Fertility and family planning trends in Karachi, Pakistan

International Family Planning Perspectives, Mar 1999 by Hagen, Catherine A, Fikree, Fariyal F, Sherali, Afroze, Hoodbhoy, Fauzia

Context: In Pakistan, total fertility rates are high, contraceptive prevalence is low and there is widespread disagreement over whether fertility has begun to decline. It is likely that any drop in births in Pakistan will be seen initially among urban, middle-class women.

Methods: A cross-sectional survey of 3,301 households in urban Karachi collected information on the reproductive history and family planning knowledge and practices of 2, 651 ever-married women aged 54 or younger. Birth-cohort analysis was used to identify time trends in fertility and use of modem contraceptives.

Results: Respondents had more education and higher socioeconomic status than the national average. Their total fertility rate was 3.0 lifetime births per woman, the general fertility rate was 98.3 births per 1,000 women aged 15-49 and the crude birthrate was 23.2 births per 1,000 population. As recently as 1976, the TFR among the sample population had been 5. 7 births per woman. Forty-two percent of married women aged 15-49 currently used a modern contraceptive method. Among women born in 1950-1954, 64% had ever used contraceptives, compared with 37% of women born in 1940-1944. The most commonly used contraceptive method among current users was the condom (40%), followed by tubal ligation (27%) and the IUD (12%). Overall, 53% of users obtained their method at pharmacies or markets, and 24% used private hospitals or clinics. Some 71% of currently married, nonpregnant respondents reported having achieved their desired family size.

Conclusions: Among a relatively well-educated, middle-class population in urban Karachi, there is a strong trend toward declining fertility and increasing utilization of contraceptives. However, considerable unmet need for family planning is still evident.

International Family Planning Perspectives, 1999, 25(1):38-43

Controversy exists over the success of the family planning program in Pakistan,l a country where the national fertility rate is estimated to be among the highest in the region.2 The 1990-1991 Pakistan Demographic and Health Survey (PDHS) indicated that fertility had declined modestly since earlier national surveys: The total fertility rate (TFR) in 1990-1991 was 5.4 lifetime births per woman,3 compared with TFRs of 6.0 in 1985,4 6.5 in 1980,5 and 6.3 in 1975.6 However, the declines appear to have been substantial only among educated women and those living in urban areas.

The "believability" of the apparent decline has been questioned because of discrepancies between the estimated TFR and the persistence of a high crude birthrate and low contraceptive prevalence.7 That the gap between the TFR and the mean number of children born to women aged 40-49 is widening over time provides some evidence of declining fertility. However, this evidence is not strong: Because most of the apparent fertility decline has occurred among the youngest age-groups, critics attribute any change in fertility to increasing age at first marriage, and debate whether the delayed births will resurface as higher age-specific fertility among 20-29-year-olds in later surveys.8 Most researchers agree that without increasing contraceptive use, substantial declines in the TFR and the population growth rate cannot be expected.

In addition, until the publication of the 1994-1995 Pakistan Contraceptive Prevalence Survey (PCPS), there had been little evidence that family planning utilization had increased over the past several decades.9 Data from Pakistan's national demographic surveys between 1965 and 1991 suggest that overall, Pakistani families have been slower to adopt family planning practices than their South Asian neighbors: By 1991, approximately 12% of Pakistani couples were attempting to limit pregnancies, and 8% were using modem family planning methods.lo By 1994-1995, these rates had increased to 18% and 13% respectively.ll

There are few studies demonstrating overall fertility decline in Pakistan, and most authors12 agree that, in spite of some methodological problems affecting comparability, the best interpretation of the available data is that there has been no substantial change in fertility in Pakistan. In this article, we examine measures of fertility and contraceptive use to explore these fertility trends among a subgroup of urban Pakistani women.

Methods

Study Population

The study employs data from a cross-sectional survey designed to provide community-based information to the Aga Khan Health Service of Pakistan (AKHSP).* The study population was defined as those living in the neighborhoods that give rise to 75% of the clients of AKHSP's three maternity homes. The study boundary did not define an exclusive catchment area, as many other private and government hospitals also function nearby.

In Karachi, the AKHSP maternity homes serve a self-referred clientele of wide geographic origin and ethnic composition, and clients travel to the homes from different parts of the city. As Karachi grew, and as the AKHSP expanded, new AKHSP maternity homes were built farther away from the core of the old city harbor. Thus, the survey sample involves an irregular, wedgeshaped territory originating near the harbor and extending to densely populated residential neighborhoods, and it includes households from a wide range of socioeconomic circumstances.