T.C. REPUBLIC OF TURKEY HACETTEPE UNIVERSITY GRADUATE SCHOOL OF HALTH SCIENCES ANALYSIS OF THE PREVALENCE, TRENDS, DETERMINANTS AND DYNAMICS OF CONTRACEPTIVE USE AND ESTIMATE OF UNMET NEED FOR FAMILY PLANNING IN PAKISTAN (Further Analysis of the Pakistan Demographic and Health Surveys) Dr. Fahad AHMED Program of Epidemiology DOCTOR OF PHILOSOPHY THESIS ANKARA 2018 T.C. REPUBLIC OF TURKEY HACETTEPE UNIVERSITY GRADUATE SCHOOL OF HALTH SCIENCES ANALYSIS OF THE PREVALENCE, TRENDS, DETERMINANTS AND DYNAMICS OF CONTRACEPTIVE USE AND ESTIMATE OF UNMET NEED FOR FAMILY PLANNING IN PAKISTAN (Further Analysis of the Pakistan Demographic and Health Surveys) Dr. Fahad AHMED Program of Epidemiology DOCTOR OF PHILOSOPHY THESIS ADVISOR OF THE THESIS Prof. Dr. Bahar GÜÇİZ DOĞAN ANKARA 2018 vi ACKNOWLEDGEMENT This thesis becomes a reality with the kind support and help of many individuals. I would like to extend my sincere thanks to all of them. Foremost, thanks to the most compassionate the merciful Allah for his kindness. May He be glorified and exalted, because of the great favors and blessings that He has bestowed upon me, the strength peace of my mind and good health to earn doctoral education. I would like to thank the great Republic of Turkey for awarding me this scholarship and giving me this opportunity to receive higher education. To the kind people of Turkey, for their generosity and for welcoming me in their country with open arms. I am appreciative to the government of Islamic Republic of Pakistan for selecting me for foreign studies in Turkey. I thank Hacettepe University for the opportunity to pursue research in an environment which provided first-class facilities and supervisors for the work. It is a great pleasure to acknowledge my deepest thanks and gratitude to Prof. Dr. Bahar GÜÇİZ DOĞAN, for suggesting the topic of the thesis and her kind supervision. It is a great honor to work under her supervision. I would like to express my sincere appreciation to Prof. Dr. Banu ERGÖÇMEN and Prof. Dr. Ayşe AKIN for generous advice, and support during the study. I would like to thank Dr. Tuğba ADALI, and Dr. Pelin ÇAĞATAY of Institute Population studies for the technical guidance for my research study. I would like express my sincere gratitude to Prof. Dr. Şevkat BAHAR, the Director of the institute of Public Health for assigning me a room for study and research. I am grateful to all other professors and faculty members whom I have had the pleasure to work with during the PhD coursework and other projects. Each member of the department of Public Health and Biostatistics has provided me extensive personal and professional guidance. I have encountered many remarkable resident doctors and fellows at the depatrment of Public Health. I also wish to acknowledge all other techincal and supporting staff. My thanks everyone at Hacettepe. I would like to thank my great friend from Pakistan, Prof. Dr. Khalid Mahmood Khawar of the Ankara University, for all the social support he has provided to me. I would like to acknowledge my Turkish friend Mr. Edip KAYA for being there whenever I needed him. I also would like to acknowledge Dr. Mehmet ERDEM and Prof. Dr. Mahmut YARDIM for their time and support in proof reading the Turkish translation. I would like to thank my loving niece, Sara Baggia for her time and responsiveness for proofreading which improved my thesis. I would like to acknowledge Prof. Dr. Pier Luigi Cocco of University de Cagliari, Italy for giving me opportunity and for his support in research on Occupational Cancer during Erasmus programme. Working with Dr. Cocco, I gained unique experience due his clinical and research skills and dealing with others with respect. I would also like to thank resident doctors at department of Public Health in University de Cagliari. http://www.hips.hacettepe.edu.tr/eng/kadro/pcagatay.shtml https://aes.hacettepe.edu.tr/sevkato?dil=TR https://aes.hacettepe.edu.tr/sevkato?dil=TR vii I would like to recognize all of my teachers and professors at Schools, DJ Science College, Hamdard University, Aga Khan University and Dow University. Especial appreciation and gratitude to Prof. Dr. Nighat Nisar, Prof. Dr. Hansotia, Prof. Dr. Yasmin Mumtaz, all other professors and colleagues in Dow University, Community Medicine department for supporting and accommodating in the overlapping period for my completion of fellowship program and start of my PhD program. This period was rather stressful for me and I could have not completed my fellowship without their assistant. I would like to thank my respected friend Dr. Asif Nazir, who encouraged me to pursue PhD degree. I want to express my sincere appreciation to all of my students in Pakistan for supporting me and especially to Dr. Khurram Iqbal who went out of his way to take care of chores during my travels and my short trips home. I am also grateful to Dr. Saba, Dr. Atta, Dr. Fazal, Dr. Sana, Dr. Hira, Mr. Abdul Hafeez, Dr. Faraz, Dr. Talal, Dr. Sidrah Dr. Asad, Dr. Haroon, and Dr. Sheharyar, who have supported me along the way. In Cagliari, Italy I am thankful to Mr. Yousf, Mr. Riaz, Mr Rafeeq Mr. Wasam, Mr. Annu, for their endless support during my stay there. I would like to thank Nadir, Jafer, Serhat, Jamal, Ibsa and Samet for their help, patience and encoragment during my hostel life. Finally, no one has been more important to me in the pursuit of this PhD degree than the members of my family. I would like to thank my parents, Ahmed Ismail and Amina Ahmed, whose love and guidance are with me in whatever, I pursue. They are the ultimate role models. Most importantly, I wish to thank my loving supportive wife, Dr. Zara Mumtaz, my In-laws, Mr and Mrs Mumtaz Khan, my sister, Fariha Baggia and my brother-in-law, Ibrahim Baggia, my niece, Sumaiya. nephew Mahmood and my dearest Abdullah. They encouraged me and kept me going, in my ups and downs. I would like to thanks my paternal as well as maternal uncles and aunts families, and all other well-wishers for their love, care and prayers since my childhood. I would also like to acknowledge Mr.& Mrs. Anwar Ismail family, Mrs. Zulaikha Ahmed, Mr. & Mrs. Yusuf Munee family, Mr. & Mrs. Ishaq Karwa, Mrs. Aisha Hashim, Mr. Uzair, Mrs. Sobia Nasir, Mr. & Mrs. Ismail Mota, Mrs. Nafisa, Mrs. Bilal, Mr. Shamim, Mr. Idress, Mr. Shoaib, for assisting my parents while I was abroad. Thank you' to all who are not mentioned here but who have contributed to my work and to my life in their own unique ways. This thesis is dedicated to all of the respected elders residents of Surti Center (Karachi, Pakistan) and Surti Community. The elders who passed away and the living elders have shown their love, affection, and encouragement. Without their prayers, I could not have achieved this degree. I pray to Allah to give them happy and healthy rest of life and for forgiveness to those who passed away. May Allah grant them Jannah on the day of Judgement, Ameen. viii ABSTRACT AHMED, F. Analysis of the Prevalence, Trends, Determinants and Dynamics of Contraceptive Use and Estimate of Unmet Need for Family Planning in Pakistan. Hacettepe Unıversity, Graduate School of Health Sciences, Epidemiology Program Doctor of Philosophy Thesis, Ankara, 2018. Family Planning is widely recognized as a cost-effective intervention linked to the Sustainable Development Goals. The world 6th most populous yet, lower middle income country Pakistan is at the cusps of demographic dividend. However, the slow fertility decline urged Government of Pakistan to scale up family planning program combined with robust population and developmental polices. That will not only control over population but also provide advantage of demographic dividend. The objective of the study was to examine the trend in contraceptive prevalence and level of unmet need for family planning, and to identify association between individual, spousal, household and community level covariates with the contraceptive use and unmet need for family planning in Pakistan. Together with this, contraceptive discontinuation, switching behavior and user failure rates were also examined. Data was extracted from Pakistan Demographic Health Surveys (1990-91, 2006-07 and 2012-13). Frequency tables were constructed to examine the trends. Logistic regression was employed to explore the relative effects of covariates on use of contraception and unmet need for family planning among currently married aged 15-49 women. Life tables were used for analysis of contraceptive discontinuation, switch and user failure rates. Results shows that current use of contraception increased from 11% in 1990 to 35% in 2012 meanwhile unmet need for family planning declined from 32 % to 20%. Remarkable heterogeneity in contraceptive use as well as unmet need was evident among different regions and different ethnic groups. The mean ideal number of children desired remained at four and intention for future use of contraception was decreased. The husband fertility desire, number and sex of children, exposure to media message, visit by Lady Health worker, place of residence and wealth status were significantly associated with current use and level of unmet need for family planning in Pakistan. It was found that one-third of episodes of contraceptive use were discontinued within a year of initiation. The highest discontinuation rate was for hormonal methods, side effects were the main reason for discontinuation. The 12 month gross failure rate for pill, condom, and withdrawal was 10.3%, 9.3% and 10.4% respectively. Key words: family planning; contraceptive use; unmet need; discontinuation rate; contraceptive failures. ix ÖZET AHMED, F. Pakistan'da Aile Planlaması Yöntem Kullanma Prevalansının Belirleyicileri, Dinamikleri ve Eğilimler ile Karşılanmamış İhtiyacın Değerlendirilmesi, Hacettepe Üniversitesi, Sağlık Bilimleri Enstitüsü, Epidemiyoloji Programı Doktora Tezi, Ankara, 2018. Aile Planlamasının, Sürdürülebilir Kalkınma Hedefleriyle bağlantısı olan maliyet etkili bir müdahale olduğu yaygın bir şekilde kabul görmektedir. Dünyanın altıncı en kalabalık ancak düşük orta gelirli ülkesi Pakistan, büyük bir genç çalışabilir nufusa sahip olmanın getirdiği ekonomik büyüme potansiyeli (demografik fırsat penceresi) açısından bir dönüm noktasındadır. Ancak, doğurganlıktaki yavaş düşüş Pakistan Hükümetini güçlü nüfus ve kalkınma politikaları ile birleştirilen aile planlaması programını genişletmeye zorladı. Bu sayede sadece nüfusun kontrolü değil, aynı zamanda demografik fırsat penceresinin avantajı da sağlanacaktır. Çalışmanın amacı doğum kontrolü kullanım sıklığındaki trendi ve aile planlaması için karşılanmamış gereksinim düzeyini incelemek ve Pakistan'da doğum kontrolü yöntemi kullanımı ve aile planlaması için karşılanmayan ihtiyaç ile bireysel, eş, hane halkı ve toplum düzeyi değişkenleri arasındaki ilişkiyi tanımlamaktır. Bununla birlikte, doğum kontrolünde devamsızlılık, yöntem değiştirme davranışı ve kullanıcı başarısızlık hızları da incelenmiştir. Veriler Pakistan Demografik Sağlık Araştırmaları'ndan alınmıştır (1990-91, 2006-07 ve 2012-13). Eğilimleri incelemek için frekans tabloları oluşturulmuştur. 