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FigureFigure5Percentage change <strong>in</strong> contraceptive method mix over time1991610 3 11117PillIUDInjectionCondom121420071788PillIUDInjectionCondom2330Female sterilizationRhythmWithdrawal2823Female sterilizationRhythmWithdrawalO<strong>the</strong>rO<strong>the</strong>rOverall, <strong>the</strong> trends <strong>in</strong> choice of method <strong>in</strong>dicate thata quarter of women use traditional methods of familyplann<strong>in</strong>g <strong>and</strong> ano<strong>the</strong>r quarter use condoms, mean<strong>in</strong>g thathalf are us<strong>in</strong>g couple-methods of family plann<strong>in</strong>g. Theo<strong>the</strong>r half use female methods, with about a quarter of<strong>the</strong>se choos<strong>in</strong>g permanent methods <strong>and</strong> <strong>the</strong> rema<strong>in</strong><strong>in</strong>gquarter us<strong>in</strong>g o<strong>the</strong>r modern female methods.Source of methodsIn 1991, when fertility decl<strong>in</strong>e had just come <strong>in</strong>to play<strong>and</strong> contraceptive prevalence was at a low 11 per cent, <strong>the</strong>government was <strong>the</strong> major supplier of modern contraceptivemethods: 56 per cent of users received <strong>the</strong>ir method froma government supplier (<strong>in</strong>clud<strong>in</strong>g government hospitals,doctors, cl<strong>in</strong>ics, family welfare centres etc.), while only30 per cent received methods from <strong>the</strong> private sector (seeTable 2). By 2007, while <strong>the</strong> government rema<strong>in</strong>ed <strong>the</strong>supplier for almost half of all contraceptive users, at 48 percent, <strong>the</strong> share of <strong>the</strong> private sector <strong>in</strong>creased by more than10 percentage po<strong>in</strong>ts to 41 per cent, <strong>in</strong>dicat<strong>in</strong>g that more<strong>and</strong> more users were pay<strong>in</strong>g for contraception.In look<strong>in</strong>g at source of method by specific method type, twotrends st<strong>and</strong> out. Over <strong>the</strong> 16-year period, <strong>the</strong> government’sshare <strong>in</strong> <strong>the</strong> supply of <strong>the</strong> pill <strong>in</strong>creased <strong>and</strong> it replaced <strong>the</strong>private sector to become <strong>the</strong> biggest supplier. On <strong>the</strong> o<strong>the</strong>rh<strong>and</strong>, IUDs, which <strong>in</strong> 1991 were supplied primarily by<strong>the</strong> government (81%), were now be<strong>in</strong>g provided equallyby <strong>the</strong> private sector as well. Among <strong>the</strong> o<strong>the</strong>r methods,<strong>the</strong> private sector saw slight <strong>in</strong>creases (correspond<strong>in</strong>g to aslight decrease <strong>in</strong> <strong>the</strong> government’s share) <strong>in</strong> <strong>the</strong> share of<strong>in</strong>jectables <strong>and</strong> female sterilization, while both <strong>the</strong> public<strong>and</strong> private sectors saw <strong>in</strong>creases <strong>in</strong> <strong>the</strong> market share ofcondoms. With<strong>in</strong> <strong>the</strong> private sector, <strong>the</strong> supply of condomsby non-medical stores was responsible for <strong>the</strong> <strong>in</strong>crease <strong>in</strong>market share.Induced abortionsDespite <strong>the</strong> fact that <strong>in</strong>duced abortions are illegal <strong>in</strong>Pakistan, except when performed to save women's lives,a study carried out by <strong>the</strong> Population <strong>Council</strong> estimatedthat 890,000 <strong>in</strong>duced abortions were performed <strong>in</strong> 2002,<strong>and</strong> <strong>the</strong> abortion rate was 29 per 1,000 women aged15-49 (Population <strong>Council</strong>, 2004). This was a mediumestimate; <strong>the</strong> low <strong>and</strong> high estimates were 25 <strong>and</strong> 31 per1,000, respectively. The abortion rate of 29 is most likelyan underestimate of <strong>the</strong> true abortion rate despite be<strong>in</strong>gmoderately high by global st<strong>and</strong>ards. The majority ofsuch abortions are tak<strong>in</strong>g place among married womenwith more than three children. Studies based on <strong>the</strong>sedata also found that a considerable proportion of womenwho <strong>in</strong>duced abortions had tried some method ofcontraception <strong>and</strong> some even reported that <strong>the</strong>y had beenus<strong>in</strong>g contraceptives, albeit <strong>in</strong>effectively, when <strong>the</strong>y becamepregnant (Arif <strong>and</strong> Kamran, 2007).Sathar et al. (2007) estimated measures of total pregnancy<strong>and</strong> unwanted pregnancy to portray <strong>the</strong> broader contextwith<strong>in</strong> which <strong>in</strong>duced abortion was occurr<strong>in</strong>g <strong>and</strong> tomeasure both <strong>the</strong> absolute level of unwanted pregnancy<strong>and</strong> <strong>the</strong> probability that women who experienced anunwanted pregnancy would seek an abortion. Resultsyielded an unwanted pregnancy rate of 77 per 1,000women, which accounted for almost two fifths of allpregnancies. Abortions accounted for almost two fifths of<strong>the</strong>se unwanted pregnancies.Unmet needDespite <strong>the</strong> low use of fertility regulation, more <strong>and</strong> morewomen <strong>in</strong> Pakistan are express<strong>in</strong>g <strong>the</strong> desire to limit orpostpone childbear<strong>in</strong>g. In 1991, 40 per cent of <strong>the</strong> women208
