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8th Postgraduate Course for Training in Reproductive Medicine and Reproductive Biology

South Asian Perspective on Fertility Regulation

Samina Shaheen Ali
Maternity and Child Welfare Association of Pakistan

Under the guidance of
Dr. H.Von Hertzen and Dr. Iqbal Shah
HRP - UNDP/UNFPA/WHO/World Bank Special Programme


Contraception has been practised within the family unit for thousands of years throughout history, various civilisations and cultures have used a variety of plant extracts, herbs and mechanical devices to control fertility. However most of these were ineffective by today’s standards. Even the spermicidal agents, mechanical barriers and the rhythm method used in modern society are not very reliable. As the world experienced a "population explosion" during the second half of the present century the need for fertility control extended beyond the family to society levels as a means of limiting the population growth to a level within their socio-economic capabilities. With the willingness of various governments to support birth control programmes and the advocacy of feminist leaders and increased financial support for biological research, the development of oral contraceptives began in 1950. However it was not until the early 1960`s that contraception became reliable and acceptability effective. The oral contraceptives remain among other things the most effective reversible methods of birth control available today, providing almost 100 percent effectiveness with an impressively high margin of safety and other important health benefits. This bibliography is about the perspectives about fertility regulation of women and men living in the subcontinent i.e. Pakistan, India, and Bangladesh with a few references to the prevalence of contraceptive use in other developing .This paper provides an overview about family planning in South Asia, with emphasis on the perspectives of men and women on contraception in general and on c methods of family planning. More specifically it seeks to,
  1. Document the demographic and socio-economic context of South Asian countries
  2. Reviews the extent of knowledge and contraceptive use in these countries
  3. Investigates the reasons for nouns, for choice of method, and for discontinuation of use

This paper is based on a review of studies related to these aspects and these give a reflection of the perspectives of the people of South Asia.

A lack of knowledge of contraceptive methods or a source of supply, cost and poor accessibility are the barriers that exist in these countries. The health concerns of these individuals also stop a lot of women and men from using modern contraceptive methods. Side effects perceived or real are a major factor for the abandoning of modern methods, unintended pregnancies leading to induced abortions are the major drawbacks in the vaginal methods, periodic abstinence and withdrawal. These methods have the least health concerns but have frequent contraceptive failures. Bongaart and Bruce(1995) estimate that the health concerns reduce a prevalence on an average of 71 percent for the oral pills, 86 percent for IUCDs and 52 percent for sterilisation. The users for contraceptive methods in the subcontinent come from different socio-economic groups and demographic subgroups within a country are highly segmented.

In reproductive health there is an awareness of women’s and men’s views on .contraception. Bruce emphasised no product can be fully acceptable if its intrinsic properties or service delivery procedures are ominous to the users personal and cultural needs.(Bruce 1987). These research articles are very informative about the views of the people on contraceptive methods and this knowledge can help us in "developing and modifying technology and family planning programmes to fit people rather than modifying the people to fit the programmes"(Marshall 1977). Women’s perspectives on technologies and services are very appreciated now, "since women bear the brunt of the responsibility for fertility regulation, it is vital to include their perspectives in research on fertility regulation (Van Look P. and Perez-Palacois 1994). WHO also aims to " expand its technical support for family planning services with broader reproductive health perspectives, placing particular emphasis on the needs of young people."(WHO EB 95/98).


An over view of the perspectives on the methods of fertility regulation of the people of Pakistan, India and Bangladesh is presented in the following paragraphs. These three countries lie close together and have many similarities in the socio-economic status, cultures and religions of their people, in fact they were one country until a partition that took place in 1947. This paper will look at the various studies and reviews written about Pakistan, India and Bangladesh over the past years, focusing more on the more recent reviews written about these countries. There are limited articles on these countries available, but I will try to show the perspectives on family planning, of the people of these countries that have gradually changed over the last two decades. As you will see the changes are more pronounced in Bangladesh and India than in Pakistan.


