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Modern Contraception in Pakistan: A Cross-Sectional Study
expand article infoYasmeen Jamali‡, David Jean Simon§
‡ Habib University, Karachi, Pakistan
§ Recherches Appliquées et Interdisciplinaires sur les Violences intimes, familiales et structurelles (RAIV), Québec, Canada

Corresponding author: Yasmeen Jamali ( yasmeenjamali@gmail.com )

© 2024 Yasmeen Jamali, David Jean Simon.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation: Jamali Y, Jean Simon D (2024) Modern Contraception in Pakistan: A Cross-Sectional Study. Population and Economics 8(1): 77-96. https://doi.org/10.3897/popecon.8.e106872
Open Access

Abstract

Despite numerous family planning awareness campaigns, modern contraceptive prevalence remains low in Pakistan. This reality stimulates risky sexual behaviours and compromises reproductive rights. Our study has explored factors associated with modern contraceptive use among sexually active married women in Pakistan.

This study used data from the 2017-2018 Pakistan Demographic and Health Survey (PDHS). A total of 10,282 married women who were sexually active during the last 3 months prior to the survey were included in this study.

The prevalence of modern contraceptive use among sexually active married women in Pakistan equals to 27.7%. Furthermore, the results indicate that age, region, education level, wealth index, fieldworker visit, and number of children were significantly associated with modern contraceptive use among sexually active married women in Pakistan.

The group of sexually active married women in Pakistan is not homogeneous. In order to increase prevalence of modern contraception in this population, different groups of women should be targeted with family planning interventions specific to their needs.

Keywords

sexually active, married women, modern contraceptive use, factors, Demographic and Health survey, Pakistan

JEL codes: I18, J13

Background

Target 3.7 of Sustainable Development Goals (SDGs) 3 proclaims a universal access to sexual and reproductive health services by 2030 globally (WHO 2018). Modern contraceptive use is recognized as an important factor for achieving SDGs as potentially improving maternal, new-born and child health outcomes (Bongaarts and Sinding 2009; Cates et al. 2010; Starbird et al. 2016). The non-use of modern contraceptive methods leads to unintended, mistimed and high risk pregnancies increasing maternal and new-born mortality (UN Department… 2020). Modern contraceptive use prevented about 308 million unintended pregnancies in 2017 and an additional 67 million could have been averted if unmet needs had been satisfied (Sully et al. 2020). However, about 1.1 billion women of reproductive age have a need for contraception to postpone or limit childbearing, and only 44% of them were using modern methods of contraception worldwide in 2019 (United Nations Department of Economic and Social Affairs 2020). Modern methods are the most reliable form of contraception and their use among married women of reproductive age increased from 55% to 57% between 2000 and 2019 worldwide (UN Department… 2020).

Despite the increase in modern contraceptive use, there are differences between the developed, low and middle income countries (Nadeem et al. 2021). Previous pieces of research have suggested that socio-demographic characteristics (Letamo and Navaneetham 2015; Debebe et al. 2017), spousal communication and decision making (Letamo and Navaneetham 2015; Belda et al. 2017; Islam 2018), exposure to mass media (Debebe et al. 2017), knowledge of modern contraceptive methods (Eliason et al. 2014), parity (Debebe et al. 2017), religious and cultural beliefs and myths (Gueye et al. 2015; Wulifan et al. 2019), and fear of side effects (Ochako et al. 2015; Ataullahjan et al. 2020) are associated with modern contraceptive prevalence among married women.

The Pakistan annual population growth rate is 2.4% (WPP UN 2022); the total fertility rate (TFR) equals to 3.6 births per woman in Pakistan; it is 3.9 in rural areas versus 2.9 in urban areas. However, the desired fertility rate in Pakistan is 2.9 meaning that women want on average 0.7 children less than the current fertility rate. Moreover, the contraceptive prevalence rate (CPR) among married women is only 34%: 25% of them using modern and 9% - traditional methods of contraception. It is worth noting that the contraceptive use has stagnated over the last five years (PDHS 2012-13, 35% and PDHS 2018-19 - 34%). Similarly, within 5 years preceding the survey, out of all births, 5% were unwanted and 7% were mistimed at the time of conception, and the abortion rate reached 50 per 1000 women aged 15-49 (National Institute… and ICF 2019). Both the population growth rate and large size challenge Pakistan to all development indicators, particularly, maternal and child health (Aziz et al. 2020; Hanif et al. 2022). This indicates the need for a higher use of contraceptives, particularly modern contraceptive methods to control the burgeoning population and improve quality of life in Pakistan.

The above discussed context of population growth and contraceptive prevalence rate calls for an analysis of the factors associated with the use of modern contraceptive methods. This study, humble in its objective, attempts to identify the factors associated with modern contraceptive use among sexually active married women in Pakistan.

History of Family Planning in Pakistan

A family planning program in Pakistan was initiated in the 1960s with a high political and financial commitment from both the government and donors (Corsa 1965; Adil et al. 1968; Robinson 1978; Robinson et al. 1981). However, it failed to achieve even its initial targets (Khan 1967; Sirageldin et al. 1976; Robinson 1978; Robinson et al. 1981; Mahmood and Ali 1997) due to several design defects including improper mix of methods for the local context and particularly heavy reliance on intrauterine devices (IUDs) (Corsa 1965; Robinson 1978), its separation from the health services, lack of involvement of the private sector (NGOs) and low marketing and education campaigns (Sirageldin et al. 1976; Robinson 1978; Rukanuddin and Hardee-Cleaveland 1992). The programme was also disrupted by the war with India in 1965. However, in the following two decades political commitment was fading away, the Bhutto regime did not prioritise family planning as the program had been initiated by his political rival and General Zia ul Haq with his Islamization regime ignored family planning, thus, the program was almost halted (Sathar 1993; Sultan et al. 2002).