15-49 yaş grubundaki kadınlar arasında doğum kontrol yöntemlerinin kullanımı ve aile planlaması konusundaki karşılanmamış ihtiyaçların göreceli etkilerini araştırmak için lojistik regresyon uygulanmıştır. Doğum kontrolünde devamsızlılık, değiştirme davranışı ve kullanıcı başarısızlık hızları analizinde yaşam tabloları kullanılmıştır. Sonuçlar, mevcut doğum kontrol yöntemi kullanımının 1990'da % 11 iken, 2012 yılında % 35'e yükseldiğini göstermektedir. Bu arada, aile planlamasına yönelik karşılanmamış ihtiyaç % 32'den % 20'ye düşmüştür. Farklı bölgeler ve farklı etnik gruplar arasında karşılanmamış gereksinim varlığında olduğu gibi doğum kontrol yöntemi kullanımında da dikkate değer heterojenlik belirgindir. İstenen ortalama çocuk sayısı dört olarak kalmaya devam etmiştir ve gelecekte doğum kontrol yöntemi kullanımı isteği azalmıştır. Kocanın doğurganlık arzusu, çocukların sayısı ve cinsiyeti, medya mesajına maruz kalma, Kadın Sağlığı çalışanının ziyareti, ikamet yeri ve refah durumu, Pakistan'da mevcut doğum kontrol yöntemi kullanımı ve aile planlaması için karşılanmamış gereksinim düzeyi ile önemli ölçüde ilişkili bulunmuştur. Doğum kontrol yöntemi kullanım epizotlarının üçte birinin başlandıktan sonra ilk bir yıl içinde kesildiği bulunmuştur. En yüksek yöntem bırakma hızı hormonal yöntemler içindir ve yan etkiler yöntem devamsızlığının ana sebebidir. Hap, kondom ve çekilme için 12 aylık brüt başarısızlık oranı sırasıyla % 10,3 , % 9,3 ve % 10,4 olarak hesaplanmıştır. Anahtar Kelimeler: aile planlaması; kontraseptif kullanımı; karşılanmamış aile planlaması ihtiyacı; yöntem bırakma hızı; doğum kontrol başarısızlıkları. x CONTENTS THESIS APPROVAL iii YAYIMLAMA VE FİKRİ MÜLKİYET HAKLARI BEYANI (DECLARATION OF PUBLISHING AND INTELLECTUAL PROPERTY RIGHTS) iv ETHICAL DECLARATION v ACKNOWLEDGEMENT vi ABSTRACT viii ÖZET ix CONTENTS x ABBREVIATIONS xv FIGURES xvii TABLES xix CHAPTER 1. INTRODUCTION 1.1. Back Ground of Research Problem 1 1.1.1. Global Population Expansion 1 1.1.2. Historical back ground of Pakistan`s Population 3 1.1.3. Physical Features of Pakistan & Country Profile 4 1.1.4. Demographic Transition in Pakistan 5 1.2. Objectives of the Thesis 15 1.2.1. Aim 15 1.2.2. Specific Objectives 15 1.3. Significance of the Study 16 2. LITERATURE REVIEW 17 2.1. Global Concern on Population Expansion and Commitment of Government of Pakistan 17 2.1.1. World Population Conferences 17 2.1.2. The International Conference on Population and Development 20 2.1.3. Fourth World Conference on Women and Beijing Declaration 25 2.1.4. United Nations Millennium Summit 26 2.1.5. London Summit on Family Planning ‘Family Planning 2020’ 29 2.1.6. Sustainable Developmental Goals 31 2.2. Evolution of Family planning and Population Policy in Pakistan. 37 xi 2.2.1. The First Decade of Family planning efforts in Pakistan (1950-1959) 37 2.2.2. The Second Decade of Family planning efforts in Pakistan (1960-1969) 38 2.2.3. The Third Decade of Family planning efforts in Pakistan (1970-1979) 40 2.2.4. The Fourth Decade of Family planning efforts in Pakistan (1980-1989) 41 2.2.5. The Fifth Decade of Family Planning Efforts in Pakistan (1990-1999) 42 2.2.6. The Sixth Decade of Family Planning Efforts in Pakistan (2000-2009) 43 2.2.7. The Seventh Decade of Family Planning Efforts in Pakistan (2010-Present) 44 2.3. Review on Family Planning and Contraception 47 2.3.1. Family Planning Past, and Present 47 2.3.2. Indicators of Family Planning Success 50 Contraceptive Prevalence Rate (CPR) 50 Evolution of Definition of Unmet Need for Family Planning 52 Revised Definition of Unmet need and its Algorithm 54 The Impact of Revising the Definition of Unmet Need 57 Criticism on Revised Definition of Unmet Need 57 Understanding the Concept of Unmet Need 58 2.3.3. Status Family Planning in the World and in Pakistan 60 Global Trend in Contraceptive Use 60 Contraceptive Use Trend in Pakistan 62 Worldwide Trends in Unmet Need for Family Planning 63 Unmet Need for Family Planning in Pakistan 65 3. DATA AND METHODS OF ANALYSIS 67 3.1. Data Sources 67 3.2. Sample Size Estimation, Study Population and Sampling Method. 67 3.3. Study Design 68 3.4. Outline of Pakistan Demographic and Health Surveys 68 3.4.1. Pakistan Demographic and Health Survey 1990-91 (PDHS-1990-91) 68 3.4.2. Pakistan Demographic and Health Survey 2006-07 (PDHS 2006-07) 70 xii 3.4.3. Pakistan Demographic and Health Survey 2012-13 (PDHS-2012-13) 71 3.5. Theoretical Model for Analysis and Research Hypotheses 74 3.5.1. Conceptual and Operational Framework for the determinants of Contraceptive use Behavior of women 74 3.5.2. Research Hypotheses 79 3.6. Selection and Definition of Dependent Variables 79 3.7. Rationalization, Construction and Operational Definition of Contextual Independent Variables 81 3.7.1. Respondent’s Socio-Demographic characteristics 81 3.7.2. Respondent’s Reproductive Characteristics 83 3.7.3. Contraceptive-Method Related Characteristics 86 3.7.4. Spousal’s Socio-Demographic Characteristics 87 3.7.5. Community Level Characteristics 88 3.7.6. Household Level Characteristics 90 3.8 Method of Analysis 94 3.8.1. Analytic Strategy 94 Univariate Analysis 94 Bivariate Analysis 95 Multivariate Analysis 95 3.8.2. Coding of Variables 98 4. RESULTS 103 4.1. Part I- Socio-Demographic Characteristics of the Respondents 103 4.2. Part II-Trends in Contraceptive Knowledge, Ever-Use, and Current-Use 127 4.2.1. Trends in Contraceptive Knowledge 127 4.2.2 Trends in Ever Use of Contraceptive 136 4.2.3 Trends in Current Use of Contraceptive 152 4.2.4. Trends in Contraceptive Prevalence Based on ‘Exposure Status’ of Women 171 4.3. Part III- Trends in Unmet Need for Family Planning 174 4.4. Part IV- Trends in Fertility Preferences and Intention for Future Use of Contraception 196 4.4.1. Trends in Fertility Preferences 196 Trend in Ideal family size 197 Desire for More Children 197 4.4.2. Trends in Intention for Future Use of Contraception. 199 xiii 4.5. Part V- Bivariate and Multilevel Analysis of Predictors of Women’s Current Use of Contraceptive 201 4.5.1. Result of Bivariate Analysis of Predictors of Women’s Current Use of Contraceptive 201 4.5.2. Result of Multivariate Analysis of Predictors of Women’s Current Use of Contraceptive 207 4.6. Part VI- Bivariate and Multilevel Analysis of Predictors of Women’s Unmet Need for Family Planning 219 4.6.1. Result of Bivariate Analysis of Predictors of Women’s Unmet Need for Family Planning 219 4.6.2. Result of Multivariate Analysis of Predictors of Women’s Unmet Need for Family Planning 233 5. DYNAMICS OF CONTRACEPTIVE USE 262 5.1 Conceptual Model of Dynamics of Contraceptive Use 262 5.2 Data and Methods of Analysis 265 5.2.1. Data 265 5.2.2. Statistical Methodology 266 5.2.3 Construction and Definition of Variables 268 5.2.4. Back Ground Theory and Analytic Detail of Contraceptive Discontinuation Rates 270 5.2.5 Back Ground Theory and Analytic Detail of Contraceptive Discontinuation Rates by the Reason for Discontinuation 271 5.2.6. Back Ground Theory and Analytic Detail of Contraceptive Method Switching Behavior 272 5.2.7. Back Ground Theory and Analytic Detail of Contraceptive Failure Rates 273 5.3 Results 274 5.3.1. Discontinuation Rates 274 5.3.2 Discontinuation Rates by Reason for Discontinuation 286 5.3.3. Contraceptive Method Switching Behavior 293 5.3.4. Comparison of Contraceptive Failure Rate 299 6. DISCUSSION 309 6.1. Trends in Contraceptive Use 309 6.2. Trends in Unmet Need for Family Planning 314 6.3. Determinants of Current Use of Contraceptives 317 6.3.1. Differences Due to Respondent’s Socio-demographic Characteristics 317 xiv 6.3.2. Differences Due to Respondent’s fertility related Characteristics 321 6.3.3. Differences Due To Spousal’s Characteristics 323 6.3.4. Differences Due To Community Characteristics 324 6.3.5. Differences Due To Household Characteristics 326 6.4. Determinants of Unmet Need for Family Planning 328 6.4.1 Differences Due to Respondent’s Socio-demographic Characteristics 329 6.4.2. Differences Due to Respondent’s fertility related Characteristics 332 6.4.3. Differences Due To Spousal’s Characteristics 336 6.4.4. Differences Due To Community Characteristics 338 6.4.5. Differences Due To Household Characteristics 340 6.5. Dynamics of Contraceptive Use 343 6.5.1. Discontinuation of Contraception in Pakistan 343 6.5.2. Reason for Discontinuation of Contraception in Pakistan 347 6.5.3. Contraceptive Switching Behavior in Pakistan 351 6.5.4. Contraceptive Failure in Pakistan 354 7. CONCLUSION 358 7.1. Executive Summary 358 7.2. Limitations and Strengths 362 7.3. Recommendations (Implications of the Findings) 365 8. REFERENCES 374 9. APPENDICES Appendix-1. DHS Contraceptive Calendar Appendix-2. Ethical approval form from Hacettepe University Appendix-3. Approval from ICF International to use DHS dataset Appendix-4. Thesis Originality Report 10. CURRICULUM VITAE xv ABBREVIATIONS A.D. After Death AIDS Acquired Immune Deficiency Syndrome B.C. Before Christ BHU Basic Health Units CBR Crude Birth Rate CDR Crude Death Rate CPR Contraceptive Prevalence Rate CRPRID Center For Research On Poverty Reduction And Income Distribution C.I. Confidence Interval CMS Continues Motivation System CMWs Community Male Workers DHS Demographic and Health Survey etc. And so on e.g. For example FATA Federally Administrative Tribal Areas FANA Federally Administered Northern Areas FP Family Planning FP2020 Family Planning 2020 GDP Gross Domestic Product GPS Geographic Positioning System Gov. Government HIV Human Immunodeficiency Virus ICPD International Conference On Population and Development IUD Intrauterine Device IMR Infant Mortality Rate LAM Lactational Amenorrhea LHWs Lady Health Workers MDGs. Millennium Developmental Goals MHSP Minimum Health Service Package MNCH Maternal and Child Health Program N.A. Not Available. NGO Non-Governmental Organizations NHS National Health Survey NHSR&C National Health Services, Regulations And Coordination NIPS National Institute Of Population Studies No./n Numbers NRIFP National Research Institute For Family Planning NWFP North West Frontier Province PBS Pakistan Bureau of Statistics PCPS Pakistan Contraceptive Prevalence Survey PDHS Pakistan Demographic And Health Surveys PRSP Poverty Reduction Strategy Paper PSUs Primary Sampling Unit xvi RH Reproductive Health RHC Rural Health Centers Ref Reference Group SDM Standard Days Method SDGs Sustainable Developmental Goal SPSS Statistical Packages For Social Sciences STDs Sexually transmitted Diseases TFR Total Fertility Rate USAID United States Agency For International Development UN United Nations UNDP United Nations Development Program UNESCO United Nations Educational, Scientific And Cultural Organization US/ USA United State of America WFS World Fertility Survey WHO World Health Organization YADR Young Age Dependency Ratio xvii LIST OF FIGURES Figure Page 1.1 World population growth 1750 to 2100 2 1.2 UN Population Division estimates and projections for average annual population growth rate for a period of one and half century by Bangladesh, China, India, Iran and Pakistan 3 1.3 Fertility decline in south Asia (1950-2015) 7 1.4 The demographic transition of Pakistan (1950-2050) 8 1.5 Trend in total fertility rate (TFR) in Pakistan (1950-2050) 9 1.6 Trend infant mortality rate in Pakistan (1950-2050) 10 1.7 Trend infant mortality rate in Pakistan (1950-2050) 10 1.8 Population pyramid of Pakistan (1950, 2000, 2025 and 2050) 11 1.9 The age structure and composition of Pakistani population during demographic transition (1950-2050) 12 1.10 Age dependency ratio in Pakistan for period of 1950-2100 12 2.1 Revised definition of unmet need for family planning 56 3.1 Conceptual framework along with independent variables contained in different dimensions 77 3.2 Operational framework along with independent variables used in multivariate analysis 78 3.3 Revised definition of unmet need for family planning (Pakistan, PDHS 2012-13) 80 3.4 Schema of variables used in the analysis 93 4.2.1 Percentage distribution of current-users of contraception by type of method (Pakistan, DHS 1990-91, 2006-07, 2012-13) 154 4.2.2 Percentage of currently married women age 15-49 currently using any method of contraceptive method, by the purpose of use (Pakistan, DHS 1990-91, 2006-07, 2012-13) 154 4.2.3 Percentage trend in knowledge, ever-use and current-use of any contraceptive method among currently married women age 15-49. (Pakistan, DHS 1990-91, 2006-07, 2012-13) 170 4.3.1 Percentage trends in unmet need for family planning among currently married women age 15-49 (Pakistan, DHS 1990-91, 2006-07, 2012-13) 174 xviii 4.3.2 Classification of currently Married women age 15- 49 on the basis of having met need, unmet need or no need for family planning in three Pakistan Demographic and Health Surveys (Pakistan, DHS 1990-91, 2006-07, 2012-13) 195 4.4.1 Trend in mean ideal family size among currently married women age15-49 (Pakistan, PDHS; 1990-91, 2006-07, 2012-13) 197 4.4.2 Trend in reproductive intention of currently married women age 15- 19. (Pakistan, PDHS; 1990-91, 2006-07, 2012-13) 198 5.1 Conceptual model of contraceptive use dynamics 264 5.2 Percentage of users still using selected methods of contraception at each duration (Pakistan; DHS 2012-13) 277 5.3 Percentage of users still using contraception (all reversible methods combined) at each duration by province (Pakistan, DHS 2012-13) 281 5.4 Percentage dissection of life table 12- month discontinuation rates by reason for discontinuation and contraceptive method (Pakistan, DHS 2012-13) 289 5.5 Percent decomposition of the 12 month discontinuation rates by status after discontinuation, by contraceptive method (Pakistan, DHS 2012-13) 295 xix LIST OF TABLES Table Page 1.1 Comparative analysis of demographic indicators of Southern Asian countries; 2015. 