Various population strategies have been initiated since 1953 but with only limited success to lower the fertility levels (Hashmi 1991). In spite of the fact that the Family Planning Association of Pakistan (FPAP) has been working for the past 40 years, the population growth rate is still one of the highest in the world .Very few surveys have been carried out to analyse the problem of resisting high growth rate. In a review of the available literature the following perspectives of the people of Pakistan have been uncovered by looking at their various aspects of their lives the education their awareness of the contraceptive methods reflects their attitudes about these methods of contraception and how much interest they are taking in fertility regulation

Despite a vigorous national family planning program and such innovations as the continuous motivation system there has been little change in contraceptive use in Pakistan in recent years. Data from 1968-69 National Impact Survey and World Fertility Survey for Pakistan show that the use ratios increased by a small amount in the urban areas, the rates in the rural areas seem to have declined. Even in urban areas contraceptive use is low in comparison with other developing countries that begun contraception at about the same time. Although it was probably due to the to the differences in economic development further investigation of programs structure and inputs was recommended.(see graph. 3)

Even in 1986-87 the government’s economic survey revealed that this is the highest growth rate among the nine most populous countries of the world. It was higher than the overall average of the developing countries then i.e. 2 percent. Even then it was recognised that this represented a significant threat to improved maternal and child health and that it should have been reduced.(Govt of Pakistan and UNICEF 1988-92)

The 1984-85 Pakistan Contraceptive Prevalence Survey showed that urban wives had more than twice the literacy rate of rural wives. The present study explored the relationship of the rural urban gap in female literacy to difference in contraceptive use. In the rural areas, literacy did not increase women’s perceptions of having reached a sufficient number of living children although the opposite was true for the urban areas. Yet rural women with insufficient number of living children were more likely to use contraception if they were literate as did their urban counter parts. Thus raising the literacy rate in Pakistan would not narrow the urban-rural gap in contraception to cease child bearing but would narrow the gap in contraception used to space wanted children further apart. Recommendations for government policy are made. (Zafar KP 1993).

In 1985 Yusufi interviewed 992 ever married women 15-49 years of age in Lahore Pakistan he did a cross sectional survey with a structured questionnaire to find out the reasons for non use of contraceptives. The main findings were that
  • women had a desire for more children
  • Recent marriage
  • Religious opposition.

Recent marriage and religious opposition appeared less significant compared to what was reported in 1960.

According to the Pakistan DHS 1990-91 the following results were obtained: in 1990-91, 69 percent of the women interviewed showed an intention to use a contraceptive method within the next twelve months. The percentage of currently married women 15-49 years of age who know any method and who know a source was as follows: any method of contraception 78 percent and 45 percent also knew the source of a method of contraception. In Pakistan, December -May 1990-91, a questionnaire given to ever married women between 15-49 years of age a total of 6611 women were interviewed and 1354 husbands (see table 1, table 2, graph. 4).

In a comparative study of 1100 women aged 25-45 users and non users of modern methods of contraception in the urban areas of Lahore and Faisalabad conducted in 1991 concluded that cultural setting and tradition exert an important influence on reproductive behaviour, independent of economic development.(Zafar. M. 1995).

Also seen in the Pakistan DHS 1990-91 was that there were large differences in knowledge between the urban and the rural women: 94 percent of the currently married women residing in major cities knew of at least one modern method of contraception and three fourths knew where to obtain one. Among rural women only 71 percent knew of a modern method and only 34 percent knew where to obtain one. Differences were also seen between the women of different parts of Pakistan, the women in the Punjab, Sindh and NWFP had the knowledge of a modern method ranging from 74-83 percent, but only 37 percent of the Baluchi women reported knowing a modern method and only half as many women knew of a source for the modern method. Only 73 percent of the women with no education knew of a modern method compared with 92 percent of primary school and 95 percent of those who had secondary school education. Similarly only 38 percent of illiterate women knew where to obtain a method, compared with 82 percent of the ones who were literate.

Only one fifth of the ever married women had used a contraceptive method in the past. 16 percent of the currently married women had used a modern method while 9 percent had used a traditional method. Periodic abstinence was the most commonly used traditional method. The most commonly used modern method were the condom 7 percent followed by the pill 5 percent and female sterilisation 4 percent less than 1 percent of the women reported having ever used a vaginal method, such as a diaphragm, spermicides or suppositories A negligible proportion reported the use of male sterilization (1 percent).

