A misplaced attitude towards family planning is gradually leading to a demographic disaster.

Sayyed Mohammad, 42, was jubilant when the nurse handed him a red-faced mousy looking newborn son — also his eleventh child.

Cultural barriers have been stumbling blocks for healthcare practitioners towards counselling couples of the myriad advantages of wanted but spaced babies. —Photo by author

"It was very, very difficult to counsel him to allow his wife to go home with a postpartum intrauterine device (PPIUCD)," said Shazia Bano Yaqoob, who has recently started working as a family planning (FP) counsellor at Civil Hospital Karachi's (CHK) gynaecological ward. "But we succeeded!" she beamed victoriously. "We made him realise that giving birth to a baby every two years was taking a toll on his wife's health," she added.

"She has blood pressure and I got scared if something happened to her, who will take care of all these children," he told Dawn.com, adding, "Because my wife's life is in danger, it is permissible in Islam then to take family planning measures."

Happy with his brood, he admitted hesitantly he did not want more. "But it is not in my hand; Allah gives and we should be grateful. Imagine the agony of the childless couples," he pointed out.

Also read: Family planning and Islam

Working as a labourer, hauling goods and taking them on his donkey cart, from one place to another, he conceded that finding daily work was getting exceedingly difficult, yet he did not stress too much about feeding 13 mouths.

"It has nothing to do with whether I find work every day or not; we all will get fed, because I am not the provider, it is Allah!", the unlettered labourer said with conviction. None of his children go to school, but a few are learning to read the Holy Quran. The eldest, who is either 20 or 21 (he is not sure of his age), helps him and another one is learning to be a mechanic.

Counselling couples is like 'talking to a wall'

Counselling requires patience, time to understand and prod the couple’s need, address and then shed their concerns, tell them the truth, and give them the confidence they are seeking. — Photo by author

A 'what will be, will be' disposition towards life, no future goal, no planning and an almost impenetrable belief that modern contraception is perilous, even un-Islamic, have been stumbling blocks for healthcare practitioners towards counselling couples of the myriad advantages of wanted but spaced babies.

Yaqoob advises over four dozen women every day in the labour room. There are three more counsellors like her doing similar work at the ward's day clinics and even inside the operation theatre. All confess their job is like talking to a wall.

And it is not that married couples do not know about some of the different family planning products available. In fact, 94 per cent of Pakistani couples have knowledge of at least one method of contraception. But a recent report by Guttmacher Institute states half of the 16.8 million married women in Pakistan who want to stop having more children or postpone having a child for at least two years, are not using a modern contraceptive method.

This is corroborated by the Pakistan Demographic and Health Survey of 2018 which has found the contraceptive use to have been stagnant over the past five years. In fact, from 35% in 2012, it has dropped to 34.2% in 2017. Of the 34 per cent who use a method of family planning, only 25% use a modern method while 9% continue using a traditional method.

Experts are concerned about the commitment Pakistan made of bringing it to up to 50% by 2020 at the 2012 London Summit.

There has been a slight decline in unmet need for family planning, from 20% in 2012-13 to 17% in 2017- 18. However, the use of modern methods and the percentage of women with demand satisfied with modern methods have remained largely unchanged in the last 5 years. —Source: Pakistan Demographic and Health Survey of 2017-2018

Apart from the myths and so-called religious compulsions that act as barriers, many women are unhappy with contraceptives and complain of menstrual irregularity and weight gain.

Dr Azra Ahsan, an obstetrician and gynaecologist (OB-GYN) who has been practising for the past 35 years, blames this lack of use/dropping out early on the poor quality of counselling.

"Counselors need to explain to the women that the former is a side effect which will go away on its own after a few months," she said. She shrugs off the weight gain complaint saying women just need to exercise more and eat less calorie-laden food.

But it's not just counsellors, who are poorly trained. "You will be surprised how little gynaecologists know regarding contraception or their side effects," said Ahsan. "You need to be passionate about your profession. Counselling requires patience, time to understand and prod the couple’s need, address and then shed their concerns, tell them the truth, and give them the confidence they are seeking," she said.

But the fact remains, because of poor counselling, many women who do get the Intrauterine Device or IUD (Rs 200) or an implant (anywhere between Rs 1,200 to Rs 1,500) inserted, return only to ask that it be removed.

"It becomes an exercise in futility," pointed out Dr Ahsan. "These are expensive products and the government is procuring them and providing these women free of charge, but are wasted without a thought."

Unintended pregnancies

No or low use of contraception means women end up getting pregnant. That is when women opt for abortions. "They think nothing of getting abortions," said Yaqoob.