14 2.1 Time series data for selected MDGs indicators related to maternal and child health as well as women’s empowerment. (Pakistan). 34 2.2 The value of Unmet Need, Modern Contraceptive Prevalence, Total Fertility Rate and Ideal Family Size in three countries at different demographic time line. 59 2.3 The value of, Total Fertility Rate Ideal Family Size, Contraceptive Prevalence and Unmet Need in Three Pakistan Demographic Health Survey (Pakistan, DHS 1990-91, 2006-07, 2012-13) 66 3.1 Basic Characteristics of the Three Nationwide Demographic and Health Surveys in Pakistan (PDHS 1990-91, 2006-07, 2012-13) 73 3.2 Categorization and Coding of Variables. 99 4.1.1 Percentage distribution of respondents in Pakistan Demographic and Health Surveys sample (Pakistan, DHS 1990-91, 2006-07, 2012-13) 104 4.1.2 Percentage distribution of currently married women, by selected socio-demographic characteristics (Pakistan, DHS; 1990-91, 2006-07, 2012-13) 106 4.1.3 Percentage distribution of currently married women by selected reproductive characteristics (Pakistan, DHS; 1990-91, 2006-07, 2012-13) 110 4.1.4 Percentage distribution of currently married women by selected contraceptive use characteristics (Pakistan, DHS; 1990-91, 2006-07, 2012-13) 116 4.1.5 Percentage distribution of currently married women by selected spousal characteristics (Pakistan, DHS; 1990-91, 2006-07, 2012-13) 120 4.1.6 Percentage distribution of currently married women by selected community characteristics (Pakistan, DHS; 1990-91, 2006-07, 2012-13) 123 4.1.7 Percentage distribution of currently married women by selected household characteristics (Pakistan, DHS; 1990-91, 2006-07, 2012-13) 126 4.2.1a Trend in knowledge of currently married women about contraceptive methods (Pakistan, DHS; 1990-91, 2006-07, 2012-13) 128 xx 4.2.1b Trends in level of contraceptive knowledge by selected socio- demographic characteristics of currently married women. (Pakistan, DHS; 1990-91, 2006-07, 2012-13) 129 4.2.1c Trends in level of contraceptive knowledge by selected spousal characteristics of currently married women (Pakistan, DHS; 1990-91, 2006-07, 2012-13) 132 4.2.1d Trends in level of contraceptive knowledge by selected community and household characteristics of currently married women (Pakistan, DHS; 1990-91, 2006-07, 2012-13) 134 4.2.2a Trend in ever use of contraceptive methods by currently married women (Pakistan, DHS 1990-91, 2006-07, 2012-13) 137 4.2.2b Trends in contraceptive method ever use by socio-demographic characteristics of currently married women (Pakistan, DHS 1990-91, 2006-07, 2012-13) 138 4.2.2c Trends in contraceptive method ever use by reproductive characteristics of currently married women (Pakistan, DHS 1990-91, 2006-07, 2012-13) 143 4.2.2d Trends in contraceptive method ever use by spousal characteristics of currently married women (Pakistan, DHS 1990-91, 2006-07, 2012-13) 146 4.2.2e Trends in contraceptive method ever use by community level characteristics of currently married women (Pakistan, DHS 1990-91, 2006-07, 2012-13) 149 4.2.2f Trends in contraceptive method ever use by household level characteristics of currently married women (Pakistan, DHS 1990-91, 2006-07, 2012-13) 151 4.2.3a Trend in current use of contraceptive methods by currently married women. (Pakistan, DHS 1990-91, 2006-07, 2012-13) 152 4.2.3b Trends in current use of contraceptive method by socio- demographic characteristics of currently married women (Pakistan, DHS 1990-91, 2006-07, 2012-13) 156 4.2.3c Trends in current use of contraceptive method by reproductive characteristics of currently married women (Pakistan, DHS 1990-91, 2006-07, 2012-13) 161 4.2.3d Trends in current use of contraceptive method by spousal characteristics of currently married women (Pakistan, DHS 1990-91, 2006-07, 2012-13) 164 4.2.3e Trends in current use of contraceptive method by community level characteristics of currently married women (Pakistan, DHS 1990-91, 2006-07, 2012-13) 167 xxi 4.2.3f Trends in current use of contraceptive method by household level characteristics of currently married women (Pakistan, DHS 1990-91, 2006-07, 2012-13) 169 4.2.4 Percentage distribution of currently married women by exposure and contraceptive method use categories. (Pakistan, DHS; 1990-91, 2006-07, 2012-13) 173 4.3.1 Trends in unmet need for family planning by socio-demographic characteristics of currently married women. (Pakistan, DHS 1990-91, 2006-07, 2012-13) 177 4.3.2 Trends in unmet need for family planning method by reproductive characteristics of currently married women. (Pakistan, DHS 1990-91, 2006-07, 2012-13) 183 4.3.3 Trends in unmet need for family planning by spousal characteristics of currently married women. (Pakistan, DHS 1990-91, 2006-07, 2012-13) 187 4.3.4 Trends in unmet need for family planning by community level characteristics of currently married women. (Pakistan, DHS 1990-91, 2006-07, 2012-13) 191 4.3.5 Trends in unmet need for family planning by household level characteristics of currently married women. (Pakistan, DHS 1990-91, 2006-07, 2012-13) 194 4.4.1 Trend in intention to use contraceptive method by currently married nonuser women aged 15-49 (Pakistan, DHS 1990-91, 2006-07, 2012-13) 200 4.5.1 Bivariate analysis of individual, spousal, community, and household level characteristics versus current use of contraception among currently married women age 15-49 (Pakistan, DHS 2012-13) 203 4.5.2 Regression analysis results assessing the affect of individual, spousal, community, and household level characteristics on the current use of contraceptives among currently married women age 15-49 (Pakistan, DHS 2012-13) 212 4.6.1 Bivariate analysis of individual, spousal, community, and household level characteristics versus unmet need for spacing among currently married women age 15-49. (Pakistan, DHS 2012-13). 221 4.6.2 Bivariate analysis of individual, spousal, community, and household level characteristics versus unmet need for limiting among currently married women age 15-49 (Pakistan, DHS 2012-13). 225 xxii 4.6.3 Bivariate analysis of individual, spousal, community and household level characteristics versus unmet need (total) for family planning among currently married women age 15-49. (Pakistan, DHS 2012-13) 229 4.6.4 Regression analysis results assessing the affect of individual, spousal, community, and household level characteristics on unmet need for spacing among currently married women age 15-49. (Pakistan, DHS 2012-13) 241 4.6.5 Regression analysis results assessing the affect of individual, spousal, community, and household level characteristics on unmet need for limiting among currently married women age 15-49. (Pakistan, DHS 2012-13) 248 4.6.6 Regression analysis results assessing the affect of individual, spousal, community, and household level characteristics on unmet need (total) for family planning among currently married women age 15-49. (Pakistan, DHS 2012-13) 255 5.1.1 The life table discontinuation rates and median duration of use by contraceptive method. (Pakistan, DHS 2012-13) 276 5.1.2 The life discontinuation rates and median duration of use for all reversible contraceptive methods combined, by selected socio- demographic factors. (Pakistan, DHS 2012-13) 279 5.1.3 The life discontinuation rates and median duration of use for condom, by selected socio-demographic factors. (Pakistan, DHS 2012-13) 283 5.1.4 The life discontinuation rates and median duration of use for withdrawal by selected socio-demographic factors. (Pakistan, DHS 2012-13) 285 5.2.1 The life table 12-month discontinuation rates by reason for discontinuation and contraceptive method. (Pakistan, DHS 2012-13) 288 5.2.2 The life table 12-month discontinuation rates by reason for discontinuation and contraceptive method by selected socio- demographic variables. (Pakistan, DHS 2012-13) 292 5.3.1 The life table 12-month discontinuation rates by status after discontinuation and contraceptive method. (Pakistan, DHS 2012-13) 294 5.3.2 The life table 12 month discontinuation rates by status after discontinuation and selected socio-demographic factors. (Pakistan; PDHS, 2012-13) 298 xxiii 5.4.1 The life table gross failure rates by contraceptive method (Pakistan, DHS 2012-13) 300 5.4.2 The life table gross failure rates by condom and selected socio- demographic characteristics. (Pakistan, DHS 2012-13) 302 5.4.3 The life table gross failure rates by pill and selected socio- demographic characteristics. (Pakistan, DHS 2012-13) 305 5.4.4 The Life table gross failure rates by withdrawal and selected socio- demographic characteristics. (Pakistan, DHS 2012-13) 307 1 1. INTRODUCTION 1.1. Background of Research Problem 1.1.1. Global Population Expansion History of human population suggests that for hundreds of years, growth of human population was very slow (1), this collapse was caused by famine, war and disease on a global scale. In 19th and 20th century due to the industrial revolution, agricultural technology improved which in turn helped to achieve better public health and sanitation. Due to this uplift, the world population has dramatically changed at the greatest exponential growth rate compared to the past history of mankind (2). The US Census bureau ascertains that in 2017, world population is more than 7 billion (3), yet two hundred years trending, prior to the nineteenth century the population was under 2 billion (4). The above measures speculate that 6.5% of those people are still alive as of present-day (5). Figure 1.1 illustrates that at the beginning of 19th century the global annual growth rate remained less than 1% (4), however, by the year 1900, it progressively ascended and in the year 1962, it has reached to the highest historical level of 2.1% (4). After this peak, during the latter half of the twentieth century, it has been gradually running down with United Nations Population Division projection estimating 0.1% global growth rate for the year 2016 (6). The twentieth century has been predominantly characterized by the sensible discussions on human population and well-being. In the meantime, the extensive growth of population has encouraged governments to take measures for the betterment of their citizens in terms of socio-economic and demographic factors, which has resulted in methodological research, modified concepts and strategic development in the field of demography, reproductive health and public health in general. 