The political support was revived in the 1990s with the launch of the National Program for Family Planning and Community Health that comprised the workforce of Lady Health Workers (LHWs) and engaged private sector via social marketing (Sathar and Casterline 1998). The LHWs were spreading the family planning message in urban and rural areas, providing basic methods of contraception to the population on the doorstep. This led to a 24% increase in CPR in the 1990s and decline in fertility rate (Sathar and Casterline 1998). The non-involvement of religious leadership in the family planning program also hindered achievement of the desired CPR (Mir and Shaikh 2013) as the program faced backlash from the conservative circles (Wazir et al. 2021). The government only realised the importance of this aspect in 2007 and designed an intervention named FALAH aimed at birth spacing rather than birth control as a strategy (Sultan et al. 2002; Mahmood 2012; Mir and Shaikh 2013; Naz and Acharya 2021). The private sector including NGOs and health facilities has increased its services for family planning (Hennink and Clements 2005; Abdullah et al. 2023). Despite an ongoing political and donor support, the program keeps failing to achieve a significant increase in CPR (Zafar and Tasneem Shaikh 2014; Wazir et al. 2021).

The law in Pakistan allows for abortion in the first three months of pregnancy (Ahsan and Jafarey 2008; Sathar et al. 2014). The colonial period Penal Code of 1860 permitted abortions only to ‘save the female life’. However, this was revised in the 1997 to bring it in accordance with the teachings of Islam. The law allows for abortion in the first trimester to save the woman’s life or in order to provide “necessary treatment”. Moreover, in the later stages of pregnancy when the organs of the foetus are developed, abortion is only permissible to save the female life (Ahsan and Jafarey 2008; Abortion in Pakistan 2009). In terms of family planning the public sector offers modern methods of contraception free of charge including implants, IUDs, injectables and female sterilisation and serve almost 44% of women (National Institute… and ICF 2019). However, the private sector including health facilities, NGOs and shops has provided contraceptives to roughly more than half of contraception users (Abdullah et al. 2023).

Data and methods

Located in South Asia, the Republic of Pakistan is the fifth most populous country in the world. According to United Nations, its population was estimated to be 240.5 million in 2023 for an area of 804 000 km2, and 63% of them living in rural areas. Further, 49,5% of the Pakistan population is composed of women, 50% of them are of childbearing age (UN Department… 2022). Pakistan’s GDP equals to $346.3 billion (current US$) (World Bank and OECD 2022). The poverty headcount measured using the national poverty line decreased from 64.3% in 2001 to 21.9% in 2018 (World Bank 2022). Administratively, Pakistan is divided into the following four provinces: Punjab, Sindh, Khyber Pakhtunkhwa, and Balochistan. Punjab is the most populated province of Pakistan with the highest economic activities and best health and educational infrastructure (UNDP 2020).

Data source

We used data from the most recent Pakistan Demographic and Health Survey (PDHS), which was conducted from November 2017 to April 2018. The 2017-2018 PDHS is a nationally representative survey implemented by the National Institute of Population Studies (NIPS) in collaboration with the Ministry of National Health Services, Regulations and Coordination (NHSRC), ICF International, and Department for International Development (DFID) of the United Nations Population Fund (UNFPA) (National Institute… and ICF 2019). The survey collected data on a wide range of public health-related issues including demographics characteristics, socioeconomic status, sexual activity, contraceptive use, maternal and child health, women’s empowerment, domestic violence, etc. The women’s data file, which contains information on demographic characteristics of women of childbearing age as well as the use of contraceptive methods, was used in this study. Further information about the 2017-2018 PDHS is provided in the full report (National Institute… and ICF 2019).

Sample design

A two-stage stratified sample design was employed to select study participants and estimate the key indicators at the national level, as well as in urban and rural areas. In the first stage, 580 enumeration blocks (EBs) were selected from a list of clusters based on the 2017 Pakistan Population and Housing Census sample frame. For the Pakistan Bureau of Statistics (PBS), an EB is a geographical area that covers on average 200 to 250 households (Pakistan Bureau of Statistics 2020). These EBs were chosen independently basing on the probability proportional to size. The second stage involved a systematic sampling of 16,240 households within each cluster from which all ever-married women of childbearing age (15–49 years), who were either permanent residents of the household or visitors who stayed over in the household the night before the survey were eligible to be interviewed. A total of 15,930 women were eligible to participate and 15,068 were successfully interviewed with a 94.6% response rate National Institute… and ICF 2019).

Target population

The study sample was limited to married women of childbearing age (n=10,282), who were sexually active during the last 3 months prior to the survey. This limitation was due to the fact that during the 2017-2018 PDHS only married women were interviewed (National Institute… and ICF 2019). Married women who were not sexually active during this period were excluded from the final analysis. Figure 1 shows the derivation of the study sample.

Figure 1.

Sample selection procedure. Source: Pakistan Demographic and Health Survey 2017-2018, Women’s data file

Study variables and measurements

Modern contraceptive use was the main outcome variable. To derive this variable, all married women were asked of the current use by method type. It was measured as a binary variable with the response categories of 1 = Yes (If the participants reported using modern contraceptives) and 0 = No (If the participants reported using traditional/folkloric/no method) during the last three months prior to the survey.

Several individual and community-level explanatory variables presented in Table 1 were chosen based on prior studies (Osmani et al. 2015; Gebre and Edossa 2020; Kumar et al. 2021; Pokhrel et al. 2021; Abdelaziz et al. 2022; Boadu 2022; Bolarinwa et al. 2022; Ekholuenetale et al. 2022; Kirana and Idris 2022; Meselu et al. 2022; Tesfa et al. 2022).