Only one fifth of the women between 30-44 years had used a modern method. Contraceptive use rates were highest in the age group between 35-39 year, where knowledge was said to be the highest. A low use rate was observed among women: in the age group between 15-19 years only 2 percent had ever used a modern method. The use of traditional methods was highest in the 35-39 years age group (13-14 percent) followed by 10 percent in the adjacent age groups of 30-34 and 40-44.

In a cross sectional survey of 608 married women 15-49 years of age living in a low income community in Karachi Pakistan the following results were seen.
  • 3.7 was the mean number of children per women
  • 53 % was the literacy rate
  • 29% were using a contraceptive method

These women were 4-5 times more likely to use contraception if they had three or more living children than if they had two or less. These results strongly suggest that the number of children and the women’s education are the key determinants in the decision making about contraceptive use (Lasee 1996).

Contraceptive use increased over 15 years from 5 percent in 1975 to 14 percent in 1991 but there was a great need for further increase. A study in 1990-91 DHS showed that the age as well as the parity of sterilized women showed a declining trend.

Over all the government supplied 56 percent of all modern methods: 85 percent of sterilizations and 81 percent of the IUD users obtained services from the government sources. the users of the pill and condoms were less dependent on the government for their supply, 72 percent sterilizations and 41 percent of the IUD insertions were provided free of charge by the government. In private practise 2700 rupees is charged for a sterilization and at least 100 rupees for an IUD insertion this is far too expensive for the majority of the population. Hence the emphasis on the provision of free sterilization is well placed (Pak.DHS 1990-91). Less people would have had a sterilization done if had to pay as the people also consider the cost of such procedures.

Although the husband wife discussion of family planning is not a necessary condition for adopting contraception earlier research in Pakistan does indicate that interspousal communication created an interest in support for regulating fertility through contraceptive use(Shah.1974).It was found that women of major cities were more than twice as likely as women in the rural areas to have discussed family planning with their husbands, 41 percent versus 20 percent. Similarly the rate of women in the Punjab who discussed family planning with their husbands was 28 percent as compared to NWFP where only 17 percent of the women discussed these issues with their husbands. The education of women was found to be a significant variable, overall 55 percent of uneducated women approved family planning, compared to 89 percent of women with secondary education. As education increased the proportion of women who reported that both, themselves and their husbands approve of the use of family planning increased from 43 percent in the case of primary education to 55 percent in the case of middle school education and 70 percent in the secondary and higher education.

Many women heard the message on radio or television. In the rural area 19 percent of women had heard the family planning message on the radio or television in the past month and 46 percent of women had heard these messages in the major cities. Eighty percent of women who heard these messages said they were effective, while 10 percent reported that they were not effective and 9 percent said they don’t know.

During the survey done in Pakistan (Pak.DHS 1990-91) 43 percent said that they did not intend to use contraception because they wanted more children. This reason was given by 64 percent of women under 30 years, but only by one quarter of women above 30 years. Religious reasons were cited by 13 percent followed by a lack of knowledge by 11 percent. Although Pakistan is stated to be a male dominated society only 6 percent of women mentioned their husbands opposition to the adoption of family planning methods as the reason for which they do not intend to use contraception. A significant number of older women reported their actual or perceived sterility as the main reason for not intending to use contraception in future. A survey on husbands showed that 56 percent of husbands approved family planning (Sultan S 1990-91).

A cross section survey was conducted in Shirin Jinnah colony in a low income urban squatter settlement in Karachi Pakistan in February 1991 in collaboration with the National Institute for Fertility Control (NRIFC)(Ashraf Lasee 1996). Six hundred and eight women were interviewed. Results showed that the current use of family planning was 40 percent if a woman desired no more children and only 19.3 percent if she wanted to have more children. The desire for more children was 46 percent in illiterate women as compared to 13 percent in literate women. This shows a strong relationship between ideal family size and education of a women. Over 33 percent of the illiterate women have an ideal family size of more than four children compared to the 4.3 percent of the college graduates. The results showed that parity and education of the mother are strong determinants in whether she uses contraception or not.