According to the Guttmacher Institute, an estimated 3.8 million unintended pregnancies take place each year in Pakistan. But if all those who did not want more kids were provided with an FP method, the report said there would be 3.1 million fewer unintended pregnancies annually, 2.1 million fewer induced abortions and nearly 1,000 fewer maternal deaths.

Women in ICT Islamabad tend to have fewer children (3.0 births per woman) than those in any other regions. The total fertility rate is highest in Gilgit Baltistan and the erstwhile Fata, with 4.8 births per woman in each region. —Source: Pakistan Demographic and Health Survey of 2017-2018

The most popular modern methods are the male condom and female sterilisation (each used by 9%). The percentage of women using an FP method — in scientific terminology called the contraceptive prevalence rate (CPR) varies with age. From 7% among women aged 15-19 to 48% for women age 40-44, and then slightly declining to 37% among women age 45-49.

Related: 'Women do not use modern methods to avoid unintended pregnancies'

While the common man may be excused for the limited knowledge about FP methods and the cultural biases surrounding them, interestingly, Dr Marium Waqas, working with the National Committee on Maternal and Child Health (NCMNH) blamed the healthcare practitioners for being the bigger barrier in the successful execution of FP programmes in Pakistan.

"The medical fraternity needs to clear the cobwebs in its mind about the myths that haunt it before counselling couples," she said. "It is not convinced with the medical evidence regarding the power of FP," she added.

A 'new step' in the right direction

Naya Qadam, a project of Pathfinder International (PI), is a three years project on increasing post-pregnancy family planning (PPFP) through expanding public and private sector services with a focus on young women (age 15 – 24) in Sindh and Punjab. — Photo courtesy National Committee for Maternal and Neonatal Health (NCMNH)

But the fault also lies with the medical curriculum. "FP is hardly given the importance it deserves and is not emphasised in routine medical courses. All healthcare practitioners, I don't mean just obstetricians and gynaecologists, should be made to feel it their duty to talk about FP to their patients," said Waqas, adding, "they are not internalising the issue."

To combat that, Pathfinder has built a skills lab in the OB-GYN ward at the CHK where they are training postgraduate students about FP. "Knowledge of contraception and FP was dismal among final year students who have carried out five years of MBBS and some are already final year students of specialisation in OB-GYN. With limited knowledge of family planning, what kind of service will they suggest to the patients coming to them?" said Waqas who is heading Pathfinder's Naya Qadam project.

The Naya Qadam project aims at increasing post-pregnancy family planning (PPFP) in public and private facilities in Sindh and Punjab with a focus on young women, between the ages of 15 and 24.

But that is not all. At one level the Naya Qadam team is training postgraduate students about counselling, PPIUCD, post-abortion FP, post-abortion care etc in tertiary hospitals, on the other level, it is training trainers at the district level for a trickle-down affect, looping in lady health visitors and community midwives.

Civil Hospital Karachi has seen a surge in the uptake of contraception in the last three months. — Photo by author

For her part, Dr Sadiah Ahsan Pal has been helping healthcare providers working in the area of sexual and reproductive health by trying to remove those very doubts from the minds of her colleagues now for over 10 years. She carries out workshops across the country called Values Clarifying and Attitude Transformation (VCAT for short) and addresses the root causes of stigma-related barriers to access and quality of FP and abortions. But her work is far from over, she says. "A lot needs to be done at all levels and cadres," she told Dawn.com.

With a brand new skills training lab, FP counsellors in place and enough supplies, the CHK has seen a surge in the uptake of contraception in the last three months.

More on this: No policy exists to reward parents having two or fewer children, PA told

Dr Sumera Mir, sees, on an average, a hundred patients every day. She finds it very difficult to find a counsel a woman about FP. "Just look at the chaos here and look at their condition," she said pointing to one woman already in labour. "Her stress level is so high, it is hardly the time to talk about FP." But she acknowledged: "It is our duty given our country's high maternal mortality rate." But Mir added before scooting away to the next patient: "We are relieved these counsellors are sharing this burden."

What do we do with the ticking population bomb?

A young activist attends the Climate March 2019, in Karachi. Family planning is key to a sustainable future. — Photo by author

Head nurse, Angelina Maqbool, who has been working in the ward since 1994, has seen it all — 24th pregnancy, miscarriages, abortions, complications, just about anything that happens in an OB-GYN ward. And she is not too impressed with Pakistani husbands. "They are incorrigible! We rejoice the day when a husband comes and asks us first about how his wife is doing soon after delivering the baby, instead of how the baby is or the sex of the baby; but those days are very rare here," she says. The point is, says the nurse, the woman's health is inconsequential.