Table 1.
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Selected individual and community-level explanatory variables

Independent variables Name Categories Variable type
Individual level Women’s age Less than 25, 25-29, 30-34, 35-39, 40 and above Ordinal
Women’s education level No formal education, Primary, Secondary, Higher Ordinal
Partner’s education level No formal education, Primary, Secondary, Higher Ordinal
Currently employed Yes, No Nominal
Knowledge of contraceptive methods Doesn’t know any method, Knows only traditional methods, Knows modern methods Nominal
Number of living children Less than 3, 3-4, 5 and above Ordinal
Community level Region Punjab, Sindh, Khyber Pakhtunkhwa, Balochistan, ICT Islamabad, FATA Nominal
Fieldworker visit Yes, No Nominal
Health facility visit Yes, No Nominal
Wealth index Poorest, Poorer, Middle, Richer, Richest Ordinal
Exposure to mass media family planning messages Yes, No Nominal

Source: composed by the authors based on the PDHS 2017-2018

Statistical analysis

Univariate descriptive statistics (frequency, percentage, mean, and standard deviation) were used to describe socio-demographic profiles of the respondents. Then, bivariate analyses were carried out to assess the prevalence of modern contraceptive use by socio-demographic parameter, and to explore independent associations (Pearson’s chi-square test) between the outcome variable and each covariate. Further, binary logistic regression model was estimated to identify significant factors associated with modern contraceptive use among married women in Pakistan. Model fitness was checked with Hosmer–Lemeshow goodness of fit test (p=0.12 >0.05). To detect potential multicollinearity, we used the variance inflation factor (VIF) at a cut-off point of 10 (O’Brien 2007; Alin 2010; Vatcheva et al. 2016). None of the variables displayed multicollinearity problems (all VIF < 10; Mean VIF=2.48). The results of the binary logistic regression were reported as crude odds ratios (cOR) and adjusted odds ratios (aOR) with the corresponding 95% confidence intervals (CIs). All frequency distribution analyses were weighted (HV005/1,000,000) and the “svyset” command was applied to correct for under- and over-sampling (Currie 2008; Elkasabi 2015). All the analyses were performed in STATA software version 14.0, and the p-value < 0.05 was considered as a significant statistical level.

Ethics statement

Permission to utilize the 2017-2018 PHDHS was obtained from the demographic health survey program (https://dhsprogram.com/data/available-datasets.cfm). The survey protocol was retrieved and approved by the Ministry of National Health Services, Regulations and Coordination (NHSRC), and Institutional Review Board (IRB) of ICF Macro. Informed consent was obtained at the beginning of each interview by the PDHS data collectors (National Institute… and ICF 2019).

Results

Socio-demographic profiles of the study participants

Slightly more than 20% of the respondents were under 25 years, while 21.3% were aged 40 years and above (Appendix Table A1). The mean age of the participants equalled to 32.1 years (SD ± 8.3). About two-thirds of them lived in rural areas (62.5%) and 52.1% came from the Punjab region. Almost half of the women had no formal education and 13.1% had higher education levels compared to 30.2% and 19.9% of their partners, respectively. Around 40% were in the poor (poorest and poorer) wealth index category, and less than 20% were employed. Also, almost all participants reported having knowledge of modern contraceptive methods, 24.1% were exposed to mass media family planning (FP) messages during the last few months preceding the survey, 53.8% were visited by a fieldworker, less than 30% visited a health facility, and nearly a quarter (24.1%) had 5 or more children.

Association between socio-demographic characteristics and modern contraceptive use

Figure 2 depicts the prevalence of contraceptive use by method type among married women in Pakistan. 27.7% (95% CI: 26.8 – 28.6) of the respondents reported using modern contraceptives, 10.3% used traditional methods, while 62.0% didn’t use any method at all.

Although prevalence of modern contraceptive use remains very low within this population, it varies significantly depending on socio-demographic characteristics of the respondents (all p-values < 0.05) (Appendix Table A2). Less than 15% of young women used modern contraceptive methods, while this proportion was over 30% among those aged 30 and above. The results underscore the major regional disparities: modern contraceptive use was most common in urban areas (31.4%) and in the Punjab region (30.4%). Women and partners who had no formal education had a prevalence of modern contraceptive use of 23.6%, while a 30 % prevalence was registered in those with higher education levels. Further, prevalence of modern contraceptive methods was higher among women from rich households (richer: 31.0%; the richest: 32.9%) and currently employed (31.4%). Similarly, the use of modern contraceptives was most common among women who were exposed to mass media family planning (FP) messages (32.8%), who were visited by a fieldworker (31.2%), who visited a health care facility (28.6%), and with 5 or more children (41.8%).

Figure 2.

Prevalence of contraceptive use by method type. Source: Pakistan Demographic and Health Survey 2017-2018, Women’s data file

Factors associated with modern contraceptive use among married women in Pakistan

In binary logistic regression, women’s age, region, women’s education level, wealth index, fieldworker visit, and number of children were significantly associated with modern contraceptive use among married women in Pakistan (Appendix Table A3).

Women in the 25-29, 30-34, and 35-39 age groups had 1.3 higher odds (aOR = 1.30, 1.31 and 1.26, respectively) of using modern contraceptives than those aged 40 and above. The odds of using modern contraceptives decreased by 50% (aOR = 0.50) among women from Balochistan compared to those from Punjab. Also, the results show that the odds of using modern contraceptives were lower among women without any formal education (aOR = 0.49), primary education (aOR = 0.67), secondary education (aOR = 0.74) compared to their peers with the highest education levels. Similarly, the odds of using modern contraceptives were lower among women from the poorest households (aOR = 0.54) than those from the richest ones. Being exposed to mass media family planning (FP) messages was associated with the increased odds (aOR = 1.33) of using modern contraceptives. In addition, the odds of using modern contraceptives decreased by 85% (aOR = 0.15) and 39% (aOR = 0.61) among women who had less than 3 children and 3-4 children, respectively compared to their peers with 5 or more children.

Discussion

The study has investigated the factors associated with the modern contraceptive use among sexually active married women in Pakistan using the latest data from the PDHS 2017-18. The estimated prevalence of modern contraceptive use equals to 27.7% (95% CI: 26.8-28.6). However, there are differences between South Asian countries like Afghanistan, Bangladesh, India, Nepal, Maldives and Pakistan (Sreeramareddy et al. 2022). The differences may be due to variation in the implementation of sexual and reproductive health policies in these countries.

The results also show that the respondent’s age, region, education level, wealth index, social fieldworker visit, and number of children were identified as determinants of modern contraceptive use. Women with higher education levels are more likely to use modern contraceptive methods. This result corroborates those of previous studies in India (Kumar et al. 2021), Ethiopia (Gebre and Edossa 2020; Meselu et al. 2022), Nigeria (Akinyemi et al. 2022), Bangladesh (Islam et al. 2016) and Afghanistan (Osmani et al. 2015). Education influences women’s behaviour towards using modern contraceptives via information on family planning. Moreover, educated women are more likely to be in better position to negotiate and bargain on modern contraceptive use with their partners (Bashir and Guzzo 2021; Adde et al. 2022; MacQuarrie and Aziz 2022).