2 Figure 1.1. World population growth 1750 to 2100. Figure adopted from Our World in Data (4). Since the middle of 1960s, there has been a declining trend in the global population growth (4). However, this global population growth pattern under cover immense heterogeneity across countries and regions. While Russia, Ukraine and Belarus are the countries currently with negative natural increase, Europe and Japan have nearly zero annual growth rates. However, many countries in Sub-Saharan Africa have annual growth rates greater than 3% (7) – which is still higher than the peak growth rates recorded for the world at the beginning of the 1960s. This heterogeneity results in great disparity among developed and developing countries on demographic and health indicators. Historically Asia ranks number one among regions of the world ordered by population. Based on the latest United Nations estimates, the current population of Asia is 4.5 billion as of January, 2017 (6). This is equivalent to 60% of the total world population of which 25% of the world`s share living in Southern Asia. Pakistan stands second after India as the most populous country in South Asia (6). The current estimated population of Pakistan as of January 2017 is about 198 million making it the sixth most populous country in the world (6). The population of Pakistan share 2.6% of the world`s population (6). In other words, 1 in every 36 people on earth is a Pakistani national. 3 Figure 1.2 presents the United Nations (UN) Population Division estimates for 1955-2015 and projections for 2016-2100 of annual population growth rate by country (8). This figure shows that since the 1960s, annual population growth rates in most of the Asian countries have dropped. Furthermore, in some cases there has been diverging trends in growth rates from same starting level. For instance, Indian and Pakistani population had comparable growth rate of about 1.7% in 1960 but took a different path altogether in the next several years. Currently, Indian population is annually growing by 1.26% and Pakistani population is growing by 2.67%. With this rate Pakistan is expected to be fifth largest country by 2050 with a population of around 300 million (6). Figure 1.2. UN Population Division estimates and projections for average annual population growth rate for a period of one and half century by Bangladesh, China, India, Iran and Pakistan (8). Figure adopted from Our World in Data (4). 1.1.2. Historical background of Pakistan`s Population The land that is now comprised of Pakistan had been at one time part of the highly developed and advanced civilization of the ancient times that had flourished around the river Indus. The history of Indus valley dates back to almost 2,500 years B.C and research has shown that Indus had a population of roughly five million (9). The people of Indus were well ahead in the art of constructing cities. Scholars believe that it was one of the most sophisticated ancient time’s societies(9). Later in 4 the history this land was conquered by many foreign invaders starting from Aryans and Alexander to British imperial powers. In 711 A.D., Arab soldiers arrived in Sindh region of Indian subcontinent where majority of population was Hindu by religion; they brought the religion of Islam with them and Muslims then started to settle as the ruling class on this land for the first time (10). Subsequent Muslim incursions from Central Asia expanded Muslim dynasty all over the subcontinent and led to establishment of Sultanate of Delhi (10). Later, the subcontinent gradually came under British rule by the foundation of British East Indies Company in 1599 by a group of merchants in search of just peaceful trade, and from 1858 to 1947, Indian subcontinent was under the British Crown (11). Struggle for the independence of British India was started in 1906 by Muslim political party All-India Muslim League and the famous Muslim philosopher and poet Muhammad Iqbal who created the ideology of ‘Two Nation Theory’ in defining the nationality of Indian Muslims (12). This theory in its simplest way implies the cultural, political, and socioeconomic dissimilarities between the two noteworthy religious groups, Hindus and Muslims of the Sub Continent. These differences were greatly instrumental in giving rise two distinct political ideologies and the strong advocacy of this ideology was taken by Muhammad Ali Jinnah, who turned it for the awakening of Muslims for creation of independent Muslim majority state Pakistan which victoriously led to the partition of British India in 1947 by the British Empire into two independent states, Hindustan and Pakistan for two separate nations (12). 1.1.3. Physical Features of Pakistan and Country Profile The Islamic Republic of Pakistan is created in the name of Islam with partition of British India in 1947. It is a federal parliamentary country in South Asia, bordered with Afghanistan, Iran, India and China. Pakistan has 1,046 kilometers long seaboard along the Arabian Sea. The total land area is about 796,096 square kilometers (13), and it is the 36th largest country in the world by area (14), but ranks sixth most populous country with about 200 million people (6). Administratively, Pakistan is made of four provinces along with the Federally Administrative Tribal 5 Areas (FATA), Azad Kashmir, and the Gilgit-Baltistan region. The capital of Pakistan is Islamabad (13). Karachi is the largest and most populous city in Pakistan; with the population of more than 15 million it ranks as the 5th largest metropolitan city in the world, having a population density of over 24,000 people per square kilometre (15). Urdu is the official language of Pakistan, however there are many different regional languages spoken around the country; which makes Pakistan an ethnically and linguistically diverse country. The topography and climate of Pakistan are diverse in nature too. It has all the four seasons ranging from bright sunny skies to snow covered mountains of Himalayas. With about 47% agricultural land and 64% rural population (13), agriculture is indispensable to the Pakistan’s economical development. As a prominent sector, it shares 21% of Pakistan’s gross domestic product (GDP) (16). A large portion of the Pakistan`s manufactured exports rely on raw materials such as cotton yarn, house linens, rice and leather apparel that are part of the agriculture sector. According to the World Bank ranking (17), Pakistan is a lower middle income country with the Gross Domestic Product per capita recorded at 1142.70 US dollars in 2015 (18). The health and the education sectors are somewhat neglected. According to the World Health Organization (WHO) (19) and United Nations Educational, Scientific and Cultural Organization (UNESCO) (20) data, health and education expenditure in terms of total percent of GDP in Pakistan was measured at 2.75% and 2.45% respectively in the year 2014. Furthermore, by means of 56% adult literacy rates, UNESCO (20) list Pakistan among lowest literate countries in the world and female adult literacy rate is only 42%. These figures highlights need for the government to play a more active role by investing time and money in making better policies that can give a boost to these underserved sectors. 1.1.4. Demographic Transition in Pakistan John Bongaart (21) asserts that the human demographics have evolved as a result of the association between the birth rate and the death rates, in the course of last 300 years. The 20th century marks the advancement of science and technology and progress in the field of medical science that has greatly impacted the health and 6 wellbeing of people around the globe. Factors such as conquest of infectious diseases, control of epidemics, improved nutrition and hygiene have attributed to sustained mortality reduction (22). However, this sustained drop in the death rate before the birth rate showed quick impact on the population size of the society. Along with the modernization and cultural changes, there has been a shift in family values; underscoring the quality rather the quantity of children. In his paper, Bhakta (23) argued that the uneven fertility decline in India demonstrates valuing women’s empowerment, which led women to have their own reproductive decisions and resulted in smaller family size. Reasoning from the above facts, societies today have gone through a fairly well defined pattern of transformation from a pre-modern era of high fertility and mortality to a post-modern era of low fertility and mortality. The corroboration and consideration of this global event has formulated a stereotypical model, acknowledged as the ‘Demographic Transition Model’, which is used to demonstrate the changes in population demographics. Prior to the transition, population growth was nearly zero because high death rate negates high birth rate. Population growth became zero later the accomplishment of the transition as the birth and death rates both achieve bottom most level (21). This demographic transition is becoming a universal phenomenon in which almost every nation had a continuum of evolution at a distinctive rate and a peculiar time. While Europe had achieved the new demographic balance, most of the Asian and African countries are still in imbalance transitional stage because of slow fertility transition (22). As regarded from Figure 1.3, Pakistan is among one of those nations that entered the fertility transition not only very late but also its rate of progression is very slow as compared to other countries in the region (8). It is evident that high fertility in the initial and intermediate stages of demographic transition eventually results in large number of youthful population; and if the fertility transition remains slows (as in Pakistan), this young population perpetuates high birth rate over the following decades, which results in further expansion of the population hence, the country becomes trapped in the transitional stage for a long time. Keyfitz (24) describes this young population effect as “Population Momentum”. Therefore, the slow pace of transition along with 7 population momentum will expected to result in exponential growth of population in Pakistan over the next coming years, even if the total fertility rate (TFR) declines to replacement level. TFR Figure 1.3. Fertility decline in south Asia 1950-2015 (8). For portraying demographic transition of Pakistan, UN population projections dataset (8) was utilized in preparing the graph to represent what may be the demographic future population of Pakistan. There are three variants of UN projections, low, medium and high, based on fertility, mortality and net migration assumptions (25). In order to get a better adjusted projection of the future, ‘medium variants’ of UN population projections was applied here while avoiding best and worst projections using low and high variant. It is important to note that projections are speculations, based on assumptions and are provide with a framework, however, these estimates can be used as guidelines to devise the future strategies. Figure 1.4 exhibits the demographic transition of Pakistan over a period of century (1950-2050). It is evident from the figure that the crude death rate (CDR) in year 1950 was about 24 per thousand, and then it fell systematically and sharply and was measured to be around 7 per thousand for year 2015. In the meantime, the crude 0 1,00 2,00 3,00 4,00 5,00 6,00 7,00 8,00 9,00 Southern Asia Afghanistan Bangladesh Bhutan India Iran (Islamic Republic of) Maldives Nepal Pakistan Sri Lanka 8 birth rate (CBR) also declined slowly and gradually from the year 1950 when it was measured as 45 per thousand to estimated value around 29 per thousand for the year 2015 (8). Likewise, during this dragging transition period population of Pakistan had grown more than five times from about 36 million in the year 1950 to about 188 million in the year 2015. Figure 1.4. The demographic transition of Pakistan; 1950 to 2050 (8). Historical trend of annual population growth in Pakistan was presented before in Figure 1.2. It can be seen that till mid 1960s the growth rate was slow and around 2 percent. However, the population growth rate peak to climax value up to 3.5 percent increase per year in 1980s and then it began to drop constantly in early 1990s. The estimated growth rate is about 2.1% for the year 2016. As evident from figure, this annual growth rate is still well above the other neighbouring Asian countries having similar socioeconomic conditions (8). The slow fertility transition in Pakistan is reflected by trend in total fertility rate given in Figure 1.5. It is evident from this figure that Pakistan had seen a noticeable decline in fertility during the 1990s with total fertility rate (TFR) sliding from more than 6 children per woman to about 4.5 children by the year 2000. Assuming that the medium variant UN population projection (8) is converted into real phenomena, Pakistan is expected to achieve replacement level fertility rate somewhere around year 2050. 