TableTable1Source of modern method over timeSourcePill IUD Injection CondomFemalesterilizationAll modernmethods1991 2007 1991 2007 1991 2007 1991 2007 1991 2007 1991 2007Government 34.9 46.1 81.1 52.4 53.0 51.2 11.7 16.9 85.1 72.4 55.7 48.2Private 56.2 39.6 15.8 47.6 42.0 44.6 47.6 58.0 13.7 25.8 30.0 41.4Medical 49.7 31.2 11.3 41.0 42.0 41.7 33.2 27.3 13.7 25.8 25.5 30.1O<strong>the</strong>r shop 6.5 7.2 0.0 0.0 0.0 1.6 13.1 30.5 na na 4.4 10.3Tra<strong>in</strong>ed birthattendant0.0 1.2 4.5 6.6 0.0 1.3 1.3 0.2 na na 1.0 1.0O<strong>the</strong>r 5.2 5.3 0.0 0.0 4.7 1.3 11.5 0.8 na na 4.3 0.9Note: na = not applicable.surveyed wanted no more children; this figure <strong>in</strong>creased to52 per cent <strong>in</strong> 2007. Regional differences <strong>in</strong> <strong>the</strong> desire tolimit childbear<strong>in</strong>g have been decreas<strong>in</strong>g steadily over times<strong>in</strong>ce more <strong>and</strong> more rural women want to have no morechildren. These trends <strong>in</strong>dicate that <strong>the</strong>re is <strong>in</strong>creas<strong>in</strong>gdem<strong>and</strong> for family plann<strong>in</strong>g among Pakistani women,particularly <strong>in</strong> rural areas. However, although more than50 per cent of women wish to limit childbear<strong>in</strong>g <strong>and</strong> about20 per cent wish to space <strong>the</strong>ir next birth, only 30 per centare us<strong>in</strong>g contraception (National Institute of PopulationStudies <strong>and</strong> Macro <strong>International</strong> Inc., 2008), support<strong>in</strong>g ahigh rate of unmet need for Pakistani women.Unmet need – <strong>the</strong> percentage of currently married womenwho are fecund <strong>and</strong> do not want to be pregnant yet arenot us<strong>in</strong>g contraception – <strong>in</strong>creased from 33 per cent(National Institute of Population Studies, 2001) to 37per cent <strong>in</strong> <strong>the</strong> 2006/07 DHS. Unmet need <strong>in</strong> rural areas,which was <strong>in</strong>itially lower, now exceeds urban unmet need,suggest<strong>in</strong>g that <strong>the</strong> availability <strong>and</strong> affordability of familyplann<strong>in</strong>g services is an obstacle <strong>and</strong> limitation to fertilitychange, a situation which applies more so <strong>in</strong> rural Pakistan.In l<strong>in</strong>e with <strong>the</strong>se f<strong>in</strong>d<strong>in</strong>gs is <strong>the</strong> trend <strong>in</strong> unplannedchildbear<strong>in</strong>g (<strong>the</strong> comb<strong>in</strong>ation of unwanted births <strong>and</strong>mistimed births): <strong>the</strong> proportion of recent births thatare unplanned rose from 21 per cent <strong>in</strong> 1990/91 to 24per cent <strong>in</strong> 2006/07. Unmet need for contraception <strong>and</strong><strong>the</strong> proportion of births that are unplanned <strong>and</strong> <strong>the</strong> highrate of abortion suggest that a large fraction of currentlymarried women <strong>in</strong> Pakistan are at risk of an unwantedpregnancy <strong>and</strong> potentially an unsafe abortion.Vulnerable group – poor womenFertility rates <strong>in</strong> Pakistan vary by women’s education <strong>and</strong>household wealth status. These <strong>in</strong>equalities can also beseen <strong>in</strong> <strong>the</strong> unmet need for family plann<strong>in</strong>g. However,unlike total fertility, <strong>the</strong> relationship of unmet need with<strong>the</strong>se background characteristics has changed over time. In1991, women from <strong>the</strong> poorest households had <strong>the</strong> lowestunmet need; over time unmet need among <strong>the</strong>se womenrose substantially, <strong>and</strong> <strong>the</strong>y now have <strong>the</strong> highest unmetneed (World Bank, 2009). The change <strong>in</strong> <strong>the</strong> relationshipbetween unmet need <strong>and</strong> wealth can be understoodby look<strong>in</strong>g at <strong>the</strong> changes <strong>in</strong> <strong>the</strong> relationship betweenpreferences <strong>and</strong> contraception <strong>and</strong> wealth (see Figure 7).The <strong>in</strong>dividual graphs <strong>in</strong> Figure 7 show that <strong>the</strong> dem<strong>and</strong>for family plann<strong>in</strong>g, as represented by <strong>the</strong> percentage ofwomen want<strong>in</strong>g no more children, rose more dramaticallyfor women from <strong>the</strong> poorest qu<strong>in</strong>tile. In fact, <strong>the</strong> figure thatshows <strong>the</strong> proportion want<strong>in</strong>g to limit childbear<strong>in</strong>g hasalmost converged at a level of about 50 per cent or morefor all wealth qu<strong>in</strong>tiles unlike <strong>the</strong> earlier period where itshowed a sharp positive association with wealth. This is<strong>in</strong> stark contrast to differentials <strong>in</strong> contraceptive use thatappear to be almost as sharp across rich <strong>and</strong> poor womenas <strong>the</strong>y were <strong>in</strong> <strong>the</strong> earlier period. Current use differentials(<strong>in</strong> absolute terms) between <strong>the</strong> poorest <strong>and</strong> richest womenwere 34 per cent <strong>in</strong> <strong>the</strong> earlier period <strong>and</strong> 32 per cent <strong>in</strong>2007, <strong>in</strong>dicat<strong>in</strong>g a negligible levell<strong>in</strong>g of contraceptive use,unlike <strong>the</strong> dramatic levell<strong>in</strong>g seen <strong>in</strong> fertility preferences.Ultimately, this expla<strong>in</strong>s <strong>the</strong> sharp <strong>in</strong>crease <strong>in</strong> unmet need,a comb<strong>in</strong>ed outcome of preferences <strong>and</strong> use, experiencedby poor women who <strong>in</strong>creased <strong>the</strong>ir dem<strong>and</strong> to limitchildbear<strong>in</strong>g without much change <strong>in</strong> contraception use.This is <strong>in</strong> contrast to <strong>the</strong> sharp fall <strong>in</strong> unmet need of <strong>the</strong>rich women who <strong>in</strong>creased <strong>the</strong>ir contraceptive use <strong>in</strong>conjunction with <strong>the</strong>ir dem<strong>and</strong> for it. The situation ofrelatively richer <strong>and</strong> poorer women has changed <strong>in</strong> <strong>the</strong>selast two decades: <strong>the</strong> differential of unmet need by wealthis significant – practically non-existent for <strong>the</strong> rich <strong>and</strong>over 30 per cent for poor women (World Bank, 2009).209