The odds of using modern contraceptives among women in the 25-29, 30-34, and 35-39 age groups increased compared with those in the 40+ age group. In line with previous pieces of research in Iran (Tehrani et al. 2001) and Bangladesh (Islam et al. 2016), this may be due to the fact that younger women are better educated and have more access to modern contraceptive methods than those aged 40 or older. Further, it should be noted that the use of modern contraceptives increases along with reproductive age (30-34 years) and then decreases. Indeed, women in the 30-34 age groups are more likely to choose to space births or limit the number of children when the desired family size was reached (Tehrani et al. 2001; Islam et al. 2016).

Region is significantly associated with modern contraceptive use among sexually active married women in Pakistan. Women in Balochistan province are less likely to use modern contraceptives compared to their counterparts from Punjab province. Balochistan is the least developed province in Pakistan with poor health and education infrastructure (UNDP 2020). This means that women from this region are much underserved by both information and family planning services. Balochistan is a very traditional province where large families are highly valued, preventing women from using modern contraceptive methods (Nadeem et al. 2021; MacQuarrie and Aziz 2022). The regional socio-economic disparities can influence the use of contraceptives and this result is supported by evidence from Bangladesh (Khan et al. 2022), Iraq (Abdelaziz et al. 2022), Nigeria (Bolarinwa et al. 2022), Ethiopia (Gebre and Edossa 2020; Meselu et al. 2022) and Sub-Saharan Africa (Tesfa et al. 2022).

Similarly, the study has revealed that wealth index is a significant predictor of modern contraceptive use. Women from poor households are less likely to use modern contraceptive methods compared to those from rich households. Consistent with research from Afghanistan (Osmani et al. 2015), India (Kumar et al. 2021; Das et al. 2022), Bangladesh (Islam et al. 2016), Sub-Saharan Africa (Ahinkorah 2020; Boadu 2022), Ethiopia (Gebre and Edossa 2020; Meselu et al. 2022), Nigeria (Bolarinwa et al. 2022), this finding is partly due to the fact that some women from poor households cannot access contraceptive services (even if they want to) because of the lack of financial resources and economic dependence (Wulifan et al. 2019). The public sector provides free of charge contraceptives via the family planning division and public health facilities to nearly 44% of women (National Institute… and ICF 2019). However, the insufficient number of health facilities and inefficiencies in the system lead to inconsistent and poor-quality services even if they are available. This situation has made more users turn to private sector as a source of contraceptive commodities and service provider (Abdullah et al. 2023).

Another important factor associated with the use of modern contraceptives by women identified by this study is a fieldworker visit. The odds of using modern contraceptives among women who were visited by a fieldworker increased compared to those who were not visited by a fieldworker. The plausible reason is that fieldworkers are a source of information for women in urban slums, small towns and villages (Upvall et al. 2002; Mumtaz et al. 2003; Bhutta et al. 2011; Memon et al. 2015; Azmat et al. 2016; Soofi et al. 2017; Bechange et al. 2021; Omer et al. 2021). Similarly, the odds of using modern contraceptives among women decreased with having less than 5 children compared to their counterparts with 5 or more children. This finding is consistent with previous evidence from Bangladesh (Islam et al. 2016). There is also evidence that women opt for tubal ligation (female sterilization) after 5 or more children (Khan et al. 2013).

Study strengths and limitations

The study has several strengths. It presents evidence that supports the importance of understanding modern contraceptive use among sexually active married women in Pakistan, which could have important implications for sexual and reproductive health policy in Pakistan. Furthermore, the study involved a large sample size, and information on contraceptive use was collected using the standard tools.

However, the study’s findings are limited in some way. First, due to the nature of the study design, it was not possible to establish a cause-effect relationship. Second, the study focused on married women only, and excluded all women who were single/separated/divorced during the data collection. Third, the study may be affected by recall bias. At last, the definition of “sexually active” used in this study is not universal. In fact, this concept varies from one study to another (Adde et al. 2022; Bolarinwa et al. 2022).

Conclusion

Prevalence of modern contraceptive use is low among sexually active married women in Pakistan. Women from Balochistan province, young age groups, less educated, poorest, those not visited by a fieldworker and having less than 5 children are less likely to use modern contraceptive methods. The findings suggest that the family planning outreach and modern contraceptive services should be expanded in Balochistan province and to the poorest and less educated women. The information campaigns about modern contraceptive methods should be increased and men should also be included in such campaigns. Integrating family planning in public health programs and services could cover a large share of population. Also, including family planning services in universal health coverage will reduce the out-of-pocket cost burden on the general population and particularly on poor couples.

Acknowledgements

The authors would like to thank Demographic and Health Surveys (DHS) Program for the approval to use the 2017-2018 PDHS data.

Availability of data and materials

The dataset used in this study is available from:

https://dhsprogram.com/data/dataset/Pakistan_Standard-DHS_2017.cfm?flag=0

References

  • Abdelaziz W, Nofal Z, Al-neyazy S (2022) Factors affecting contraceptive use among currently married women in Iraq in 2018. Journal of Biosocial Science 55(3): 449–62. https://doi.org/10.1017/S0021932022000104
  • Abdullah M, Bilal F, Khan R, Ahmed A, Khawaja AA, Sultan F, Khan AA (2023) Raising the contraceptive prevalence rate to 50% by 2025 in Pakistan: an analysis of number of users and service delivery channels. Health Research Policy and Systems 21: 4. https://doi.org/10.1186/s12961-022-00950-y
  • Adde KS, Ameyaw EK, Mottey BE, Akpeke M, Amoah RM, Sulemana N, Dickson KS (2022) Health decision-making capacity and modern contraceptive utilization among sexually active women: Evidence from the 2014–2015 Chad Demographic and Health Survey. Contraception and Reproductive Medicine 7: 21. https://doi.org/10.1186/s40834-022-00188-7
  • Adil E, Hardee JG, Sadik N (1968) Pakistan: The Family Planning Program, 1965-1967. Studies in Family Planning 1(26): 4–11. https://doi.org/10.2307/1965195
  • Ahinkorah BO (2020) Predictors of modern contraceptive use among adolescent girls and young women in sub-Saharan Africa: a mixed effects multilevel analysis of data from 29 demographic and health surveys. Contraception and Reproductive Medicine 5: 32. https://doi.org/10.1186/s40834-020-00138-1
  • Ahsan A, Jafarey SN (2008) Unsafe abortion: global picture and situation in Pakistan. JPMA. The Journal of the Pakistan Medical Association 58: 660–1.
  • Akinyemi JO, Dipeolu OI, Adebayo AM Gbadebo BM, Ajuwon GA, Olowolafe TA, Adewoyin Y, Odimegwu CO (2022) Social consequences of COVID-19 on fertility preference consistency and contraceptive use among Nigerian women: insights from population-based data. Contraception and Reproductive Medicine 7: 14. https://doi.org/10.1186/s40834-022-00181-0
  • Ataullahjan A, Vallianatos H, Mumtaz Z (2020) Needles Don’t Agree with Me, Pills Don’t Agree with Me: Experiences of Contraceptive Use among Pakhtun Women in Pakistan. Studies in Family Planning 51(4): 361–75. https://doi.org/10.1111/sifp.12137
  • Aziz A, Saleem S, Nolen TL, Pradhan NA, McClure EM, Jessani S, Garces AL, Hibberd PL, Moore JL et al. (2020) Why are the Pakistani maternal, fetal and newborn outcomes so poor compared to other low and middle-income countries? Reproductive Health 17: 190. https://doi.org/10.1186/s12978-020-01023-5
  • Azmat SK, Hameed W, Hamza HB, Mustafa G, Ishaque M, Abbas G, Khan OF, Asghar J, Munroe E, Ali S, Hussain W, Ali S, Ahmed A, Ali M, Temmerman M (2016) Engaging with community-based public and private mid-level providers for promoting the use of modern contraceptive methods in rural Pakistan: results from two innovative birth spacing interventions. Reproductive Health 13: 25. https://doi.org/10.1186/s12978-016-0145-9
  • Bashir S, Guzzo K (2021) Women’s Education, Spousal Agreement on Future Fertility Intentions, and Contraceptive Use in Pakistan. Studies in Family Planning 52(3): 281–98. https://doi.org/10.1111/sifp.12167
  • Bechange S, Schmidt E, Ruddock A Khan IK, Gillani M, Roca A, Nazir I, Iqbal R, Buttan S, Bilal M, Ahmed L, Jolley E (2021) Understanding the role of lady health workers in improving access to eye health services in rural Pakistan – findings from a qualitative study. Archives of Public Health 79: 20. https://doi.org/10.1186/s13690-021-00541-3
  • Belda SS, Haile MT, Melku AT, Tololu AK (2017) Modern contraceptive utilization and associated factors among married pastoralist women in Bale eco-region, Bale Zone, South East Ethiopia. BMC Health Services Research 17: 194. https://doi.org/10.1186/s12913-017-2115-5
  • Bhutta ZA, Soofi S, Cousens S, Mohammad S, Memon ZA, Ali I, Feroze A, Raza F, Khan A, Wall S, Martines J (2011) Improvement of perinatal and newborn care in rural Pakistan through community-based strategies: a cluster-randomised effectiveness trial. The Lancet 377(9763): 403–12. https://doi.org/10.1016/S0140-6736(10)62274-X
  • Boadu I (2022) Coverage and determinants of modern contraceptive use in sub-Saharan Africa: further analysis of demographic and health surveys. Reproductive Health 19: 18. https://doi.org/10.1186/s12978-022-01332-x
  • Bolarinwa OA, Babalola TO, Adebayo OA, Ajayi KV (2022) Health insurance coverage and modern contraceptive use among sexually active women in Nigeria: Further analysis of 2018 Nigeria Demographic Health Survey. Contraception and Reproductive Medicine 7: 22. https://doi.org/10.1186/s40834-022-00187-8
  • Bongaarts J, Sinding SW (2009) A Response to Critics of Family Planning Programs. International Perspectives on Sexual and Reproductive Health 35(1): 39–44. https://doi.org/10.1363/3503909
  • Cates W, Abdool Karim Q, El-Sadr W, Haffner DW, Kalema-Zikusoka G, Rogo K, Petruney T, Averill EMD (2010) Family Planning and the Millennium Development Goals. Science 329(5999): 1603. https://doi.org/10.1126/science.1197080
  • Currie J (2008) Healthy, Wealthy, and Wise: Socioeconomic Status, Poor Health in Childhood, and Human Capital Development. National Bureau of Economic Research, Working Paper 13987. https://doi.org/10.3386/w13987
  • Das M, Anand A, Hossain B, Ansari S (2022) Inequalities in short-acting reversible, long-acting reversible and permanent contraception use among currently married women in India. BMC Public Health 22: 1264. https://doi.org/10.1186/s12889-022-13662-3
  • Debebe S, Andualem Limenih M, Biadgo B (2017) Modern contraceptive methods utilization and associated factors among reproductive aged women in rural Dembia District, northwest Ethiopia: Community based cross-sectional study. International Journal of Reproductive BioMedicine 15(6): 367–74. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5605858/
  • Ekholuenetale M, Owobi OU, Shishi BT (2022) Socioeconomic Position in Modern Contraceptive Uptake and Fertility Rate among Women of Childbearing Age in 37 Sub-Saharan Countries. World 3(4): 858–75. https://doi.org/10.3390/world3040048
  • Eliason S, Awoonor-Williams JK, Eliason C, Novignon J, Nonvignon J, Aikins M (2014) Determinants of modern family planning use among women of reproductive age in the Nkwanta district of Ghana: a case–control study. Reproductive Health 11: 65. https://doi.org/10.1186/1742-4755-11-65
  • Gebre MN, Edossa ZK (2020) Modern contraceptive utilization and associated factors among reproductive-age women in Ethiopia: evidence from 2016 Ethiopia demographic and health survey. BMC Women’s Health 20: 61. https://doi.org/10.1186/s12905-020-00923-9
  • Gueye A, Speizer IS, Corroon M, Okigbo CC (2015) Belief in Family Planning Myths at the Individual and Community Levels and Modern Contraceptive Use in Urban Africa. International Perspectives on Sexual and Reproductive Health 41(4): 191–9. https://doi.org/10.1363/4119115
  • Hanif M, Khalid S, Rasul A, Mahmood K (2022) Maternal Mortality in Rural Areas of Pakistan: Challenges and Prospects. In: Bacha U (ed.) Rural Health. IntechOpen. https://doi.org/10.5772/intechopen.96934
