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The population challenge

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Rising population poses a serious threat to Pakistan’s progress. Here are a few suggestions by experts to stem the crisis

The population challenge
 The biggest issues facing Pakistan are the booming population growth and the lack of awareness across the board regarding how big a threat this poses to the country’s progress. Simply put, the country has too many people and not matching resources in the spheres of food, health, education, and employment systems. Conferences are held and experts join their heads in exasperation to think of policies and projects that can manage this unbridled growth. Yet, the most basic of problems is often overlooked — raising awareness.

If enough efforts are not made to slow down Pakistan’s population growth rate, the population will likely increase from the current 189 million people to 310 million by 2050 (UN DESA, 2015). But this is a conservative estimate. According to President Population Association of Pakistan and Chairman Punjab Higher Education Commission Dr Nizamuddin, the country’s population would cross the 395 million mark by 2047. He said this at the recently held Eighteenth Annual Population Research Conference, Population Growth and Investing in Human Resource Development, in collaboration with Government College University Lahore. With just three years left to achieve its FP 2020 targets, Pakistan’s high growth rate of 2.4 per cent depicted in Population Census of 2017 asks for serious efforts.

Speakers at the conference gave different and relevant solutions to how the challenge can be met. Dr Aziz Rab of Greenstar Marketing emphasised on a number of ideas, all aimed at raising general awareness among people regarding family planning, like a toll free number where people can get guidance regarding FP, as well as free air time for the purpose. However, all of this would need political will and support from the government.

If enough efforts are not made to slow down Pakistan’s population growth rate, the population will likely increase from the current 189 million people to 310 million by 2050 (UN DESA, 2015). But this is a conservative estimate.

Dr Attiya Inayatullah, Chairperson Rahnuma Group of Pakistan, pressed upon the need for public-private partnerships to achieve the desired targets. She expressed the need to bring the private sector on board in all FP efforts, as well as leveraging men to become allies in this endeavour. Stalwarts of the field like Dr Mehtab S. Karim, Executive Director, Centre for Studies in Population & Health, Dr. Zeba A. Sathar, Country Director, Population Council, and Dr. Farid Midhet, Vice President, Population Association of Pakistan & Country Director, Jhpiego Pakistan, participated in the conference.

A panel discussion on Pakistan’s 6th population census results, organised by Jhpiego and the Population Association of Pakistan, had experts debating the methodology of the population census 2017. Journalist Zofeen Ebrahim who was invited as a panelist at the session, said that now that Pakistan has a fair idea of the numbers “we need to focus on planning for the people in earnest instead of quibbling over the methodology of the census”.

As Dr Inayatullah pointed out, Pakistan has the know-how and can achieve the targets. What it needs right now is a reality check, she said. “There are two gaps: Implementation is key for which we must get down to the grass roots. And secondly, where do we find a political leader who will speak out boldly in an upfront manner about this?”

A possible solution

While moots like the aforementioned conference give the much needed impetus to the issue at the top of the pyramid, doctors working at grassroots level like obstetrician Dr Halima Yasmeen at the Jinnah Postgraduate Medical Centre (JPMC) Karachi, feel that growth rate cannot be slowed down till awareness is raised. For this, dedicated counselors who can talk to women and convince them to use contraceptives can play a core role.

“It is an evidence-based fact that introducing a cadre of FP counselors shows better results when it comes to use of contraceptives. These counselors should be there at hospitals 24/7, just like nursing and janitorial staff is there round the clock. And their job should be only to talk to people,” she said, emphasising the importance of convincing people to use contraceptives.

“Our doctors are fulfilling their own dreams, and are on autopilot mode. What they are not doing is fulfilling the needs of this country as a whole,” said Dr Azra Ahsan, gynaecologist and consultant at the National Committee for Maternal and Neonatal Health (NCMNH). Dr Ahsan, while talking to The News on Sunday, expressed that the key to solving this problem lies in sensitising healthcare practitioners. “Every healthcare provider should know about providing family planning (FP) services. But they are not taught how to do it properly even in medical colleges. They don’t even know how to manage post-partum hemorrhage, because there is no glamour in this kind of healthcare service,” she says.