In 1993 the population growth rate stood at 2.8 percent per annum. This means that the population, if it continued to grow at the same rate, would double in 25 years and in 2031 it will stabilise at 270 million according to a project done by the World Bank.

In another project it was again estimated that Pakistan is experiencing one of the most rapid rates of population growth in the world. At present the average annual increase is 3.1 percent it will only take 22 years for the population to double in size from 110 million in 1993 to 220 million in the year 2013 (PRB 1993) ( Zafar 1995).

Population experts from Pakistan have stressed the need for basic research on fertility behaviour within the frame work of the people’s values and beliefs about family formation (Hashmi 1991; Jillani 1986).


Some surveys have been done in India. The information obtained from these surveys and studies will be presented in the following paragraphs.

In a study in India in 1989 initiated by the Indian Council of Medical research (ICMR) it was found that the mean age for IUD users was 25.5 years and the mean gravity was 1.9. Of these 77 percent were literate and 80 percent accepted the device in the interval period. Dropouts were due to pregnancy with the device in situ.

A survey was carried out in 1990 in two rural areas in south India. The results of this survey showed that the contraceptive prevalence rate for all modern family planning methods was 41 percent but only 2 percent were reversible methods.

An interview with 35 health programme professionals (815 married women of reproductive age, 130 husbands and 60 community leaders) revealed that neither the demand for reversible methods nor the supply of sources was strong in these areas.

In the National Family Health survey 1992-1993 the following facts were unveiled: of the women who were interviewed 99 percent of the urban and 94 percent of the rural women had knowledge of family planning. At least one method of contraception was spontaneously reported by 82 percent of urban and 64 percent of rural women. Most of the women seemed to have knowledge about female sterilization but not of male sterilization. Traditional methods are less well known than modern methods. Thirty nine percent of currently married women knew about periodic abstinence and 20 percent about withdrawal method. The best known method was the contraceptive pill. Sixty six percent of currently married women knew of it, followed by IUD (61 percent) and condoms (58 percent). Only 19 percent knew of injectable contraceptives.

Interstate variations in the knowledge of any modern contraceptive method were most pronounced. Less than two thirds of the women in the following provinces were knowledgeable of any modern temporary contraceptive method: Nagaland, Pradesh, Rajasthan, Orissa, Andhara, Pradesh, ArunachalPradesh and Meghalaya, as compared to more than 90 percent of the women in Haryana, West Bengal, Punjab, Tripura, Kerela and Delhi. Although 96 percent of currently married women knew at least one method of family planning, only 47 percent used a modern method. Forty-two percent used modern methods and 12 percent the traditional ones. Twenty seven percent of currently married women used female sterilization and male sterilization was used by only 4 percent of the couples. The contraceptive prevalence rate was 41 percent in India at that time.

Female sterilization accounts for 67 percent of the current contraceptive prevalence in 1993 in the percentage of ever use of contraceptives by residence in rural or urban settings.. The prevalence rates varied greatly with the differences seen in religion, e.g. the lowest was among the Muslims 28 percent then Hindus 42 percent, Christians 48 percent, Buddhists 50 percent, Sikhs 58 percent, and Jains 63 percent. This portion of differentials are seen to disappear with higher education of the women. Also the current use of modern contraceptives seems to be influenced by the level of education. There is a marked difference in the values.

Parity is another factor that altered the attitude of women towards the use of contraceptive methods. It was seen that contraception was practised by only 2 percent of women having no children, by 13 percent of women with one child, by 40 percent of women with 2 children and by 55 percent of women with 3 children and by 49 percent of women with 4 or more children and it was lowest for women who had no sons. In the NFHS a large majority shows a preference for the ideal number of children is 2-3. This shows a change in trend in India. Some critics argue that women tend to adapt their fertility ideals upwards in keeping with their actual family size.(Lightbourne and MacDonald 1982).A large number of studies has discovered a strong preference for sons, particularly in north India( Miller 1981, Das Gupta 1987, Basu 1989 , Khan et al 1989, Rastgoi and Raj Kumar 1992, population research centre CRRID 1993).

NFHS also found that 79 percent of contraceptives are supplied by the government only 21 percent of users got them from other sources. This shows that many users depend on the government for supplies.