  • Islam AZ (2018) Factors affecting modern contraceptive use among fecund young women in Bangladesh: does couples’ joint participation in household decision making matter? Reproductive Health 15: 112. https://doi.org/10.1186/s12978-018-0558-8
  • Khan N, Akter S, Islam MM (2022) Availability and readiness of healthcare facilities and their effects on long-acting modern contraceptive use in Bangladesh: analysis of linked data. BMC Health Services Research 22: 1180. https://doi.org/10.1186/s12913-022-08565-3
  • Letamo G, Navaneetham K (2015) Levels, trends and reasons for unmet need for family planning among married women in Botswana: a cross-sectional study. BMJ Open 5(3): e006603. https://doi.org/10.1136/bmjopen-2014-006603
  • MacQuarrie KLD, Aziz A (2022) Women’s decision-making and contraceptive use in Pakistan: an analysis of Demographic and Health Survey data. Sexual and Reproductive Health Matters 29(2): 2020953. https://doi.org/10.1080/26410397.2021.2020953
  • Memon ZA, Khan GN, Soofi SB, Baig IY, Bhutta ZA (2015) Impact of a community-based perinatal and newborn preventive care package on perinatal and neonatal mortality in a remote mountainous district in Northern Pakistan. BMC Pregnancy and Childbirth 15: 106. https://doi.org/10.1186/s12884-015-0538-8
  • Meselu W, Habtamu A, Woyraw W, Birlew Tsegaye TB (2022) Trends and predictors of modern contraceptive use among married women: Analysis of 2000–2016 Ethiopian Demographic and Health Surveys. Public Health in Practice 3: 100243. https://doi.org/10.1016/j.puhip.2022.100243
  • Mir AM, Shaikh GR (2013) Islam and family planning: changing perceptions of health care providers and medical faculty in Pakistan. Global Health: Science and Practice 1(2): 228–36. https://doi.org/10.9745/GHSP-D-13-00019
  • Mumtaz Z, Salway S, Waseem M, Umer N (2003) Gender-based barriers to primary health care provision in Pakistan: the experience of female providers. Health Policy and Planning 18(3): 261–9. https://doi.org/10.1093/heapol/czg032
  • Nadeem M, Malik MI, Anwar M, Khurram S (2021) Women Decision Making Autonomy as a Facilitating Factor for Contraceptive Use for Family Planning in Pakistan. Social Indicators Research 156: 71–89. https://doi.org/10.1007/s11205-021-02633-7
  • Naz S, Acharya Y (2021) The Effect of Reframing the Goals of Family Planning Programs from Limiting Fertility to Birth Spacing: Evidence from Pakistan. Studies in Family Planning 52(2): 125–42. https://doi.org/10.1111/sifp.12155
  • Ochako R, Mbondo M, Aloo S, Kaimenyi S, Thompson R, Temmerman M, Kays M (2015) Barriers to modern contraceptive methods uptake among young women in Kenya: a qualitative study. BMC Public Health 15: 118. https://doi.org/10.1186/s12889-015-1483-1
  • Omer S, Zakar R, Zakar MZ, Fischer F (2021) The influence of social and cultural practices on maternal mortality: a qualitative study from South Punjab, Pakistan. Reproductive Health 18: 97. https://doi.org/10.1186/s12978-021-01151-6
  • Osmani AK, Reyer JA, Osmani AR, Hamajima N (2015) Factors influencing contraceptive use among women in Afghanistan: secondary analysis of Afghanistan Health Survey 2012. Nagoya Journal of Medical Sciences 77(4): 551–61. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4664587/
  • Pokhrel T, Aryal K, Adhikari R, Dulal BP, Karki DK, Dahal HR, Dangol MS, Poudel P, Bhattarai N, Lamichhane P (2021) Socioeconomic Determinants of Inequalities in the Use of Modern Contraception among Currently Married Women. Journal of Nepal Health Research Council 19(4): 705–11. URL: https://pubmed.ncbi.nlm.nih.gov/35615826/
  • Robinson WC, Shah MA, Shah NM (1981) The Family Planning Program in Pakistan: What Went Wrong? International Family Planning Perspectives 7(3): 85–92. https://doi.org/10.2307/2948041
  • Rukanuddin AR, Hardee-Cleaveland K (1992) Can Family Planning Succeed in Pakistan? International Family Planning Perspectives 18(3): 109–15. https://doi.org/10.2307/2133410
  • Sathar ZA (1993) The Much-Awaited Fertility Decline in Pakistan: Wishful Thinking or Reality? International Family Planning Perspectives 19(4): 142–6. https://doi.org/10.2307/2133498
  • Sathar ZA, Casterline JB (1998) The Onset of Fertility Transition in Pakistan. Population and Development Review 24(4): 773–96. https://doi.org/10.2307/2808024
  • Sirageldin I, Norris D, Hardee JG (1976) Family Planning in Pakistan: An Analysis of Some Factors Constraining Use. Studies in Family Planning 7(5): 144–54. https://doi.org/10.2307/1964859
  • Soofi S, Cousens S, Turab A, Wasan Y, Mohammed S, Ariff S, Bhatti Z, Ahmed I, Wall S, Bhutta ZA (2017) Effect of provision of home-based curative health services by public sector health-care providers on neonatal survival: a community-based cluster-randomised trial in rural Pakistan. The Lancet Global Health 5(8): e796–e806. https://doi.org/10.1016/S2214-109X(17)30248-6
  • Sreeramareddy CT, Acharya K, Tiwari I (2022) Inequalities in demand satisfied with modern methods of family planning among women aged 15–49 years: a secondary data analysis of Demographic and Health Surveys of six South Asian countries. BMJ Open 12: e049630. https://doi.org/10.1136/bmjopen-2021-049630
  • Starbird E, Norton M, Marcus R (2016) Investing in Family Planning: Key to Achieving the Sustainable Development Goals. Global Health: Science and Practice 4(2): 191–210. https://doi.org/10.9745/GHSP-D-15-00374
  • Sully EA, Biddlecom A, Darroch JE, Riley T, Ashford LS, Lince-Deroche N, Firestein L, Murro R (2020) Adding It Up: Investing in Sexual and Reproductive Health 2019. Guttmacher Institute, New York. https://doi.org/10.1363/2020.31593
  • Sultan M, Cleland JG, Ali MM (2002) Assessment of a New Approach to Family Planning Services in Rural Pakistan. American Journal of Public Health 92: 1168–72. https://doi.org/10.2105/AJPH.92.7.1168
  • Tesfa D, Tiruneh SA, Azanaw MM, Gebremariam AD, Engidaw MT, Tiruneh M, Dessalegn T, Kefale B (2022) Determinants of contraceptive decision making among married women in Sub-Saharan Africa from the recent Demographic and Health Survey data. BMC Women’s Health 22: 52. https://doi.org/10.1186/s12905-022-01636-x
  • Upvall MJ, Sochael S, Gonsalves A (2002) Behind the mud walls: The role and practice of lady health visitors in Pakistan. Health Care for Women International 23(5): 432–41. https://doi.org/10.1080/073993302760190038
  • Wazir MA, Alazar YM, Kadirov B (2021) Family planning: Smartest investment for achieving the Sustainable Developments Goals for Pakistan. The Journal of the Pakistan Medical Association 71(Suppl 7): S12–S19.
  • Wulifan JK, Mazalale J, Kambala C, Angko W, Asante J, Kpinpuo S, Kalolo A (2019) Prevalence and determinants of unmet need for family planning among married women in Ghana – a multinomial logistic regression analysis of the GDHS, 2014. Contraception and Reproductive Medicine 4: 2. https://doi.org/10.1186/s40834-018-0083-8
  • Zafar S, Tasneem Shaikh B (2014) Only systems thinking can improve family planning program in Pakistan: A descriptive qualitative study. International Journal of Health Policy and Management 3(7): 393–8. https://doi.org/10.15171/ijhpm.2014.119