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Family Pla
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ForewordThe Asia <
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Part 1Part 1Asia <
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Ensuring that <str
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of methods for all, in</str
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and undertake <str
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Report on the Regi
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SESSION 1: Changin
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that improving <st
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at a hospital would be offered post
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Bounkoung Phichit, Deputy M
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medicines
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Thus, while knowledge of modern met
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Hon. Mr. Malakai Tabar, Chairman, P
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curricula. If the
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dialogue as well as regional <stron
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BackgroundGlobal development effort
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TableTable1EventNational policyYear
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A third observation is that reporte
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TableTable2Current Contraceptive Pr
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Figure(-1.2), Cook Island</
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FigureTableTable3Trends in<
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Nam. Nearly all economies i
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2008 2009% Bilateral % Multilateral
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family planning wi
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IntroductionFamily
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The advent of the
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FigureFigure1Oceania and</s
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next 25 years, however, TFR fluctua
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FigureFigureFigure2Total fertility
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family planning pr
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esponsible for the
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that estimates of CPR for earlier p
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Figuremarried at an older age compa
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As previously mentioned most <stron
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FigureFigure945Relationship between
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The concept of “unmet need” has
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TableTable8Percentage of th
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TableTable9Percentage of reasons fo
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family planning pr
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As far as the supp
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Socio-cultural challenges tofamily
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likely to use contraception than yo
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15 Tests of statistical significanc
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of the South <stro
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104
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Figurewill exceed the</stro
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in urban (67%) tha
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ased service delivery poin<
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Most FWAs who were recruited two to
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are considered, unmet need for effe
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Households pay the
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Effective public-private partnershi
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ConclusionThe Bangladesh Fa
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the Family
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National Institute for Population R
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IndiaIndiaFamily <
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IntroductionThe use of contraceptiv
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TableTable2Indicators of tra<strong
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FigureFigureFigure1Contraceptive pr
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TableTable5Indicators of contracept
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TableTable6Adjusted odds ratios for
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FigureFigure3Contraceptive prevalen
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TableTable7Adjusted and</st
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the north
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TableTable10Differences between nor
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TableTable11 Total fertility rate <
