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Family Planning in Pakistan: Unraveling the Complexities

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Family Planning in Pakistan: Unraveling the Complexities Family Planning in Pakistan: Unraveling the Complexities by Anushka Ataullahjan A thesis submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Public Health School of Public Health University of Alberta © Anushka Ataullahjan, 2018 Abstract With a population of 207 million, Pakistan is the sixth most populous country in the world. Recognizing uncontrolled population growth as a threat to economic prosperity and development, the Pakistani Family Planning Program has sought to increase the awareness and use of contraceptives. However, increasing uptake of family planning methods has proved to be difficult. In 2013, after nearly 60 years of effort, only 35% of eligible users reported using a contraceptive, with a mere 26% using a modern method. A large body of literature has sought to explain the low prevalence of contraceptive use in the country. Primarily focused on the failure of delivery of family planning services, and mostly using the survey methodology, these studies have operated under the assumption that increasing knowledge and access will address the reluctance to use contraceptives. This approach, I argue, oversimplifies the many and complex considerations that influence family planning use. Missing from the family planning discourse in Pakistan today is a nuanced analysis of the beliefs and values that underlie family size and notion of fertility control. Specifically missing is an understanding of the ideologies, values and practices underlying birth control in a context characterised by religious conservatism, strong patriarchal values, fragility, an unresponsive health care system, poor governance and prolonged low-level conflict. My dissertation seeks to fill this gap in our knowledge. It does so by exploring:1) the influence of Islamic beliefs and practices on fertility control and choice; 2) whether fertility is considered within the locus of individual control and what values form the basis of this judgment; 3) what ideological, socioeconomic class, security, or logistical considerations determine how fertility choices are made; 4) how fertility behaviour is regulated through identity ii and community belonging, and 5) who is included in fertility decision-making and how responsibility is allocated. I conducted a critical ethnography in a village in Khyber Pakhtunkhwa, Pakistan. Over the course of 13 months I conducted 242 observations of daily life, 109 informal interviews and 197 in-depth interviews with 76 participants (41 women and 35 men). Each participant was interviewed a minimum of two times. Interviews were audio recorded and transcribed. Data were analysed using a latent content analysis approach guided by my research objectives. The data demonstrate that fertility decisions in my field site are situated in complex historical, socioeconomic, and geopolitical landscapes. The first paper unpacks family size ideals. It illustrates that large family sizes are a response to precarity of life in a context characterised by economic deprivation, violence, and insecurity. My second paper explores how regional and global geopolitics contribute to anxiety about fertility control. The third paper focuses on the complex role of Islam on family planning decision-making. It describes how respondents engage with and negotiate their religious beliefs to reconcile their contraceptive use. The fourth and final paper challenges biomedical approaches to the body and calls for a culturally situated understanding of contraceptive side effects. By centering the voices of the respondents, this work brings into focus “subaltern” voices which Pakistan’s family planning discourse has tended to neglect. I demonstrate that a large failing of the Pakistani Family Planning Program is its focus on increasing contraceptive prevalence while overlooking the upstream structural issues that create a preference for specific reproductive strategies. Overall, my dissertation is a call to Pakistani family-planning programmers and policy makers to centre the voices and concerns of their citizens. iii Preface This thesis is an original work by Anushka Ataullahjan. The research project, of which this thesis is a part, received research ethics approval from the University of Alberta Research Ethics Board, Project Name “Family Planning in Pakistan: Unraveling the complexities”, Pro00040882, 7/23/13. iv Dedication for my parents their parents their parents’ parents and the others forgotten and erased v Acknowledgements My degree is the culmination of years of work, none of which would’ve been possible without the support and love of my family. First and foremost, I would like to thank my parents for nurturing my dreams and encouraging me to follow them wherever they took me, be that the Canadian prairies or rural Pakistan. My sister, Shaanzéh, I am not sure where I would be without your support; thank you for believing in me even when I doubted myself. My cousin-sister, Sonya, for fiercely advocating for me and cheering me on. My long-lost cousin, Usman, for always being available to workshop an idea or paper and sharing his wealth of language and cultural expertise. I must also thank Ilona and Horazio, my Edmonton family, I cannot ever repay your generosity. Hima and Mahsa, thank you for always seeing me as I truly am. My aunts and uncles in Pakistan who made Islamabad and Peshawar feel like home. Syra, Sabrina, and Tun Tun Aunty, I am certain Kaka is watching with pride. Bilbo and Jasmine, thank you for always being by my side. Lastly, I must thank my grandfather who may not have understood why I was doing this work but supported me nonetheless. I would also like to extend gratitude to my supervisor, Dr. Zubia Mumtaz, who challenged me to expand the boundaries of my knowledge and develop a nuanced understanding of the ways in which gender, class, and caste influence quality of life and health care access in rural Pakistan. I am thankful for the incredible opportunities that I have been afforded by my PhD work with Dr. Mumtaz. I am also indebted to my supervisory committee, Dr. Emma Varley, Dr. Helen Vallianatos, and Dr. Stephen Kent, for their advice and invaluable contributions to my dissertation. I must also particularly acknowledge and thank Dr. Varley for going above and beyond her role as a committee member; I am so grateful for all of the academic and moral support she has provided. I would also like to thank Dr. Arif Alibhai and Dr. Jeff Johnson for vi their support and encouragement. I have been lucky to have an incredible group of colleagues at the School of Public Health, and I must acknowledge Amy Colquhoun, Janis Geary, Melissa Visconti, Maricon Hidalgo, and Nikki Kain for their support through the years. Ultimately, none of my fieldwork would’ve been possible without the help of a network of people in Pakistan. Sultan Kaka, Noor Khan, Shaukat, Sulaiman, Taza Gul, Ijaz, Taj, and Husseini, deera merebani, I am indebted to you for all your assistance through those 13 months. My research team, Samar, Masooma, Sana Ullah, Murad, and Naeem, I appreciate your commitment to my work and your contributions to my research. The people of Nashpatai Kalay, thank you for welcoming me into your homes and your hearts. I will always cherish the lovely memories of my time in the field and the conversations shared over cups of tea, and warm sukruk. I have benefitted from an incredibly supportive global community which includes more individuals than I could possibly mention. I am so grateful for all the acts of kindness afforded to me throughout these 8 years. To everyone who has been part of this journey, thank you, thank you, thank you. vii Table of Contents 1 Chapter 1: Introduction and Literature Review .................................................................................... 1 1.1 Introduction ................................................................................................................................... 1 1.2 Literature review methods ............................................................................................................ 4 1.3 Family Planning Globally ............................................................................................................. 6 1.3.1 The Importance of Family Planning ..................................................................................... 6 1.3.2 Funding for Family Planning ................................................................................................ 9 1.4 Family Planning in Pakistan ....................................................................................................... 11 1.4.1 Family Planning in Pakistan: An Historical Perspective .................................................... 12 1.4.2 Contraceptive Use ............................................................................................................... 14 1.5 Theoretical background............................................................................................................... 28 1.5.1 Biopower ............................................................................................................................. 29 1.5.2 Anthropology of Islam ........................................................................................................ 30 1.6 Research Questions and Objectives ............................................................................................ 32 1.6.1 Research Objectives ...........................................................................................................
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