0 5,0 10,0 15,0 20,0 25,0 30,0 35,0 40,0 45,0 50,0 0 50 000 100 000 150 000 200 000 250 000 300 000 350 000 Seri 3 Seri 1 Seri 2 P o p u la ti o n ( 0 0 0 ) Population Crude birth rate Crude death rate P e r 1 ,0 0 0 P e o p le 9 Figure 1.5. Trend in total fertility rate in Pakistan (8). Infant mortality is one of the important indicators of health and development (26). Reduction in infant mortality increases the probability of survival during the successive stages of life and ultimately formulates an increased life expectancy. Figure 1.6 shows infant mortality rate in Pakistan dropped from approximately 250 in the year 1950 to 102 in late 1990s and 67 in 2015 (8). This rapid decline in infant mortality is instrumental for the high life expectancy while diverging fertility and mortality indicators resulted in escalation of population growth rate. The cumulative effects of these trends reveal an increasing median age and draw a youthful picture of current Pakistani population. Figure 1.7 demonstrates that the population median age in Pakistan began to rise in early 1980s when the median age was recorded as 18 and now in year 2017 it is 23. It is further estimated to increase and will be 33 years by 2050 (8). In other words, Pakistan`s population demographics has evolved over time, that means, its survival rate has improved, and there has been a shift seen in the trend from adolescence to youth. 1,00 2,00 3,00 4,00 5,00 6,00 7,00 1 9 5 0 -1 9 5 5 1 9 5 5 -1 9 6 0 1 9 6 0 -1 9 6 5 1 9 6 5 -1 9 7 0 1 9 7 0 -1 9 7 5 1 9 7 5 -1 9 8 0 1 9 8 0 -1 9 8 5 1 9 8 5 -1 9 9 0 1 9 9 0 -1 9 9 5 1 9 9 5 -2 0 0 0 2 0 0 0 -2 0 0 5 2 0 0 5 -2 0 1 0 2 0 1 0 -2 0 1 5 2 0 1 5 -2 0 2 0 2 0 2 0 -2 0 2 5 2 0 2 5 -2 0 3 0 2 0 3 0 -2 0 3 5 2 0 3 5 -2 0 4 0 2 0 4 0 -2 0 4 5 2 0 4 5 -2 0 5 0 2 0 5 0 -2 0 5 5 2 0 5 5 -2 0 6 0 T o ta l F er ti li ty R a te 10 Figure 1.6. Trend in infant mortality rate in Pakistan (8). Figure 1.7. Trend in median age of the population in Pakistan (8). A `Population Pyramid` is a perfect approach to present changes in the age structure of the population. Figure 1.8 presents population pyramid of Pakistan over a century with 25 years apart. The population age structure during early half of the century looks like a classical demographic pyramid with slight shrinkage at the base. In the year 2025, the age structure of population shows a plausible shift with the figure changing its pyramidal appearance; and in the following 25 years the 0 50 100 150 200 250 300 1 9 5 0 -1 9 5 5 1 9 5 5 -1 9 6 0 1 9 6 0 -1 9 6 5 1 9 6 5 -1 9 7 0 1 9 7 0 -1 9 7 5 1 9 7 5 -1 9 8 0 1 9 8 0 -1 9 8 5 1 9 8 5 -1 9 9 0 1 9 9 0 -1 9 9 5 1 9 9 5 -2 0 0 0 2 0 0 0 -2 0 0 5 2 0 0 5 -2 0 1 0 2 0 1 0 -2 0 1 5 2 0 1 5 -2 0 2 0 2 0 2 0 -2 0 2 5 2 0 2 5 -2 0 3 0 2 0 3 0 -2 0 3 5 2 0 3 5 -2 0 4 0 2 0 4 0 -2 0 4 5 2 0 4 5 -2 0 5 0 In fa n t M o rt al it y R at e 15,0 17,0 19,0 21,0 23,0 25,0 27,0 29,0 31,0 33,0 1 9 5 0 1 9 5 5 1 9 6 0 1 9 6 5 1 9 7 0 1 9 7 5 1 9 8 0 1 9 8 5 1 9 9 0 1 9 9 5 2 0 0 0 2 0 0 5 2 0 1 0 2 0 1 5 2 0 2 0 2 0 2 5 2 0 3 0 2 0 3 5 2 0 4 0 2 0 4 5 2 0 5 0 M e d ia n A ge ( Y e ar s) P e r 1 ,0 0 0 L iv e B ir th s 11 population age structure undergoes remarkable modification from its previous shape and approach to an almost cylindrical shape (8). Figure 1.8. Population pyramids of Pakistan for years; 1950, 2000, 2025 and 2050 (8). As mentioned earlier, demographic transition is almost always accompanied by alteration in the age composition of population and the age structure (as shown in Figure 1.9), which in turn, influences the fiscal performance of the country. Large number of young or old dependency ratio tends to draw relatively high proportion of resources for consumption, often limiting economic growth. During the early stage of demographic transition, young age dependency ratio (YADR) first rises as a result of increased fertility and child survival; in later stages with declining fertility YADR falls and birth cohort of previous stage moves into working age group. This rising proportion of working age group creates an opportunity for economic growth of the population. As there are more earning hands, there is an increase in the labour force which results in high per capita income, which also indicates less spending on care. 12 Figure 1.9. The age structure and composition of Pakistani population during demographic transition (8) Utilizing the advantage of demographic transition for economical growth and development is known as the 'demographic dividend' by Bloom and Jeffrey (27). This is a onetime fixed interval reward for society passing through transition period. The gradual transition in young and old age dependency ratio in Pakistan over a period of 150 years is evident from Figure 1.10. Figure 1.10. Age dependency ratio in Pakistan for the period of 1950-2100 (8). It is vital for a country to establish effective policies in the field of education, job-creation, and governance as these are crucial to attain a sustained growth cycle. 13 Without adequate policies, a country may lag behind and miss out on the opportunities for economic growth. This disharmony can cause disequilibrium in the society which may run the risk of high unemployment, increased crime rates, and social instability. The comparative analysis of some demographic indicators of south Asian countries and Pakistan are presented in Table 1.1. 1 4 Table 1.1. Comparative analysis of demographic indicators of Southern Asian countries, 2015. * United Nations. World Population Prospects, 2015 (8). ** Trends in Contraceptive Use Worldwide, 2015 (28). CBR: Crude Birth Rate TFR: Total Fertility Rate CDR: Crude Death Rate IMR: Infant Mortality Rate CPR: Contraceptive Prevalence Rate . Country Population size* (thousand) Population density* (persons per square km) CBR* (births per 1000 population) TFR* (children per women) CDR* (deaths per 1000 population) IMR* (infant deaths per 1000 live births) Growth rate* (percent) Median age* (years) CPR** (any method) (Percent) Unmet need for family planning** (percent) Southern Asia 1 822 974 284.8 21.5 2.56 7.1 44 1.36 26.1 58.6 13.8 Afghanistan 32 527 49.8 35.6 5.13 8.6 71 3.02 17.5 29.3 27.1 Bangladesh 160 996 1236.8 20.4 2.23 5.5 33 1.20 25.6 64.2 12.2 Bhutan 775 20.3 18.2 2.10 6.3 30 1.46 26.7 67.8 10.6 India 1 311 051 441.0 20.4 2.48 7.4 41 1.26 26.6 59.8 13.1 Iran 79 109 48.6 18.1 1.75 4.7 15 1.27 29.5 76.6 6.5 Maldives 364 1212.2 21.7 2.18 3.8 9 1.79 26.4 42.0 25.0 Nepal 28 514 198.9 21.0 2.32 6.5 32 1.18 23.1 52.4 23.9 Pakistan 188 925 245.1 29.8 3.72 7.5 70 2.11 22.5 38.5 20.4 Sri Lanka 20 715 330.3 16.4 2.11 6.7 8 0.50 32.3 71.6 7.4 15 1.2. Objectives 1.2.1. Aim The aim of this study is to evaluate the prevalence, trends, determinants and dynamics of contraceptive use and estimates of unmet need for family planning in Pakistan in order to deduce possible interventions to increase effective utilization of contraception in Pakistan. 1.2.2. Specific Objectives The specific objectives were: 1. To examine the levels and trends of contraceptive prevalence among currently married women of reproductive age in Pakistan and to describe differentials in the use of contraception over the past twenty years from 1992 to 2012. 2. To investigate the levels and trends of unmet need for family planning among currently married women of reproductive age in Pakistan from 1992 to 2012. 3. To assess the trend in intention to use contraceptives among non-users currently married women of reproductive age in Pakistan from 1992 to 2012. 4. To determine the association between current-use of contraceptive methods and socio-demographic, reproductive, spousal, community and household factors among currently married reproductive aged women in Pakistan, 2012-13. 5. To determine the association between unmet need for family planning and socio-demographic, reproductive, spousal, community, and household factors among currently married reproductive aged women in Pakistan, 2012-13. 6. To identify factors associated with contraceptive discontinuation in Pakistan, 2012-13. 7. To examine the reasons for contraceptive discontinuation and contraceptive method switching behaviour of currently married reproductive age women in Pakistan, 2012-13. 8. To identify factors associated with contraceptive failure in Pakistan, 2012-13. 16 1.3. Significance of the Study The slow pace of fertility decline along with the poor social and economic development in Pakistan necessitate substantial intervention. Family planning is the one of the advantageous cost-effective intervention which not only controls population expansion but also helps social and economic development. However, the low contraceptive use as well as a higher unmet need of family planning requires identification of factors that are barriers to family planning method for the couples specially women who want to delay or cease child bearing. The findings of this study help to identify sociodemographic and sociocultural factors that are barriers to use of family planning methods by women who wants to delay or stop child bearing. Additionally, no other research about contraceptive use dynamics has ever been conducted in Pakistan. The findings might assist to evaluate the efficiency and effectiveness of national family planning programs and along with this it will serve as a beginning of venture for additional comprehensive researchers leading to appropriate interventions regarding continuation of contraceptive use by women of reproductive age, furthermore developing new approaches towards increasing and improving effective use of contraceptives. The recommendations made by this study might play an important role towards developing specific responses to issues of unmet need for family planning as well as improving family planning services, and thereby contribute towards reaching the sustainable developmental goals by virtue of decreasing maternal and child mortality. 17 2. LITERATURE REVIEW 2.1. Global concerns on Population Expansion and Commitment of Government of Pakistan Since United Nation (UN) came in to existence on October 1945, it highlighted concerns over emerging population issues, expert committees and stake holders’ conferences on the overpopulation and human development. These conferences were held at global level to congregate logical information on population factors, determinants and aftermath to develop detailed picture on the demographic circumstance of the countries and to provide technical assistance to deal with overpopulation problem by creating population polices. By virtue of third largest contributor to the world population in the following the commitment of government of Pakistan at various international forms will be reviewed. 