The main reason for discontinuation of contraception has been found to be the desire for more children in 28 percent of the cases. Health problems were quoted as the reason in 15 percent, menstrual disturbances in 7 percent and method failure in 5 percent were found to be the reason for discontinuation of contraceptive methods. The NFHS study has been shown the desire for more children was higher among women below 30 years (80 percent), religion or the husbands who did not agree (8 percent), and 28 percent of the women reported actual or perceived sterility as the main reason for not using a contraceptive method.

Rajretram and Deshpande (1994) carried out an interview in two rural districts Karnath state India. 815 women and 136 husbands were interviewed and the main reasons for non using contraceptives were again found to be:
  • Desire for more children
  • Opposition from others (20%)

It was also found that 28 percent of the women and 33 percent of the men wanted to use a contraceptive method in the future. Most of them preferred female sterilization .

A study in India revealed that out of 43.3 couples who were protected, 30.1 percent are protected by sterilization, 6.3 percent by IUD, 1.9 percent by using oral contraceptive pills and 5 percent by conventional methods. This once again shows a preference for the terminal methods.

Acceptability of oral pills was also studied (contraception 1994). The failure rate was 1.5 percent (mostly due to irregular use of the method). Another reason for discontinuation was due to menstrual disorders and other minor side effects.

Vasectomy acceptance has been declining in India during the past 20 years. Specific efforts to promote its acceptance must continue in India (Tripathy 1994). It shows the reluctance of men to shoulder the responsibility for fertility regulation. Also, that women do not want them to do so.

A survey was conducted in Gurat India to check the survey statistics generated by the Indian Family Planning Programme. It revealed a discrepancy in the records and the actual status of the users: e.g. 15-39 percent of the women who were recorded as users of reversible methods were not actually using them. About 19-27 percent of IUD users were on record and only 3-4 percent of the recorded users confirmed using these devices. (Visara 1994) This shows that there may be discrepancies in the recording of users and that at any given time the actual number of users may be much lower than the number reported.

200 women were interviewed in Bombay and it was found that 20 percent of all graduate couples used condoms or the rhythm method immediately after marriage. After the birth of the first child 80 percent of the educated couples were using spacing methods where as even after the birth of the third child more than 55 percent of the uneducated couples did not. Spacing methods are popular among educated and terminal ones among the uneducated. The conclusion from this study is that education was the main variable in the decisions regarding family size and contraceptive awareness.(Kanojia 1996).

A prospective study of 972 married women was carried out in the rural area of Bihar India. Tubal sterilization was found to be the most popular method of contraception among the women surveyed (20.6) The incidence of sterilization increased with age: 11.6 percent of the women were aged 21-30 years and 51 percent of the women were in the 31-40 year age group. Reversible forms of contraception (IUD, contraceptive pills and condoms) were used only by 6.8 percent of the women included in the study. Married girls at 15-20 years were not using any method at all, it was noted that none of the women in this group had used any contraceptive method prior to her first pregnancy. Forty percent of women in the age group 21-30 years and 41.1 percent in the age group 31-40 years who had 2 or more children but did not use contraception. This shows that birth spacing was not a common practise among these women (Kumar 1998).

In India the desired level of fertility regulation has not yet been achieved. According to the most recent reports the contraceptive prevalence rate stands at 41 percent for any method and at 36 percent for modern methods(UNFPA 1998).

The fertility rate is however on a slow decline.


Women’s lives are in transition. There is a definitive fertility decline in Bangladesh that begun in 1980. Women’s statements reveal their awareness of socio-economic transition and their interest in family size limitation which was bolstered by a strong family planning programme. Although shifts in the social and economic circumstances are not large, in conjunction with strong family planning programmes they constitute a powerful force for a change in attitudes, ideas and behaviour in these women (Simmons R. 1996).

Some studies have been carried out in Bangladesh Many of them in the Matlab area were family planning workers have been offering various methods of contraception for at least 20 years. In a study conducted here in 1987-1988 a women remembered the arrival of a community based family planning worker in her village 10 years earlier before she was married. The discussions showed that many young unmarried women learn about family planning at an early age from these community based family planning workers, female relatives, and the media (Mitra R 1995).