With mobility restrictions and traditional barriers, women don’t readily come to hospitals and clinics. However, the rates of women opting for deliveries in hospitals or healthcare units has gone up considerably, and this allows a great opportunity to convince them for post-partum contraception. “Most women do not come back for follow ups, which means that they will not get contraception-related advice in time,” says Dr Ahsan, commenting on golden opportunities that keep slipping through the net.

A project of NCMNH involved stationing two to three dedicated FP counselors in selected hospitals in Karachi, and this strategic placement multiplied the number of women opting for contraceptives like Intra-Uterine Devices (IUDs). “The day the counselors didn’t come, we saw that no women opted for contraceptives,” says Dr Ahsan.

Women in rural Pakistan champion the cause of population planning

By Farahnaz Zahidi Published: July 11, 2015

Benazir With the government lagging behind, women in villages of Pakistan are working for population planning. PHOTO COURTESY: SHIRKATGAH

KARACHI: Her father earns a meager Rs4000 a month as a gate keeper in the village school. Yet, this 18-year-old girl, whose biggest dream in life is to have her own computer, choses to do social work free of charge. “Anything that will help my people,” she says. She visits every home in the tiny village of Allan Chandio in district Shaheed Benazirabad, Sindh, convincing them to practice family planning (FP) and allowing their daughters to study so that they can make informed decisions about their lives. “I even visit my uncles,” says Benazir Chandio with a broad smile. She does this in a culture where issues like contraception are brushed under the carpet. “They say you are too young to be teaching us. I reply that if God has given me more awareness than you, then I have every reason to teach you.” Benazir, who has been given a well-deserved place in Shirkatgah’s “Building Momentum – Strengthening Champions” initiative, convinced two families to delay the weddings of their very young daughters. “Postponing those weddings for two years gave those girls some time to get ready for marriage and motherhood,” she says, and shares with pride that one of those girls recently gave birth to a baby girl at the right time. For women in her village, having anywhere between eight to 12 children is a norm. But she feels that with counseling, villagers are getting convinced to plan their families. Standing at number six among the world’s most populous nations, Pakistan needs more such girls. In absence of satisfactory performance from the government, the onus to cause a change has fallen on the civil society. Read: Addressing the baby boom: Women’s reproductive health an urgent issue Experts like Country Director Population Council Zeba Sathar express dissatisfaction over Pakistan’s success in FP. “Pakistan’s performance in lowering its fertility is indeed dismal; while we had some success in the 90s, the last 15 years have been a virtual standstill,” says Sathar. According to the Pakistan Economic Survey 2014-15, Pakistan’s estimated population is over 191.71 million. While there seems a definite decline in Pakistan’s population growth rate (1.49 per cent in 2014, according to CIA’s World Fact Book), there is much to be done. At the 2012 London Summit on Family Planning, Pakistan had committed to increase the contraceptive prevalence rate to 55 per cent by 2020. Five years short of 2020, the world looks on to see if the commitment will be honoured. “Pakistan’s pledge at the London Summit is an opportunity, perhaps the last, to actually ratchet up efforts, drum up the political will and redesign the programs to accelerate family planning in Pakistan,” says Sathar. Dr Azra Ahsan, technical consultant to the National committee for Maternal and Neonatal Health (NCMNH), says that health care providers need to be convinced first. “When they are not on board, how can we convince patients? What our medical students are taught is not relevant to ground realities. We know more about endoscopic and robotic surgeries, but our medical graduates don’t know about maternal health or public health policies.” Ahsan adds that every health care provider should be trained to guide patients in FP. “Why is it just the gynecologist’s job? Between being referred from one specialist to another, patients slip away,” says Ahsan, and suggests that The World Health Organization’s (WHO) medical eligibility criteria (MEC) wheel should be on every doctor’s table. “It is such a simple guide advising which contraceptive is advisable for whom.” Dr Farid Midhet, demographer and Country director Jhpiego, feels that one factor could be the general instability on many fronts in the country. “We are struggling with the same issues since the last two decades.” One thing that could work, according to Midhet, is integrating population planning into the public health system. Talking about unmet needs of contraceptives, he says that the use of traditional methods of contraception have gone up by ten per cent, citing the latest PDHS results. However, traditional methods in his opinion are not reliable enough. “A Population Council Pakistan research on Barriers to Contraceptive Use, 2013, shows that contrary to popular belief, neither religion nor male dominance are the main reasons for unmet need. Supply is the main factor here,” he says, adding that if supply is steady and is accompanied by counseling, use of contraceptives in Pakistan can go up by 50 per cent safely. Sharing research showing the gap between what women want and the four million unwanted and mistimed pregnancies that are happening annually, Sathar says, “Two million of these end up in abortions, which could be avoided by better family planning programs.” The aforementioned Population Council study confirms what most experts say – that Punjab is way ahead other provinces in terms of reaching developmental goals, including FP. “Punjab is the only province that may abide by its commitments in this regard. It is initiating the post-partum contraception program, which will be putting to use new technology,” says Midhet, adding that in comparison, Sindh faces more serious issues like lack of implementation of policies, corruption and shoddy governance. Read: One death too many: One death in childbirth every 37 minutes “The provinces are ready to play their role and have set ambitious goals for 2020,” says Sathar, expressing hope that the provincial governments now realize that they must set family planning as a priority. “While there are improvements in the budget lines for contraceptives (previously supplied by donors), funds and priority still lag behind.” Conflict and insecurity has affected more than just health initiatives, with mental illnesses on the rise in Pakistan, especially in women, says Dr Rukhsana Ansari from Indus Hospital, Karachi. “It has a close link with inflation and poverty. Too many children exacerbate women’s problems,” she says, adding that mothers from underprivileged backgrounds suffer from nutritional deficiencies, muscular and skeletal diseases and sleep deprivation. In turn, the children they give birth to are also malnourished. Mothers feel frustrated when they cannot go back to work because of their small children dependent on them, in situations where earning could alleviate their miseries. “If at all women chose to use contraception, the decision is not theirs. It is either the husband or the mother-in-law who decides.” Mehnaz 1 If the Lady Health Worker (LHW) program is re-focused on FP, it could yield results. Mehnaz is one such promising LHW. She has succeeded in convincing most households in the village of Kahazana Dheri, District Mardan, in Khyber-Pakhtunkhwa, to use contraceptives. “I can safely say that now at least half of the couples in our village are using contraception,” says the 36-years-old woman, another one of the Shirkatgah Champions. Yet, the obstacles are many. “Our area was devastated by the 2010 floods. Additionally, incidences of terrorism affect everything – when roads and bridges are blown off in bomb attacks, how will contraceptives reach small health facilities? People lose jobs in conflict areas. For an unemployed man, feeding his family becomes priority instead of buying contraceptives.” Published in The Express Tribune, July 11th, 2015. http://tribune.com.pk/story/918815/women-in-rural-pakistan-champion-the-cause-of-population-planning/