2.1.1. World Population Conferences United Nations (UN) had organized The First and Second World Population Conferences in Rome, 1954 and in Belgrade, 1965 respectively (29, 30). They were premier global level scientific conference attended by various experts and academicians on the problems of population to generate complete picture on the demographic situation of world. The main focus of second conference was to determine control over fertility in shaping human development and population growth. United Nation Secretary General has formally designated the year 1974 as “The World Population Year” and asked the member states to formulate and participate activities regarding trend in human population growth and economical and social development (31). The main event of the year was The Third World Population Conference also known as “International Conference on Population” was the main event of the year that was held, in August 1974 in Bucharest, Romania (32). It was the first intergovernmental conference arranged by United Nations and 18 attended by representatives of 135 countries including Pakistan. This conference had provide a platform to exchange the views to improve knowledge about population trends among governments, nongovernmental organizations and individual experts. The debate was mainly focused on the relationship between human development and population growth. The Conference was concluded by “World Population Plan of Action” (32), that provides recommendations and guidelines aimed at ‘a better quality of life and rapid socio-economic development for all people’ (33). The world population plan of action recognized inherent link in population growth and economical development, accordingly it emphasize that the population growth should be harmonized with trends of socio-economic development. The Plan places a high priority towards formation and implementation of national population policy and recommends the government to support the right of couples to decide their own family size. Plan urges governments to unify family planning services with other health related services such as primary health care, and make it available for all individuals. Among other principles, the Plan states: 'All couples and individuals have the basic right to decide freely and responsibly the number and spacing of their children and to have the information, education and means to do so; the responsibility of couples and individuals in the exercise of this right takes into account the needs of their living and future children, and their responsibilities toward the community' (33). It also states: ‘Improvement of the status of women in the family and in society can contribute, where desired, to smaller family size, and the opportunity for women to plan births also improves their individual status (34). The above declaration had expended international cooperation in population filed and increase technical assistance to countries needing and desiring it. The world population conference at Bucharest and related activates at that moments sharpens the awareness of government of Pakistan about overgrowing 19 population problems and their implications. Although the conference was extremely polarized by views on population growth, the government of Pakistan was in opinion to realize that rapid population growth intensifies problem in socioeconomic development (32). It was the first time for government of Pakistan to consider the relationship of basic demographic problems with economic and social development. Subsequently, Government had re-formulated national policies and actions programs to promote human welfare and development. This conference also represents a breakthrough on the technical aspect of population regulation by family planning programs in Pakistan by receiving international cooperation with expended contraceptive supply and technical assistance addressing population expansion (35). However because of frequent political changes and inadequacy of primary health care services, government policies and programs were not sustainable and failed to achieve their targets and goals. Decade after the first International Conference on Population in Bucharest, the Second International Conference on Population was held in Mexico City, August 1984 (36). It was attended by delegate from 147 countries including Pakistan. The global demographic, socio-economic and political climates had changed noticeably since first World Conference and in the light of the latest data and researches provided by member states this conference adopted “Recommendations for Further Implementation of the World Population Plan of Action” (37). Taking slow development for women empowerment into account, it was emphasize that governments should take proper actions for thorough integration of women in all phase of developmental process including policy and decision making. The Plan of action recommends. “Governments wishing to decrease fertility levels should adopt development policies that are known to reduce the level of fertility, such as improved health, education, integration of women and social equity.” (37) In addition, it was recommended that Governments should upgrade the quality and expend the coverage of reproductive health services particularly in rural areas. Also, 20 Governments were advice to involve the nongovernmental-organizations, especially women's organizations, in expending availability of family planning services. It was states that “All countries should ensure that fertility control methods conform to adequate standards of quality, efficacy and safety” (37). However, the family planning program and women’s right was a dark area in Pakistan history as the country was led by conservative government agenda backed by military regime. After assuming power in 1977, the military dictator government had frozen the family planning program (38) due to its antagonism to the former elected government who were strongly motivated to make the population program accessible and popular on priority basis. The International concern on population growth in Pakistan and subsequent external pressure lead the government of Pakistan to take some corrective actions. National Institute of Population Studies (NIPS) was establishes in 1985 with aim to conduct research in the field of national demography (39). 2.1.2. The International Conference on Population and Development (ICPD) The first largest intergovernmental land mark conference on population and development known as “International Conference on Population and Development (ICPD)” was organized on September 1994 in Cairo (40). 179 countries participated along with hundreds of UN agencies, intergovernmental and non-governmental organizations and they acknowledged that population policies should be centered at empowering couples especially women to decide their own family size, and Governments should provide necessary information and resources for this decision. Along these lines, a state-of-the-art concept of population policy was formulated in ICPD which gives eminence priority to reproductive health (RH) and women’s empowerment for future development. Governments also recognized the deep-rooted association between sustainable development, and gender equality (40). Furthermore, for the first time, global forum states consensually accepted that reproductive rights are human right in repercussion, member states admit to make RH and family planning services available, accessible, and affordable and provided 21 through primary health care system (41). The outcomes of the conference, “ICPD's Programme of Action” states: “All countries should strive to make accessible through the primary healthcare system, reproductive health to all individuals of appropriate ages as soon as possible and no later than the year 2015” (41) The ICPD had undeniably given border mandates on social and economical developmental affairs than preceding population conferences. It was successful in developing awareness among governments that population, poverty, patterns of production and consumption and the environment are so closely interconnected that none of them can be considered in isolation. In addition, the ICPD's Program of Action also recommends: “At the international, regional, national and local levels population issues should be integrated into the formulation, implementation, monitoring and evaluation of all policies and programs relating to sustainable development. Developmental strategies must realistically reflect the short, medium and long term implications of and consequences for population dynamics as well as pattern of production and consumption” (41). ICPD's Programme of Action highlights the paramount aspect of women’s empowerment and provides guideline for implementation of reproductive health and reproductive rights. By adopting ICPD's Program of Action, member countries are obliged to take policy, constitutional, fiscal, and other measures to accomplish the paramount principles and renowned rights maintained in the testimonial document. The program of action urge: “Eliminating all practices that discriminate against women; assisting women to establish and realize their rights, including those that relate to reproductive and sexual health” (41). 22 ICPD had changed the paradigm of Family Planning (FP) programs; Pre- ICPD, the aim of FP programs was only to reduce population growth for achieving demographic targets of population policies however Post-ICPD, FP program focuses on fulfilling the needs of individual and couples for accomplishing developmental goal of population policies and in the meantime deemphasizing demographic goals as the program drivers. The ICPD program emphasize to: “Help couples and individuals in meeting their reproductive goals in a framework that promotes optimum health responsibility and family well-being, and respect the dignity of all persons and their right to choose the number, spacing and timing of the birth of their children” (41). Consecutively, ICPD's Program of Action was reaffirmed in the Fourth World Conference on Women, held in year 1995 and in United Nations Millennium Summit. Since ICPD, compelling progress women’s empowerment and in availability and accessibility to FP and reproductive health services has occurred worldwide (42). In the context of Pakistan, the timing of ICPD was most significant for population policies and reproductive health program because there was major shift in attitude among the people in regard to family planning and government was led by liberal democratic government headed by first women prime minster late Benazir Bhutto who had great interest in empowerment of women, eradication of poverty and addressing the population issues. In her speech at Cairo she stated: “I dream of a Pakistan, of an Asia, of a world where every pregnancy is planned, and every child conceived is nurtured, loved, educated and supported. I dream of a Pakistan, of an Asia, of a world not undermined by ethnic divisions brought upon by population growth, starvation, crime and anarchy. I dream of a Pakistan, of an Asia, of a world, where we can commit our social resources to the development of human life and not to its destruction” (43). 