It was after her sixth pregnancy that Lubna Shaukat, 41, finally got herself sterilised. “I was feeding my first child, born within the first year of our marriage when I became pregnant again. I was only 19 years of age then, with two boys, eleven months apart.”

After her fourth child was born she decided to undergo a medically safe permanent contraceptive procedure. In the meantime she had terminated two of her unplanned pregnancies. “I knew the risks of abortion but twice I had to seek a dai’s help as no public health facility would entertain me,” adds Shaukat.

Naseem Jehan, 45, a domestic servant had three abortions within a period of four years after which she got herself sterilised at a family planning (FP) hospital in the G-10 sector of the capital city.

Married for twenty seven years, Jehan lives in a kachi abadi in the outskirts of Islamabad, with her husband, their five children and her mother-in-law. Although Jehan and Shaukat belong to different social and economic strata, their problems are more or less similar.

According to the Pakistan Demographic and Health Survey (PDHS 2006-7), women have about four children on the average although they want only three, or less. Among modern methods for FP, sterilisation (eight per cent) is most popular, followed by male contraception (seven percent).

The average number of births per woman currently stands at 4.1. As of 2007, Pakistan’s maternal mortality ratio (MMR) is estimated to be 276 per 100,000 live births, although the figures are known to be higher in remote, rural areas.

Globally the highest numbers of maternal deaths take place in South Asia at an astounding 35 per cent. According to UNICEF, State of the World’s Children 2009 (SoWC), one in every 89 Pakistani women dies of childbirth related causes compared to one in 8000 in the developed world.

According to UNFPA, one in three of all deaths related to pregnancy and childbirth can be avoided if women who wanted effective contraception had access to it. FP for optimal birth spacing is no doubt one of the most effective and cheapest interventions available to improve maternal, newborn and child health.

“For a long time, FP has been considered and propagated only for stopping births and not planning the family which requires both partners to communicate, plan and be responsible for the health of mother and child. Men were never made to realise their responsibility as husbands and fathers. Even protection for men was sold and distributed to women by women,’ says Rehana Rashdi of PAVHNA, a civil society organisation working for maternal health.

“A significant factor in women not using contraception or spacing birth is lack of awareness and several fallacies attached to the available contraceptive methods. They ignore their reproductive health and well-being, and end up having unplanned pregnancies. It isn’t until women have had three or more children that they really begin to think about contraception. After having five or more children, women opt for sterilisation,” adds Rashdi.

“Lack of awareness and myths that modern methods could be harmful to their health, religious misconceptions and non-availability of services in the areas where these are most needed contribute to the failure of our FP programmes”, says Attiya Qazi, a communications expert with Unicef Pakistan.

According to Qazi, the issue of FP has always been promoted as an economic rather than a health issue. She believes that the active involvement of religious leaders in these campaigns is a positive step and is expected to have an impact on male members of the society. Not just that, it will also  rectify religious misconceptions.

Girls who give birth before the age of 15 are five times more likely to die during childbirth than women in their twenties (Unicef 2009). Girls in their teens face the highest risk of premature delivery, a major factor in newborn deaths. As their bodies are not fully matured, they are also at risk of obstructive labour, which often results in infant death.

Dr Shazra Abbas, a gynaecologist formally working at the Pakistan Institute of Medical Sciences, (PIMS) Islamabad, says that in order to address the issue effectively, it is important to understand the context in which early childbearing occurs. Women who give birth as adolescents are generally  poor and early childbearing can create further economic and social disadvantages.

Sixty plus years down the road, the numbers tell a dismal story with the contraceptive prevalence rate (CPR) being 30 per cent with only 22 per cent use of modern FP methods. “The unmet need for FP has risen from 28 per cent (in 1991) to 37 per cent (in 2007) while unwanted fertility has risen from 0.7 (in 1991) to 1.1 (in 2007)”, says Dr Zeba Sathar, Pakistan Country Director Population Council.

Explaining the disconnect between the demand and supply of FP services, Dr Sathar says, “About 52 per cent women want no more children, while more than 20 per cent of women in Pakistan want to space  pregnancies but unavailability of health care services for a large number of married couples seems to be a major hurdle, while only 30 per cent practice FP. Almost two-fifth of pregnancies are unwanted with an abortion rate of 30 per 1000 women.”

“It’s too late in the day. We are short of contraceptive commodity support and ensuring its availability, distribution and coverage to the poor and inaccessible by the public sector through health outlets needs to be on top priority,” she adds.