Pakistan is the fifth most populous country in the world and has the highest fertility rate after Nigeria in the top 10 most populous countries of the world. The steady rise in its population over the last few years shows no sign of decline or even slowing down. With these facts and figures in mind, one wonders why there is an insistence upon having children in a country where resources are scarce and poverty levels are high.

Government initiatives on encouraging family planning have been operational for years, but have often been met with suspicion and religious opposition.

“Women want to use birth control and often times will come to us secretly to opt for an IUD [intrauterine device] or a contraceptive injection, without their husbands’ knowledge,” says Sarin Ishaque, who worked at a private company providing family planning services and has seen issues upfront with family planning.

“But in a lot of cases, women were beaten and abused by their husbands and in-laws for getting an IUD [when they found out],” says Ishaque. “So they returned asking for its removal. In some horrible instances, their husbands even tried to forcefully remove their IUDs themselves.”

Despite decades of family planning programmes, Pakistan’s population is exploding. Why are our programmes not effective? Is it because they focus primarily on women?

The fact that women sought out help at a family planning clinic shows their reluctance to go through with unplanned pregnancies. Unfortunately, many of these same women are forced to carry such pregnancies to term. Some of the factors contributing to unplanned pregnancies stem from a husband’s reluctance to use protection and his casual attitude towards it.

“Husbands are reluctant to use safety and precautions,” says Dr Rubina Izhar, an obstetrician-gynaecologist at Abbasi Shaheed Hospital in Karachi. She usually prescribes women-centric contraceptive methods since she believes husbands cannot be entrusted with the responsibility of curbing unplanned pregnancies.

It can be argued that men’s cavalier attitudes towards contraceptives are because they do not have to personally bear the burden of a pregnancy. If unprotected sex leads to their wife becoming pregnant, the burden of responsibility falls mostly on the woman. While the wife experiences major physical and mental challenges during and after pregnancy, men often only provide for the child financially. Even that duty is alleviated at times if the wife is also earning, or can ask her parents or in-laws for financial help.

If the finances are too much of an issue, men sometimes make their wives opt for abortions. “The majority of women who come to us for an abortion are unaware of other preventive methods for pregnancies,” says Dr Izhar. “Even though Plan-B pills are available at subsidised rates, these women usually have no clue about them.”

Abortions, especially in a country like Pakistan, come with a lot of psychological pain for women, in addition to the physical pain that they may experience. Unfortunately, women sometimes end up in this position because of their partner’s refusal to use contraception. “Over the years, I have noticed that most [women] patients seldom decide their own pregnancy,” says Dr Izhar. “It is usually the husband or the elders in their family making the decision for her.”

It often all boils down to control. Impregnating a woman allows men to control her and ties her to them beyond marital contracts.

“I conceived soon after my marriage,” says Hina Khurshid, a high court advocate. “When our daughter was only three months old, my husband insisted on having another child. I was not ready for a pregnancy and told my husband that. But I still became pregnant because my husband was secretly damaging the protection he used.”

Khurshid struggled with her second pregnancy, and gave birth to her son alone in a hospital after life-threatening labour. Since the father had little interest in the child or the mother’s life, he did not even bother showing up for the birth. Khurshid is now divorced and raising her children as a single mother.

Apart from the major hurdles family planning professionals face from religious factions, the sheer negligence husbands play when it comes to their wife’s reproductive health should be cause for serious concern.

The fact that so many women are made to seek abortions by their husbands shows that reluctance to use protection is not merely for religious reasons.

“When both the husband and wife were counselled about preventive methods which involve placing devices within the uterus after delivery, they would often opt for it, since the method is completely internal and places no responsibility on the husband,” shares Dr Izhar.

Zainab Ali works as a project manager at a private company in Karachi. Since the first week of her marriage, her husband and mother-in-law started badgering her about getting pregnant. A month and a half later, Zainab was expecting her first child.

Upon hearing the news, her husband was more than thrilled with the idea of her pregnancy being proof of his ‘manhood’ rather than finding any joy in impending fatherhood or hitting a milestone together as a couple.

Zainab ended up divorcing her husband, since he and his family were unwilling to pay for her and her child’s expenses. He has never met his daughter and shown no interest in doing so either.

Dr Izhar has seen dozens of cases of women abandoned at hospital entrances, bleeding to death because of complications in their pregnancy. “With the rare chances that these women survive, they still refuse to use contraception, lest they upset their husbands,” she says.

Male-centric contraceptive methods are often ignored by men as they are viewed as an unnecessary hassle. And it makes sense — the consequences of not using contraception are much higher for a woman. After all, in a Pakistani marriage, the cost of not using contraception is always paid by the wife.

But this does not have to be the case. Studies in North African countries demonstrated that when family planning initiatives involved both partners, rather than just the woman, the success rate was much higher.

While studies conducted in India showed a similar trend, when men were the main focus of reproductive health education, family sizes were smaller and the usage of protection much higher.

This ties into what Dr Izhar has seen in her practice too. When the husband is involved and educated, there is more hope for successful results. If doctors and family planning professionals focus more on educating husbands, perhaps we would make more progress in curtailing a rampant growth rate. And maybe for the future, that is what we need.

Rameeza Ahmad writes on feminism, mental health and K-Pop.

She tweets @rameezay

Published in Dawn, EOS, April 3rd, 2022