Other sources of information

Abortion in Pakistan (2009) In Brief Series, N°2. Guttmacher Institute, New York. URL: https://www.guttmacher.org/sites/default/files/report_pdf/ib_abortion-in-pakistan_1.pdf

Elkasabi M (2015) Sampling and Weighting with DHS Data. URL: https://blog.dhsprogram.com/sampling-weighting-at-dhs/ (accessed: April 8, 2020)

National Institute of Population Studies (NIPS) [Pakistan], ICF (2019) Pakistan Demographic and Health Survey 2017-18. NIPS and ICF, Islamabad, Pakistan and Rockville, Maryland, USA. URL: https://dhsprogram.com/pubs/pdf/FR354/FR354.pdf

Pakistan Bureau of Statistics (2020) Final Results (Census-2017). URL: https://www.pbs.gov.pk/content/final-results-census-2017.

UN Department of Economic and Social Affairs (2020) World Family Planning 2020: Highlights: Accelerating Action to Ensure Universal Access to Family Planning. United Nations. https://doi.org/10.18356/9789210052009

UN Department of Economic and Social Affairs (2022) World Population Prospects 2022 Online Edition. URL: https://population.un.org/wpp/Download/Standard/Population/

UNDP (2020) Pakistan National Human Development Report 2020. The three Ps of inequality: Power, People, and Policy. URL: https://www.undp.org/sites/g/files/zskgke326/files/migration/pk/NHDR-Inequality-2020---Overview-Low-Res.pdf

World Bank (2022) Poverty headcount ratio at national poverty lines (% of population) – Pakistan. URL: https://data.worldbank.org/indicator/SI.POV.NAHC?locations=PK

World Bank, OECD (2022) National accounts data. URL: https://data.worldbank.org/indicator/NY.GDP.MKTP.CD?locations=PK&most_recent_value_desc

WHO (2018) World health statistics 2018: monitoring health for the SDGs, sustainable development goals. World Health Organization, Geneva. URL: https://apps.who.int/iris/handle/10665/272596 (accessed: December 12, 2022).

WPP UN (2022) Standard projections (Estimates and Projection scenarios). URL: https://population.un.org/wpp/Download/Standard/Population/

Appendix

Table A1.
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Socio-demographic characteristics of the study population

Socio-demographic characteristics Married women sexually active
N Percentage
Age
Less than 25 2105 20.5
25-29 2128 20.7
30-34 2037 19.8
35-39 1822 17.7
40 and above 2189 21.3
Place of residence
Urban 3856 37.5
Rural 6426 62.5
Region
Punjab 5357 52.1
Sindh 2480 24.1
KPK 1577 15.3
Balochistan 588 5.7
ICT/FATA 280 2.7
Education level
No formal education 5042 49.0
Primary 1699 16.5
Secondary 2199 21.4
Higher 1343 13.1
Partner’s education levela
No formal education 3102 30.2
Primary 1571 15.3
Secondary 3535 34.4
Higher 2044 19.9
Don’t know 30 0.3
Wealth Index
Poorest 1907 18.5
Poorer 2019 19.6
Middle 2100 20.4
Richer 2078 20.2
Richest 2177 21.2
Currently employed
Yes 1716 16.7
No 8563 83.3
Knowledge of contraceptive methods
Doesn’t know any method 180 1.8
Knows only traditional methods 15 0.1
Knows modern methods 10087 98.1
Exposure to FP messages (medias)
Yes 2482 24.1
No 7800 75.9
Fieldworker visit
Yes 5529 53.8
No 4753 46.2
Health facility visit
Yes 7609 26.0
No 2670 74.0
Number of children
Less than 3 4620 44.9
3-4 3182 31.0
5 and above 2480 24.1
Total 10282 100.0

Source: Pakistan Demographic and Health Survey 2017-2018, Women’s data file a Missing data: partner’s education level (n = 1); currently employed (n = 3); health facility visit (n = 3)
Table A2.
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Bivariable association between modern contraceptive use and socio-demographic characteristics of the study population