Taking Family Planning Religiously

Taking family planning religiously
While the voice from the pulpit carries a lot of weight, they will need to be convinced, informed and educated before their help is sought
By Farahnaz Zahidi Moazzam

“What do you think Islam says about Family Planning (FP)?”, I asked an urban, educated friend. Her response was as expected. “Isn’t FP a complete no-no in Islam?” she replied, a mother of two, whose two children have a carefully planned age difference of four years and who has been using an Intra-Uterine Device (IUD) for a long time as a method of contraception. A staunch Muslim, she believes FP is not allowed in Islam, yet is practicing it for years, and has not bothered to delve into the subject, avoiding tricky subjects.

As we approach the World Population Day on the 11th of July, the topic of understanding FP via religious rulings remains taboo. A fatalistic approach and a misfounded assumption that Islam is categorically against FP remains a key reason why Pakistan is sitting on a ticking time bomb of a population explosion. It also remains an under-discussed area in both print and electronic media.

“Today Pakistani population is five times as large as it was in 1950 and about 4 million people are added to it every year,” said Dr John Bongaarts of the Population Council, New York, at a recent seminar arranged by the Population Council in Pakistan. “By 2050, the population in the country is expected to reach 300 million.” If it hits that number, Pakistan would become the fourth largest country in the world. It has already replaced Brazil as the world’s fifth largest nation.