There is a lack of interspousal communication and a misunderstanding of spousal views on family planning and on specific methods. Among other areas in Bangladesh where 11 percent of the husbands under reported condom use, while 44 percent of the wives did (Ahmed et al 1987). Reasons for the under reporting were not reported.

In 1988 data collected in the Matlab area (Stud. F.P. 1996) showed that women of all age groups were aware of the widespread contraceptive use in their communities, but they are also conscious of the onset of fertility decline. Side effects were the major reason for the non-use of contraceptives in these communities. Vasectomy was considered a major threat to men’s health. Most of the men did not like condoms. A contraceptive revolution is transforming their lives, women note both the burdens and the benefits of contraceptive use and recognise the gender imbalances that define their lives and within this context take responsibility for limiting the size of their families.

The Bangladesh Fertility Survey of 1989 was a nation wide survey conducted under the national Institute of Population Research and training (NIRPORT). Ever married women under the age of 50 were eligible for the interview. A total of 11,905 women were interviewed between the ages of 10-49 years. Results showed that the higher the parity the higher the acceptance of contraceptive methods. The parents’ demand for more children is still one obstacle to the wider use of contraception in both urban and rural Bangladesh. Child death is seen to have a statistically significant negative effect on the use of contraception. Women’s education was found to have a significant positive effect on contraceptive use. Therefore it is suggested that increasing the educational opportunities can help to further reduce fertility in Bangladesh.

Another study examined discrepancies between the perspectives of husbands and wives (Bernhart and Uddin 1990 ). It was found that 27 percent of those men who were reported to be against family planning by their wives contended that they or their wives were using a contraceptive method. In addition to this 50 percent of men who were reported to be against family planning indicated that they approved it, even though they were not using it. Incorrect assumptions of spouses attitudes towards family planning is apparent. It was concluded that opposition by the husband was more passive as far as contraception was concerned.

The Bangladesh Demographic health survey 1993-94 has revealed the following results.
  • 100% of women knew of a modern method of contraception.
  • 100% knew about the contraceptive pill.
  • 99% knew about female sterilization.
  • 97% knew about the injectable contraceptives.
  • 90% knew about IUD.
  • 87% knew about condoms.
  • 83% knew about male sterilization.
  • 96% knew a source in order to get supply for a method of contraception.

The proportion of women who heard of IUD increased from 42 percent in 1983 to 89 percent in 1993-94. Table 3 shows that oral contraceptive pills are the most widely used methods of contraception as compared to other methods. Forty percent of all contraceptive users use the pill. There has been a steady increase in the level of ever use of family planning over the past 15-20 years from 14 percent in 1975 to 63 percent in 1993-94. The contraceptive prevalence rate has increased 5 fold from 8 percent in 1975 to 45 percent in 1993-94.

The reasons for the acceptance of oral contraceptive pills were stated by 40 percent of the users that they found the pill easy to use. One quarter of the users said that the side effects of the other methods led to their use of the oral pill. Ten percent said that it was their husbands preference. Seventy-five percent of the oral pill users were found to be using the pills provided free of charge by the government. The pill was also found to be the most popular method selected for future use.

The living standards are stagnant and broad indicators of poverty remain relatively unchanged (Cleland 1994) and leads to conclusion that socio-economic changes do not explain the fertility decline.

It was found that current use of modern contraceptive methods was one and a half times more among women whose husbands had secondary or higher school level of education than those whose husbands had no formal education. Also the probability of the current use of modern contraceptive methods was higher among women who discussed family planning with their husbands than those who did not.

DPMA is increasingly used in Bangladesh (Riley et al 1994). Ninety-two percent of the users of DPMA selected this method because they were experiencing problems with other methods, particularly oral contraceptives and IUD (38 percent reported having difficulty in remembering to take the pill daily). Amennorhoea was not considered a problem. The women who came to the clinics also expressed an interest in using Norplant. Condom use is under reported in Bangladesh. Its use is low and it has not shown much increase. (Ahmed et al 1987)

A study in Bangladesh revealed that a majority of women choose to delay the initiation of contraception until menses resume often several months after the birth. In-depth interviews reveal that the majority of women believes that they are adequate protected during amenorrhoea, though most do not recognise an association between this diminished risk of contraception and breast feeding. In addition data illustrate that women are primarily concerned with their own health and that of their newly born child and the well being in the period following childbirth, both of which are perceived to be extremely vulnerable. These perceptions, plus an understanding that modern modes of contraception are ‘strong’ and potentially damaging to health, means that a large number of women are reluctant to adopt family planning methods soon after birth, particularly during postpartum amenorrhoea (Salways, Nurani 1998).