Socio-demographic characteristics Modern contraceptive use P-value
Yes (N/%) No (N/%)
Age 0.000
Less than 25 278 (13.2) 1827 (86.8)
25-29 512 (24.1) 1616 (75.9)
30-34 679 (33.3) 1358 (66.7)
35-39 644 (35.3) 1178 (64.7)
40 and above 732 (33.4) 1457 (66.6)
Place of residence 0.000
Urban 1209 (31.4) 2647 (68.6)
Rural 1636 (25.5) 4790 (74.5)
Region 0.000
Punjab 1626 (30.4) 3731 (69.6)
Sindh 648 (26.1) 1832 (73.9)
KPK 421 (26.7) 1156 (73.3)
Balochistan 87 (14.8) 501 (85.2)
ICT/FATA 64 (22.9) 216 (77.1)
Education level 0.000
No formal education 1190 (23.6) 3851 (76.4)
Primary 528 (31.1) 1170 (68.9)
Secondary 670 (30.5) 1529 (69.5)
Higher 457 (34.0) 886 (66.0)
Partner’s education level 0.000
No formal education 733 (23.6) 2369 (76.4)
Primary 479 (30.5) 1092 (69.5)
Secondary 972 (27.5) 2563 (72.5)
Higher 651 (31.8) 1393 (68.2)
Don’t know 10 (33.3) 20 (66.7)
Wealth Index 0.000
Poorest 358 (18.8) 1549 (81.2)
Poorer 501 (24.8) 1519 (75.2)
Middle 626 (29.8) 1474 (70.2)
Richer 644 (31.0) 1434 (69.0)
Richest 716 (32.9) 1461 (67.1)
Currently employed 0.000
Yes 538 (31.4) 1178 (68.6)
No 2307 (26.9) 6256 (73.1)
Exposure to FP messages (medias) 0.000
Yes 813 (32.8) 1668 (67.2)
No 2032 (26.1) 5768 (73.9)
Fieldworker visit 0.000
Yes 1723 (31.2) 3806 (68.8)
No 1122 (23.6) 3631 (76.4)
Health facility visit 0.000
Yes 2179 (28.6) 5430 (71.4)
No 665 (24.9) 2005 (75.1)
Number of children
Less than 3 611 (13.2) 4009 (86.8) 0.000
3-4 1196 (37.6) 1986 (62.4)
5 and above 1037 (41.8) 1442 (58.2)
Total 2845 (27.7) 7437 (72.3)

Source: Pakistan Demographic and Health Survey 2017-2018, Women’s data file
Table A3.
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Binary logistic regression of modern contraceptive use among Pakistan married women by socio-demographic parameters

Socio-demographic characteristics Unadjusted Odds Ratio cOR (95% CI) Adjusted Odds Ratio aOR (95% CI)
Age
Less than 25 0.30*** (0.25 - 0.37) 1.12 (0.87 - 1.46)
25-29 0.63*** (0.53 - 0.76) 1.30* (1.05 - 1.60)
30-34 0.99 (0.84 - 1.19) 1.31** (1.07 - 1.59)
35-39 1.09 (0.91 - 1.30) 1.26* (1.05 - 1.53)
Ref = 40 and above
Place of residence
Urban 1.34*** (1.19 - 1.50) 1.04 (0.89 - 1.22)
Ref = Rural
Region
Sindh 0.81** (0.71 - 0.93) 0.95 (0.81 - 1.12)
KPK 0.84* (0.72 - 0.98) 0.98 (0.82 - 1.16)
Balochistan 0.40*** (0.32 - 0.50) 0.50*** (0.39 - 0.65)
ICT/FATA 0.67*** (0.56 - 0.81) 0.86 (0.70 - 1.07)
Ref = Punjab
Education level
No formal education 0.60*** (0.50 - 0.71) 0.49*** (0.38 - 0.64)
Primary 0.88 (0.71 - 1.08) 0.67** (0.52 - 0.88)
Secondary 0.85 (0.70 - 1.04) 0.74** (0.59 - 0.93)
Ref = Higher
Partner’s education level
No formal education 0.66*** (0.56 - 0.78) 0.95 (0.77 - 1.18)
Primary 0.94 (0.77 - 1.14) 1.07 (0.85 - 1.35)
Secondary 0.81** (0.69 - 0.95) 0.89 (0.74 - 1.07)
Don’t know 1.09 (0.36 - 3.28) 1.23 (0.43 - 3.54)
Ref = Higher
Wealth Index
Poorest 0.47*** (0.39 - 0.57) 0.54*** (0.40 - 0.72)
Poorer 0.67*** (0.56 - 0.81) 0.80 (0.62 - 1.04)
Middle 0.87 (0.73 - 1.03) 0.95 (0.76 - 1.18)
Richer 0.92 (0.77 - 1.09) 1.02 (0.83 - 1.24)
Ref = Richest
Currently employed
Yes 1.18* (1.01 - 1.38) 1.12 (0.95 - 1.32)
Ref = No
Exposure to FP messages (medias)
Yes 1.38*** (1.21 - 1.58) 1.11 (0.95 - 1.29)
Ref = No
Fieldworker visit
Yes 1.46*** (1.30 - 1.65) 1.33*** (1.17 - 1.52)
Ref = No
Health facility visit
Yes 1.20** (1.06 - 1.36) 1.03 (0.90 - 1.18)
Ref = No
Number of children
Less than 3 0.21*** (0.18 - 0.25) 0.15*** (0.12 - 0.18)
3-4 0.84* (0.72 - 0.97) 0.61*** (0.52 - 0.72)
Ref = 5 and above

Source: Pakistan Demographic and Health Survey 2017-2018, Women’s data file *p < .05. **p < .01. ***p < .001.

Information about the authors

Yasmeen Jamali – PhD in Demography, assistant professor at School of Arts, Humanities & Social Sciences (AHSS), Habib University, Karachi, 75290, Pakistan. Email: yasmeenjamali@gmail.com

Jean Simon David - PhD in Demography, researcher at Recherches Appliquées et Interdisciplinaires sur les Violences intimes, familiales et structurelles (RAIV), Québec, G1V 0A6, Canada. Email: djeansimon90@yahoo.fr

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