Generally, world over, a reduction in fertility rates and population growth has been seen, but Pakistan’s has increased. Pakistan’s total fertility rate (TFR: the number of live births the average woman has in her lifetime) is reported by the UN to be 3.2, the highest of any of the populous countries.

Pakistan Demographic and Health Survey 2007 (PDHS) reveals that only 24 percent of married women of rural Pakistan use contraception. Could religion have something to do with it?

This July, world leaders gather in London for a Family Planning Summit, co-hosted by the Bill and Melinda Gates Foundation and the U.K. Department for International Development, supported by the U.S. Agency for International Development and the U.N. Fund for Population Action. Will the role of religious and cultural sensibilities be discussed there, one wonders.

In strongly faith-oriented societies such as Pakistan, unless something is endorsed by the clergy, meeting the development goals may be too far-fetched. As the bigwigs of family planning rack their brains over how to control Pakistan’s population, an important point might be being missed. The implications of an absence of national consensus-building with religious leaders on board may be a key reason. Indonesia, the world’s fourth most populous nation, also THE most populous Muslim country in the world, seems to have discovered this key and unlocked the answers. The result: Indonesia today is known as the “poster child” among countries aiming to slow down their growth rate. This is an incredible achievement, considering that Indonesia is a country with an almost 90 percent Muslim population, accounting for 13 percent of the world’s Muslim population. Studies show that Indonesia’s fertility rate at the 1965 level was averagely 5.6 children per woman. By incorporating a community-based family planning and reproductive health program, Indonesia has been able to slow down the TFR to an exemplary 2.6. How has Indonesia managed this?

The answer could lie in the fact BkkbN, Indonesia’s population and family planning board, employed the ingenious method of approaching the leaders of the two largest Muslim welfare groups in Indonesia: Muhammadiyah and the Nahdlatul Ulama, who have millions of followers. Both are traditionalist Islamic groups, yet with the government have achieved a consensus that they will work hand-in-hand for the welfare of the country. In line with true Islamic teachings, they work towards spiritual, emotional, physical and material well-being of their people. Taking health and education into their loop, it was but logical that reproductive health and FP are included in their program.

Dr. Atikah Zaki, the health and social coordinator of Asyiyah, the women’s branch of Muhammadiyah, adorns a hijaab. She is a practicing Muslim woman, unapologetic about her faith and evangelism. Simultaneously, she is also unapologetic about the fact that her organization promotes family well-being and family planning. Asyiyah promotes family planning through a network of 86 hospitals, hundreds of clinics, 87 universities and over 4,000 schools. Their local leaders counsel people about reproductive health issues, mediate disputes between couples and even address sensitive subjects like domestic violence. “We are just obeying the Prophet Mohammed,” said Zaki with a smile, explaining the concept of FP in Islam, quoting from the Quran and ahadith of the Prophet Muhammad (pbuh) at the recent Women’s Edition Seminar for female journalists, held at Jakarta.

Islam, and other religions for that matter, are not against contraception in totality. If the Quranic injunction on breastfeeding the child for two years is adhered to, it would automatically result in “lactational amenorrhea” which would result in spacing between children.

A major body of Islamic scholars, globally, agrees that in Islam, temporary and reversible methods of contraception are allowed. But contraception practiced with an aim to have a permanently childless marriage would not be permissible. Abortion is not permissible, and especially after a 120 days period has lapsed in the pregnancy, it is categorically forbidden because life is sacred. Temporary contraceptive methods that do not harm the health of the mother, and natural methods like Coitus Interruptus (withdrawal) and the Rhythm method that relies on knowledge of a woman’s ovulation cycle in order to avoid pregnancy, are preferred and allowed.

Relaying public health messages across to the population of Pakistan would become easier if they came through Imams of local mosques. But the religious leadership, human rights’ activists and health experts should work unanimously towards this goal. This requires dialogue and an understanding of each other’s view points.

Talking about the Pakistani society and involving clergy in realisation of the FP goals, journalist Zofeen Ebrahim says, “While the voice from the pulpit carries a lot of weight, they will need to be convinced, informed and educated before their help is sought, otherwise all the work towards it will come to naught. Not much time and we have to make up for the lost time. Therefore, everyone needs to be involved and taken on board.”

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