23 As reported by National Health Survey of Pakistan 1990–94 (44) and Pakistan Demographic and Health Survey 1991-92 (45) before ICPD, there were inadequate reproductive health services that resulted in high maternal mortality ratio about 300–399 maternal deaths per 100,000 live births and infant mortality rate was approximately 91 per thousand live births in Pakistan (44,45). At that point, the modern contraceptive prevalence was only 11% and 80% deliveries were conducted by “dais” the traditional birth attendants (45). After ICPD, a particularly encouraging trend has been observed in Pakistan for intensifying political commitment to achieve population related targets and Government had bold initiatives for family planning programs. “The Prime Minister’s Program for Family Planning and Primary Health Care Pakistan” (46) was initiated during the same year soon after ICPD conjunction. With this, initially about 33,000 Lady Health Workers (LHWs) were employed under supervision of Lady Health Supervisors (46,47). The specific goal of this initiative was to expand family planning services and made them available in urban-slums and rural areas throughout the country (46). In accordance with ICPD program of action, the First Women Bank (48) was set up by Prime Minister Benazir Bhutto to eliminating poverty and assuring gender equality. The aim of this Bank was to help and encourage women in achieving economic independence by running small industries and practicing profession. Post-ICPD, the most notable achievement was extending family planning service delivery throughout the country by growing number of non-governmental organizations (NGOs). There were 121 NGOs in 1994 providing family planning and reproductive health services and their number became 171 in 1998, more over their scope of operation had also expended (49). Another initiative of Government after ICPD was the development of Social Action Program (50) with the financial and technical support of World Bank and other donor agencies to uplift social sectors in the area of community primary health care, education, water supply and sanitation. Historically, Pakistan’s first national health policy was formulated in the year 1990, and was based on "Health-For-All" approach (51) particularly addressing the core health care problems. The main objective of that policy was strengthening of the poor primary healthcare system as an essential instrument to contest basic health 24 issues, but family planning and reproductive health was not separately given importance in that policy. However inclusion of reproductive health along with primary health care in Second Pakistan National Health Policy, 1997 (51) in post ICPD area did reflect the government of Pakistan holistic approach to address individuals right for family planning as described in ICPD agenda. Latter in the year 1999, National Reproductive Health Service Package was introduced by the Ministry of Health for providing comprehensive protocol of reproductive health services, including family planning, safe motherhood, infant health care, prevention of HIV and other STDs, management of infertility, screening of cervical and breast cancers (52). Through this package, it was aimed to transfer reproductive health and family planning skills to traditional birth attendance and paramedical staff at the Rural Health Centers (RHC) and Basic Health Units (BHU) throughout the country. After ICPD, the UN Commission on Population and Development was given responsibility to monitor, review and assesses implementation of the ICPD agenda at every five year interval. The first five-year review, known as ICPD +5, was done in the year 1999 (53). Regardless of Pakistan’s remarkable commitment towards increasing the family planning and reproductive health (RH) services, the five-year review regarding implementation of the ICPD recommendations had shown limited successful results. As can be evident from contraceptive prevalence by that time was only 27% (49); maternal mortality ratio and infant mortality rate were 306 per 100,000 live birth (54) and 88 per 1000 live births (55) respectively. At ICPD +5 the delegation of Pakistan stated: “….Our reproductive health indicators, however, still require considerable improvement to match the international standards. Our efforts will continue. …The full implementation of ICPD agenda requires such amount of resources that are beyond the capacity of developing countries including Pakistan. In 1994, all nations had agreed that greater financial allocation was needed from both the donor and recipient countries. However, on a worldwide basis, the international community has seriously lagged behind its funding commitments made at the ICPD.…. Despite its resource constraints, Pakistan has increased its public investment in health and family planning sectors manifold. In 25 addition, substantial investments are being made by the private sector. The donor assistance has neither matched our requirements nor their commitments at the Cairo Conference in 1994.…” (49). It was acknowledged in meeting that full implementation of ICPD agenda require sufficient domestic and external resources (53), yet Pakistan has increased its public investment in health and family planning more than fivefold between 1988 and 1998, but the international donor assistance has not matched its requirements for meeting the desired goal (49). However on the ground there were many flaws in health policies and social welfare program in Pakistan as well that will be discussed separately. At ICPD+5, Pakistan had committed to drop population growth below 2 percent per annum till year 2002, and to coming down to 1.3 percent by year 2007 (49). 2.1.3. Fourth World Conference on Women and Beijing Declaration UN’s Beijing Conference on Women in 1995 was culmination of a long process for equality for women that was first highlighted in the year 1975 during the first World Conference of International Women's Year which was held in Mexico City (56). The Beijing Conference attracted unprecedented amount of attention by international community and included 189 governments’ representatives and about 17,000 participants from various international institutions, civil societies and nongovernmental organizations had attended. The agenda of the Beijing Conference was to address eradication of poverty, illiteracy, poor health, unemployment, and violence against women and promotion of women’s empowerment. By the time the conference ended, it had produced “The Beijing Declaration and Platform for Action” (57) an utmost revolutionary master plan ever made for advocating women’s rights. Pakistan had participated in this conference and the first women Prime Minister of Pakistan, Benazir Bhutto addressed critical areas of concern of the women of Pakistan (56). The Prime Minister Benazir Bhutto and her cabinet was fully sensitive to safeguards women’s right and took significant steps for social political, economical and legal empowerment of Pakistani women. In the conference she stated: 26 “As the first woman ever elected to head an Islamic nation, I feel a special responsibility towards women's issues and towards all women.” (58). Bhutto’s government had made efforts to fulfill its international and national commitments to protect the women’s rights as pursued in ICPD and Beijing Declaration, and in order to implement the plan of action, Government of Pakistan had launched a National Plan of Action for Women in August 1998 (59). It was a guideline document which outlines strategic actions for social, economical, political and legal empowerment of Pakistani women. The national action plan emphasized that women’s empowerment may be achieved through recognition of women’s human right, their right to political participation and in decision making at all levels. There after significant amendment were done in the existing law to protect the women’s rights, legal empowerment and for elimination of violence against women (59). Women have been given increased role in every sphere of life. Their representation in Senate, National and Provincial assemblies and in local government had significantly increased (59). During the year 2002, Ministry of Women Development formulated National Policy for Development and Empowerment of Women which articulate Pakistan's another affirmation to incorporate women’s issues in the education, employment, labor, health, child welfare policies for enhancement of empowerment of women (60). 2.1.4. United Nations Millennium Summit At the beginning of new millennium on September 2000, leaders from 189 countries gathered at UN General Assembly building in New York to create global partnership for reducing extreme poverty and augmenting human development during twenty-first century. During the summit, world leaders committed their nations to eradicate poverty and hunger, provide primary education, advocate gender equity and, improve health conditions by combating disease and ensure environmental sustainability through a framework of new global partnership. By the closure of summit, the world leaders endorsed United Nations Millennium 27 Declaration (61) that contains eight time bounded goals known as Millennium Developmental Goals (MDGs) (62). The first Millennium Developmental Goal focused directly on poverty for those living on less than one dollar a day (62), while the following six concentrated on the elementary reasons of poverty, such as illiteracy, poor health, gender inequality, and environmental deterioration. The eighth goal was to expand global partnership between developed and developing countries for achieving above seven at universal level (62). Based on the extensive deliberations during three days summit, 18 targets and 48 indicators were formulated in order to supervise the progress of eight basic goals within fifteen year period with endpoint year 2015. Initially, family planning was not included in Millennium Developmental Goals (63). In 2006, the countdown to MDGs 2015 deadline the developing countries were not on track to achieve these time bounded goals (64). The policy makers were debating evidence-based effective and efficient means to accelerate progress toward MDGs. It was almost 15 years past the International Conference on Population and Development (ICPD), the world once again realized the missing link of family planning and human development and there after MDG target 5b “the achievement of universal access to reproductive health” (62, 63) was included with indictor 5.3 “contraceptive prevalence rate” and 5.6 “unmet need of family planning” (62) which directly advocate for family planning were used to monitor progress. By that time, evidence based researches form many countries proved that family planning was not only directly related to achieving MDG goal 3 and 4 but moreover investing in family planning and reproductive health, states can cost- effectively accelerate their progress bring about the MDGs (65-69). John et al. discussed ‘promotion of family planning in developing countries has averted 32% of all maternal deaths and about 10% of childhood deaths’ (66). Studies from Africa and Latin America evidenced that ’providing universal access to contraception in Kenya and El Salvador could generate a net savings of 200 and 46 million $ respectively for the social sector in meeting the MDG (67). Frost et al. found ‘for every dollar invested in family planning, up to 4 $ are saved in other development areas (68). Wire linked family planning to environmental protection and described ‘cost benefit analysis concluded that family planning is five times 28 economical than other environment friendly technologies for reducing future CO2 emissions (69). Eventually in conjunction with other goals MDG target 5b that necessitates “Universal Access to Reproductive Health Care Including Family Planning” was included in the MDGs check list (62). Inclusion of this target reaffirmed that access to contraceptive services and supplies is essential for poverty reduction and advancement of social development. Government of Pakistan was the signatory of MDGs and was geared to achieve the targets till 2015 In order to maintain commitment to accomplish the Millennium Developmental Goals (MDGs) the government of Pakistan had prepared agenda for human development and health sector reform. Success