the population welfare programme that started way back in the 60s initially as population "control" and then changed to population "welfare" never quite received the attention it needed.

"The situation got worse after it got scandalised in General Ayub Khan’s time when he introduced the 'paki pakai roti'. It was looked upon with suspicion as an effort by the west to limit the Muslim Ummah," recalls Thaver.

"Subsequently, no political leader championed this cause, except Benazir Bhutto who introduced the Family Planning and Primary Healthcare Workers (the Lady Health Workers LHWs)," he points out. But over the years, these LHWs' workload has increased resulting in decreased focus on FP activities, he laments.

Never the twain shall meet

Another reason for the failure, say experts, is that population was always kept in a separate silo from health. As a result, all population programmes suffered from being rudderless.

"As far as I know, Pakistan is the only country where population and health departments are working separately," says Thaver.

But to be fair, lots of effort was made over the years to integrate the two departments — health and population welfare — but these proved futile because each wanted to maintain the territorial integrity of its department and staff. "Politics plays a major role in it," he adds, but does not elaborate.

He says the situation had worsened after devolution. "Some of the provinces are not interested in limiting their population size because one of the parameters of the National Finance Commission Award or the NFC Award (a programme to alleviate horizontal fiscal imbalances of the four provinces) was the population."

Regrettably, during all its failures, the government did not even prop up the private service providers/organisations, especially social marketing organisations and NGOS, that had stepped in to fill the gap, says Thaver.

Is the 'Do Bachhey He Achey' slogan still relevant?

Minister Tarrar recently also lamented about how a legislation limiting the number of children per family, or linking the number to family income, could not be drafted because it was not in accordance with Islam and her nostalgic musings about the 'do bachey he achey' slogan and how it had made an impact.

She may wish to revive the two-child family, but clearly the message of having a two-children family did not work then and will not work in today's Pakistan with such dismal education indicators.

"The slogan would have worked if our middle class had grown the way it did in India," pointed out Midhet acknowledging there was appeal for it among the literate middle class only.

As for the legislation, he quips: "We don’t need legislation. All they [government] need to do is improve the counselling, supplies and governance and the CPR will jump to at least 50pc almost overnight." He adds discontentedly that this [both provincial and central governments] were by far the "most lethargic ever" when it came to FP.

Taking a more rights-based approach, Qazi says: "We cannot prompt the number of children," adding that it should be left to the couple to make the decision. However, she adds: "My choice for the slogan would be: 'Let every child be a wanted child'."

According to Thaver, there should be clear emphasis that FP is not about stopping pregnancy, but about having space in the family in order to have a healthy mother and baby.

Demographic dividend

It may be unwieldy and unstoppable, but the country's population today has the highest number of young people — about 60pc of population is aged below 24 years. At the same time, life expectancy at birth has increased from 63.4 years in 1981 to 66.5 years in 2013 for females and from 62.4 years in 1981 to 64.6 years in 2013, for males. This means there would mean be more dependents (not earning) in each family in the times to come.

This also means a huge generation of young people is now entering the workforce. If there are no jobs and services for them, the demographic dividend can turn into a disaster.

And for this, say demographers, to turn the country's economy, one critical paradigm shift to be made is to improve the status of women and girls.

Demographers say to turn the country's economy, one critical paradigm shift to be made is to improve the status of women and girls. — Photo by author

"Young illiterate women, especially those married early, have little or no economic contribution, are oppressed and not capable of being good mothers," says Midhet adding: "Unless a society invests in education, it would remain primitive and even a fertility decline with a shrinking of younger age group would be largely useless or even counter-productive."

Strife, crime and conflict

A crowded Pakistan will be a burden on its limited resources. "While I don't see outbreak of a civil war or high intensity conflict, I do foresee increase in riots, protests, organised crime and armed conflict unless the large swath of our youth who have already missed out on education are provided with skills and employment opportunities," said Midhet.

But haven't we reached the tipping point? Is it possible to turn our youth into an asset or have we missed the bus?

"It is still possible, we have few years before opportunity is lost," says Qazi.

The demographic dividend first became available in the 1990s. The window of opportunity will close around 2045, by which time the society will be ageing rapidly. During this period, investment in the next generation will have a huge impact on Pakistan's long-term prospects.

Midhet was not sure if Pakistan has till 2045. "The impact of population overgrowth is already here; after 2030, even damage control would be difficult if not impossible," he says.

Growing urbanisation

At the same time, it is important to examine the link between youth bulge and urbanisation as it will pose a demographic challenge by putting pressure on limited resources.

Going by a 2011 urban development report by the Planning Commission of Pakistan, by 2030, an estimated 45.6pc of Pakistan’s population will be living in urban areas and around 12 major cities will house more than one million people each.

Noted architect and urban development expert, Arif Hasan says the population residing in squatter settlements has now increased to 61pc or 1.2 million households. Energy use could quadruple; water will be an increasingly scarce resource.

"The kind of violence that you see today in Karachi, is just a trailer of what is to come in the not so far future," warned Midhet.

Solutions anyone?

If she were asked to put things right, the first thing Qazi would like is to "bring health and population to work in tandem and make it mandatory for every provider to give FP services, streamline contraceptive supply chain, improve quality of services and work closely with other development agendas like education, women development, youth to work on population issues".

Thaver says he would want more emphasis on FP in the pre-service training of the doctors and nurses and the tertiary care hospitals. "They are not usually advocating or even offering FP services," he says.

Since the target is youth, Thaver says using social media, mobile phone technologies, free online help services would prove beneficial. Keeping social and cultural sensitivity in mind, age-appropriate discussions on the issue of ‘population explosion’ and its consequences can also be made part of the school educational curriculum.