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End Note1The first camp was success
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152
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154
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Figure1980s and ex
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Page 238 and 239: Figureeconomic growth durin
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Page 256 and 257: FigureTrends and p
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FigureFigure3TRF54.5Scatter plots o
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ReferencesAng, Eng Suan (2007). Stu
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Demographic data sheet: population
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population size, with just 336,000
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NuptialityIn Myanmar nuptiality is
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FigureIn Myanmar, birth-spac<strong
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Scope of coverage and</stro
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FigureIn Myanmar, out of six select
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equirements. The Min</stron
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according to <stro
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Adolescent sexual and</stro
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FigureHIV/AIDS. An HIV-positive wom
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National Population PolicyMyanmar i
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Linkages with o<st
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TableTable4Achievements of Myanmar
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monitoring <strong
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Nay Pyi Taw, 26 October 2010.53 Sit
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TableTableA296
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dispense and adm<s
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(1) I am against a
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FigureFigureFigure3Use of modern co
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FigureFigure7Traditional method use
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Figureprojection, and</stro
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Figure 11 summarizes the</s
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correlating <stron
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Figurethe use of c
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FigureFigure15Sexual behaviour <str
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track the distribu
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Figureservices, which should <stron
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FigureFigureFigure18 Population <st
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National Statistics Office, <strong
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TableTable6TableTable7TableTable832
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TableTable11326
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TableTable14TableTable15TableTable1
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TableTable19Laws and</stron
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worker and hours w
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334
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336
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includin</
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TableTable1Contraceptive prevalence
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These results suggest that about 70
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2 The (period) TFR is the</
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346
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FigureThe existence of traditional
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Guinea case by <st
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The establishment of provin
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provide family plannin</str
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Figurelegal requirement nor a condi
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FigureTableTable5TableTable6Figure4
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modern method and
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married or in unio
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Figureolder. Both the</stro
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TableTable15The immediate past Nati
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out that the “ne
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Commodity securitySupply cha<strong
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is able to achieve. In Papua New Gu
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Qualitative assessments by a number
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increasin<
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service delivery poin</stro
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Population: Views from Men
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1545-1730Day 2: December 9Session 2
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Day 3, December 10Session 50830-100
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15Mr. Tong Sithen1
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54Ms. Shadiya IbrahimAssistant Repr
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93Mr. Melkie AntonProject OfficerUn
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131Dr. John P. SkibiakDirectorRepro
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International <str
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