of developed countries shows that building population policy is a fundamental step to create the frame work of collaboration among various sectors to obtain common goals and objectives regarding population growth, social welfare and economical development. Unfortunately, since independence in 1947, Pakistan did not have any well- enunciated population policy approved and implemented by government. The Pakistan’s First Population Policy (70) was launched in the year 2001, which expressly determined the expending population issues of the country and enthusiastically the vision of that policy focus the mission of ICPD. Around the same time, Third National Health Policy of 2001 (71) was formulated. This policy was based on "Health-For-All" vision for expanding and upgrading the health sector. That policy had ten key areas. The key area 4 in some way emphasize the “need and promotion of greater gender equity in the health sector” with some focuses on provision of essential reproductive health services. It was also planned in that policy to establish “Women-Friendly-Hospitals” under Women Health Project. It is important to know that a draft for separate National Reproductive Health Policy was also prepared in the same time but was remained on paper (72) and the momentum sustained at the theoretical level till Pakistan National Policy for Development and Empowerment of Women (60) was introduced in 2002 with concurrent objective about eradication of poverty and assuring gender equity. Women’s issues essentially reproductive health rights, contraceptive services and provision of primary health care, in particular reproductive health services were 29 highlighted in this policy. The role of lady health worker was also expended and it was planned to increase the number of lady health worker up to one hundred thousand. Since the year 2003, The Planning Commission of Pakistan (73) had performed a remarkable role in making directions for national policies, monitoring the trend of progress, and coordinating the efforts of different stakeholders for achieving MDGs. With the support of United Nations Development Program (UNDP), the Center for Research on Poverty Reduction and Income Distribution was established in the Planning Commission, which has served as a source of information and recommendations on MDGs by qualitative, factual and policy oriented research on fundamental issues (74). Like other developing countries, Pakistan in the year 2003 introduced its Poverty Reduction Strategy Paper (PRSP) which explicitly suggested rising expenditure on reproductive health along with spending in prevention and control of disease (75). The Fourth National Health Policy (76) was introduced in 2009. The policy identified major flaws and gaps in national health systems and various objectives have been defined to make essential health care accessible and affordable by every citizen. This new policy retains few focuses of 2001 policy, however, it appeared though not very accurate that the reproductive health and contraceptive services as a part of essential services package was somewhat neglected in that policy. 2.1.5. London Summit on Family Planning ‘Family Planning 2020 (FP2020)’ A global partnership “Family Planning 2020” (FP2020) was created in London Summit on Family Planning, which was held in year 2012. The aim of this partnership was to expand family planning information as well as services to millions of women in the developing countries by year 2020. The aim was also for supporting the rights of women to decide freely about timing and number of children they want to have (77). The principle of FP2020 is based that all women, no matter where they live should have access to lifesaving contraceptives. Above 20 governments, along with Pakistan, had made commitments in London Summit to address the policy, financing, delivery, and socio-cultural barriers to women accessing contraceptive information, services, and supplies. Donors also 30 pledged an additional US$2.6 billion in funding to meet international family planning goals (77). Pakistan has cited specific target to revitalize Family Planning in the country at the London Summit “Family Planning 2020” in July 2012, and made renewed commitments toward achieving universal access to reproductive health and raising the contraceptive prevalence rate to 55% by 2020. Government also commits to increasing the amount spent on family planning, to nearly US $200 million in the year 2012-13, and further in future years and including contraceptive services in the essential service package by the year 2013 (78). On 11 July 2017, a global summit on family planning was held in London in collaboration with Family Planning 2020 to demonstrate continued and increased leadership on family planning by member states and provide a platform for donors to complement critical investments (79). Reading the statements made by Pakistan’s delegation, it is hoped that some corrective actions are underway (79). Despite above efforts, the progress directed to family planning, reproductive health and women empowerment was painfully slow in Pakistan. In fact evident form Table 2.1 that the ending point of time frame i.e. the year 2015 had been past and neither the targets that were stated in the World Population Plan of Action at ICPD nor in the MDG’s have been fully met. The overall socio-economic development of the country was hampered by various geopolitical and socioeconomic challenges, natural disasters and external and internal security threats. The outcome of MDGs was inevitable painful and Pakistan lags behind on many targets at the deadline because there were huge gaps between declared goals in planning documents on the one hand and the resources and implementation instruments needed to achieve those goals on the other. Moreover, National Health Policies were formulated on biomedical model of health and human behavior and other determinants of health and disease such as socio-cultural and environmental factors were ignored. Evidence based research emphasized that investment in rights-based family planning was one of key element for success especially for developing countries (63). Compelling research has demonstrated that family planning advocacy has direct impact on bring down maternal mortality (66) -the fifth Millennium Development 31 Goal (MDG 5)- because total parity of women is directly related to maternal mortality ratio. Maternal health is fundamental for achieving other goals. Maternal mortality can endanger child’s wellbeing (80), as children who lose their mothers at young age are prone to die themselves (that is MDG 4). Maternal and child mortality and morbidity cost huge burden on country’s economic growth (81) which in turn, result in poverty and hunger (for instance MDG 1). The eradication of malnutrition would improve child health and can increase the school attending rate (namely MDG 2) (82). As educated women enter the labor force, the status of women in the community would be uplifted (viz. MDG 3) (83). Moreover, reduction in population growth along with increasing education level will contribute to environmental sustainability (that is to say MDG 7), (69). However, the progress in contraceptive prevalence in Pakistan was extremely slow during last decade. As evident from demographic and health survey (DHS) in 2012-13, there were millions of women who desire safe and effective methods of contraception but most of them had either fear of adverse effect or lack of access (84). Moreover, the population momentum in the last three decade has created relatively larger reproductive-age cohort in current Pakistan but the Total Fertility Rate was stagnant at about four children (84). The above mentioned facts highlight the importance of including human behavior and socio-cultural models in formulating national health and population polices. 2.1.6. Sustainable Developmental Goals (SDGs) The United Nations General Assembly on September 2015 ratifies a new development agenda “Transforming our world: the 2030 agenda for sustainable development” (85). This new agenda comprise of exceptional range of economical, social and environmental scopes and ambitions and is applicable to all countries. The sustainable development goals (SDGs) include 17 goals with 169 targets (85). Reflecting many linkages between health and other goals, health is not only place indispensable contributor to sustainable development goal but scope of health goal is broadened, in this new agenda; SDG-3 calls for “Ensure healthy lives and promote well-being for all at all ages” (85). 32 SDG-3.7 - “Universal access to sexual and reproductive health care services, including family planning” (85) is one of the 13 health targets set in SDGs. It advocates a complete framework for implementation of a far-flung, enthusiastic and integrated reproductive health agenda in all member states. This goal is a cross- cutting element and concatenation of events for achieving additional health and developmental targets. It is important to mention that the year 2010 brought major shift in power distribution in Pakistan from federal to provincial government by 18th amendment to the national constitution. Under this amendment, increased autonomy on health with federal support was given to provinces in July 2011. It was aimed to deliver the more equitable health services through a resilient and responsive system based on local need and priorities in order to improve the progress of health related MDGs target. This shift in responsibility and authority has created challenges as well as freedom for provincial health departments and the re-established Ministry of National Health Services, Regulation and Coordination. Significant gaps and lack of a consensus in post 18th amendment constitutional role and responsibility of national and provincial health departments were noted (86). It was needed to develop a national vision document on health that is aligned with federal vision, provincial strategies, and international commitments. A comprehensive policy document National Health Vision Pakistan 2016-2025 (86) was formulated to harmonize provincial, federal, and inter-provincial efforts for achieving the desired health goals. It was acknowledged that progress in achieving MDGs has been constrained by fragmentation of service delivery, and inadequate resource commitment and strategic and coordinated approach to achieve the targets of newly adopted SDGs were defined. In this document family planning services was acknowledged as priority area for health facilities and Federal Health Ministry had showed its strong commitment for implementation of it. World Bank research had proved that the reproductive health along with family planning is the one and the only cost-effective investment for accomplishing developmental goals (63). In consonance with above argument and from the challenges faced by Government of Pakistan during the MDG era, it can be concluded that attaining the ‘universal access to family planning’ at national and sub 33 national level is simple and within governmental grasp, however for this government of Pakistan oblige to prioritize family planning program by rising investment in contraceptive services, and make more evidence based policies that including human behavior and socio-cultural factors. According to United Nations Development Program (87), attaining universal access to reproductive health services is estimated to returns of $120 for every dollar invested. 34 Table 2.1. Time series data for selected MDGs indicators related to maternal and child health as well as women’s empowerment (Pakistan). Goals Indicator Definition 1990 1995 2000 2005 2008 2011 2015 Target MDG1 Prevalence of underweight children under 5 years of age (%) Proportion of children under 5 ye