The religion of the respondents emerged as a significant factor in the current use of modern methods versus traditional methods. Non-Muslim women were found less likely to use modern methods as compared to Muslim women .Local social and cultural factors play an important part in the users preference for a certain type of contraceptive method, e.g. a side effect such as amenorrhoea was tolerated in Bangladesh because of the high Muslim population, where women do not mind amenorrhoea because menstruation disturbs their five prays a day.


This literature review leads to the following conclusions:

No specific method can be singled out as the perfect choice for women of this region (see graph 2). There are variations across the whole subcontinent. A preference for four methods has been expressed by women in the area for oral contraceptive pills, injectable contraceptives, female sterilisation and IUDs. Expressed preferences are not static and are subject to change either as a result of additional information or because of experience with the method or the changing needs of the couple. It is frequently seen that clients avoid open disagreement with the health workers but will not practise a method that is not their first choice. It is important to have a wide range of contraceptive options and a free choice among those options as it was seen in Bangladesh (Khan et. al 1989). In the Matlab area where all methods were provided various observations were made in this region as follows.

1. Knowledge and use of contraception.

A majority of the women in India and Pakistan depend on female sterilisation in preference to other temporary methods available. In Bangladesh the oral contraceptive pill is more popular (graph 3). The use of various methods vary from country to country. Most of the people know at least one method of contraception and its source. In Pakistan more men than their wives reported knowing at least one method. The gap between knowledge of a method and having a source of supply is especially wide in Pakistan. The over-all contraceptive prevalence rate in Pakistan was below 10 percent around 1990. Now it is 23.9 percent according to a recent report (family planning survey 1996-97).

2. Reasons for non use of contraceptive methods.

The main reason for non use of contraceptive methods was found to be a desire for more children and concerns about health (including side effects), the opposition of the husband or the mother-in-law and traditional and socio-economic causes prevalent in these countries.

3. Contraceptive effectiveness.

The reversible methods most likely to be discontinued within the first year because of contraceptive failure were the vaginal methods, withdrawal and periodic abstinence.

4. Cultural and social factors.

These concepts and their impact on contraception were not examined thoroughly enough. There are a number of cultural and religious drawbacks that make certain methods unacceptable. These should be investigated in more detail. There is a great need for communication between the spouses and women are showing a greater control over decisions about accepting contraceptive methods.

5. Lack of information.

The persistence of values, norms and traditions are unfavourable to the explanation for high fertility and low contraceptive use in the subcontinent. We do not have enough information about the reasons for the different communities accepting modern contraceptive methods. Why women in the subcontinent are not making use of the contraceptive methods even if they are available? Which methods would be more acceptable to these women? On a lot of issues the information is incomplete or missing. There is not enough information about the failure of oral contraceptive pills (which varies from 3-9 percent by the end of a year of use). There have been few studies of the determinants of pill compliance apart from knowledge approval and inter spousal communication. There have been few studies about the role of the male partner and the acceptability of male methods also remains a research question. The determinants of induced abortion, especially repeat abortions, need to be better understood. The extent to which induced abortions are caused by method failure or poor information on how to use it requires further assessment. The role of the providers is very important. The provider-client relations play an important role in the peoples perspectives. There is a dearth of studies investigating the perspectives of women and men in the subcontinent. The acceptability of fertility regulating methods which provide protection against both pregnancy and STD’s is largely unknown for married couples and subgroups with a high risk behaviour. The extent to which the choice of methods may be affected by a consideration to avoid pregnancy and or STD’s is also important for further studies.