"If it were important, would they not agree to adopt some FP method?" she asks and adds, "For these men, a woman is just a toy, for his pleasure, who cares what she's going through," she retorts angrily.

This lackadaisical attitude towards a woman's well being is also having disastrous consequences — a runway population in a resource stretched country like Pakistan. With a population that has crossed 208 million and growing at a high rate of 2.4%, and at sixth position globally, demographers worry if things remain the same, it will soon become the fifth most populous country of the world.

Editorial: 217m and counting

Currently, Indonesia, the US, India and China have higher populations than Pakistan. Unless concrete steps are taken to halt this trend, the country’s population could exceed 300m by 2050, warns a UN report this year.

Therefore, despite 64% of Pakistan's population under the age of 30 and which could have been a demographic dividend for the country; people's misplaced attitude towards FP, a lack of counselling towards its use coupled with non-availability of the contraception of choice and further aggravated by the bad rap the latter continue to carry, it is turning into a demographic disaster.

Uneducated, unskilled, stunted (four in 10 under-five children are stunted according to the new National Nutrition Survey 2018 while 17.7% suffer from wasting), the next generation will become a huge burden on the state already reeling from climate-induced shocks — food, water and energy shortages along with declining employment opportunities.

The World Bank, terming under-nutrition as world's most "serious but least addressed development challenges", looks at it through the lens of "lost national productivity" and calculates this loss to be anywhere from 2% to 3% of GDP in some countries and up to 11% of GDP in Africa and Asia each year.

Use LARC, plan your family

Doctors have a very short window from the time a woman comes to a healthcare facility to have her baby to introduce and administer IUDs to her because once she leaves, they've lost her until her next pregnancy. — Photo by author

With a population emergency at hand, experts say perhaps the most effective way of stemming the tide of unwanted babies is to provide women with long-acting reversible contraceptives (LARC).

Among LARC — including injections, intrauterine devices (IUDs) and subdermal contraceptive implants (a thin rod the size of a matchstick — inserted under the skin of a woman's upper arm), Dr Azra, like so many others, prefer the IUDs, that too, right after a woman has delivered the baby. "I'm all for it," she said, especially now that 66% are delivering at a health facility and 69% births delivered by a skilled provider.

Related: What is LARC and how can it tackle Pakistan's runaway population problem?

"We have a very short window from the time the woman comes to a healthcare facility to have her baby because once she leaves, we've lost her," she said. Furthermore, the procedure takes not more than 10 minutes, and 10 minutes after the delivery of the placenta up to 48 hours, she said.

Aasia, 25, a domestic help just had her second child at a government hospital in Karachi. "For now, my family is complete; I had a son and just gave birth to a daughter," she said looking very satisfied.

Having some knowledge about FP methods and with her husband in between work, she was concerned about not getting pregnant a third time and not so soon so she asked for a method she could start on. "My baji, who I worked for, had told me to get the challa inserted right after delivery," she said referring to the PPIUCD. But the doctor on duty told her she should wait for six weeks and they would discuss once she returns for her postnatal check-up.

"If I had been the doctor on duty, I'd have been thrilled to get a woman, so eager. Usually, it requires pleading and cajoling the entire family to start the woman on contraception immediately," said Ahsan. The reason for the urgency to start them on some form of contraception is that most women never show up for a checkup and return either with an unplanned and unwanted pregnancy or request for an abortion or with complications from an unsafe abortion.

The advantage of spacing is huge if you ask Dr Rubina Sohail, professor of obstetrics and gynaecology at the Services Institute of Medical Sciences, in Lahore. "When a mother spaces her births it will have a positive influence on her and everyone around her. She will be able to recuperate well after having delivered and not be stressed about getting pregnant soon." In addition, she said, the mother will be able to breastfeed her new baby and give attention to the other older kids as well.

But all her pleas are falling on deaf ears. "Unless politicians talk about FP all the time, and constantly, in every speech that they make, it will not sink in," she said. She also held the media to account for not doing enough. Media, said Sohail, can turn the tide in favour of FP and bring a change in the mindset of the people faster than healthcare professionals.

Explore: Family planning may be our last hope

Furthermore, the political will of the top leadership was of the utmost importance.

"Remember how the chief minister of Punjab tackled dengue some years ago? He would hold an early morning meeting every day and ask for a progress report. A similar strategy adopted by chief ministers demanding progress on FP would keep everyone and all departments on their toes. "You will see the difference in just a few months!" Sohail said.

Zofeen T. Ebrahim is a Karachi based independent journalist. She has written extensively on development issues including climate change, water, energy, renewables, sanitation, health, diseases, gender, child rights and women’s rights. She tweets @Zofeen28.