6. Parity.

As analysed from the classic Princeton Fertility Survey (USA) that birth rates were lower among those who had achieved their desired number of children and now wanted to stop child bearing than those who wanted more children. Similarly, education is a great determinant usually expected to change the woman’s attitude and as a consequence reduce her expected family size and increase her use of family planning methods.

The assessment of fertility trends indicate that no country has achieved the desired fertility rate to an ideal replacement level of 2.1 births per women with out achieving a contraceptive prevalence rate of at least 50 percent.

The contraceptive prevalence rates according to the last reports available from the three countries are as follows. (see graph 5).
  • 23.9% in Pakistan.
  • 41% in India.
  • 45% in Bangladesh

Pakistan is far behind its neighbours in the transition to lower fertility. With its high annual population growth rate of 2.8 percent Pakistan is likely to become the worlds third most populous country by 2050 (Ann Tinker). Although all three countries are socio-economically, culturally and religion-wise very similar there is still a lower contraceptive prevalence rate in Pakistan as compared to the other two countries (graph 1 and graph 3). The level of literacy is almost the same for all three countries (62-76 percent). Therefore the main issue is not only education there is are other reasons for the comparatively lower contraceptive prevalence rate in Pakistan. More research is necessary to look into the reasons for the acceptability and the nonacceptability of contraceptives in Pakistan. A family planning programme should be geared towards the promotion and availability of methods that are more acceptable to the women of Pakistan. Health workers can play a major role in educating people about family planning methods. A large number of women are still not using contraception.



Table 1. The preferred method for future use of a contraceptive method, (in percentages)



female sterilization


male sterilisation


oral contraceptive pills


injectable contraceptives






vaginal methods






other methods


don’t know any method


(Pakistan DHS 1990-91)

Table 2. The percentage of men out of 1354 interviewed revealed that:

know of one method 79%
approved of family planning 56%
used a contraceptive method. 18%
had used any method at all. 25%
currently using a modern method of contraception. 10%
were using any method of contraception 15%

(Pakistan DHS 1990-91).

Table 3. The percentage of users of various contraceptive methods in Pakistan and Bangladesh



Any method



Oral contraceptive pill






Injectable contraceptives



Vaginal Methods






Female Sterilization



Male Sterilization



Any Traditional Method












Number of women



(PFFPS 1996/97 and Bangladesh DHS 1993-94)


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(Pak DHS 1990-91 and Bangladesh DHS 1993-94)


(PFFPS 1996/97, Population reference 1996)


(Pak DHS 1990-91, Bangladesh DHS 1993-94, India NFHS 1993-94)


(Pak. DHS 1990-91, Bangladesh DHS 1993-94).


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(Improving women’s health in Pakistan -Ann Tinker)



This refers to beliefs attitudes, opinions, perceptions, as well as behaviour which may be direct or in direct reflection of the perspective.

Reproductive health:

Reproductive health is not just the absence of disease. It refers to a spectrum of conditions and events and processes throughout life including profoundly life-affirming and life threatening conditions, ranging from health sexual development, physical comfort and closeness and the joys of childbearing, to abuse, disease and death. Perhaps with more than with any health condition reproductive health cannot be viewed as merely a medical issue understanding the social context of reproductive health, therefore is essential to improving reproductive health in all its complexity.(Myntti Web, Vanlook 1998).This is a beautiful and complete definition of reproductive health and fertility regulation plays a major role in reproductive health.

Family planning:

Family planning implies the ability of individuals and couples to anticipate and attain their desired number of children and spacing and timing their births using temporary contraceptive methods such as periodic abstinence, coitus interruptus, oral pills, long acting injections, implants, placement of IUCD`S, or barrier methods i.e. using condoms, diaphragms and spermcide. Present methods of contraception include male and female sterilisation.

Fertility regulation:

Fertility regulation is the process by which individuals and couples regulate their fertility. The methods used for this purpose include delaying child bearing using contraception, seeking treatment for infertility, interrupting unwanted pregnancies and breast feeding

Contraceptive prevalence rate:

This refers to the proportion of all couples of child bearing age who are currently using a particular contraceptive method. This includes modern and traditional methods.

Total fertility rate:

This refers to the number of live births a women would have throughout her entire reproductive life.


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