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Fertility and Family Planning Trends in Karachi, Pakistan by Catherine A

Fertility and Family Planning Trends in Karachi, Pakistan by Catherine A

Fertility and Trends in , By Catherine A. Hagen, Fariyal F. Fikree, Afroze Sherali and Fauzia Hoodbhoy

pregnancies, and 8% were using modern Context: In Pakistan, total fertility rates are high, contraceptive prevalence is low and there is family planning methods.10 By 1994–1995, widespread disagreement over whether fertility has begun to decline. It is likely that any drop in these rates had increased to 18% and 13% births in Pakistan will be seen initially among urban, middle-class women. respectively.11 Methods: A cross-sectional survey of 3,301 households in urban Karachi collected information There are few studies demonstrating on the reproductive history and family planning knowledge and practices of 2,651 ever-married overall fertility decline in Pakistan, and 12 women aged 54 or younger. Birth-cohort analysis was used to identify time trends in fertility and most authors agree that, in spite of some use of modern contraceptives. methodological problems affecting com- parability, the best interpretation of the Results: Respondents had more education and higher socioeconomic status than - available data is that there has been no al average. Their total fertility rate was 3.0 lifetime births per , the fertility rate was substantial change in fertility in Pakistan. 98.3 births per 1,000 women aged 15–49 and the crude birthrate was 23.2 births per 1,000 pop- In this article, we examine measures of fer- ulation. As recently as 1976, the TFR among the sample population had been 5.7 births per tility and contraceptive use to explore woman. Forty-two percent of married women aged 15–49 currently used a modern contracep- these fertility trends among a subgroup tive method. Among women born in 1950–1954, 64% had ever used contraceptives, compared of urban Pakistani women. 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%). Over- Methods all, 53% of users obtained their method at pharmacies or markets, and 24% used private hos- pitals or clinics. Some 71% of currently married, nonpregnant respondents reported having Study Population achieved their desired family size. The study employs data from a cross-sec- tional survey designed to provide com- Conclusions: Among a relatively well-educated, middle-class population in urban Karachi, there munity-based information to the Aga is a strong trend toward declining fertility and increasing utilization of contraceptives. However, Health Service of Pakistan (AKHSP).* The considerable unmet need for family planning is still evident. study population was defined as those liv- International Family Planning Perspectives, 1999, 25(1):38–43 ing in the neighborhoods that give rise to 75% of the clients of AKHSP’s three ma- ternity homes. The study boundary did not ontroversy exists over the success the gap between the TFR and the mean define an exclusive catchment , as of the family planning program in number of children born to women aged many other private and government hos- CPakistan,1 a where the na- 40–49 is widening over time provides pitals also function nearby. tional fertility rate is estimated to be some evidence of declining fertility. How- In Karachi, the AKHSP maternity homes among the highest in the region.2 The ever, this evidence is not strong: Because serve a self-referred clientele of wide geo- 1990–1991 Pakistan Demographic and most of the apparent fertility decline has graphic origin and ethnic composition, and Health Survey (PDHS) indicated that fer- occurred among the youngest age-groups, clients travel to the homes from different tility had declined modestly since earlier critics attribute any change in fertility to parts of the . As Karachi grew, and as national surveys: The total fertility rate increasing age at first , and de- the AKHSP expanded, new AKHSP ma- (TFR) in 1990–1991 was 5.4 lifetime births bate whether the delayed births will resur- ternity homes were built farther away from per woman,3 compared with TFRs of 6.0 face as higher age-specific fertility among the core of the old city . Thus, the - in 1985,4 6.5 in 1980,5 and 6.3 in 1975.6 20–29-year-olds in later surveys.8 Most re- vey sample involves an irregular, wedge- However, the declines appear to have searchers agree that without increasing shaped originating near the har- been substantial only among educated contraceptive use, substantial declines in bor and extending to densely populated women and those living in urban areas. the TFR and the rate residential neighborhoods, and it includes The “believability” of the apparent de- cannot be expected. cline has been questioned because of dis- In addition, until the publication of the Catherine A. Hagen is an adjunct professor in the De- crepancies between the estimated TFR and 1994–1995 Pakistan Contraceptive Preva- partment of Community Health Sciences, University of Northern British Columbia, George, . the persistence of a high crude birthrate lence Survey (PCPS), there had been little Fariyal F. Fikree is senior lecturer in the Department of 7 and low contraceptive prevalence. That evidence that family planning utilization Community Health Sciences, University, had increased over the past several Karachi, Pakistan. Afroze Sherali is chairperson and at *The Aga Khan Health Service of Pakistan (AKHSP) is decades.9 Data from Pakistan’s national the time the study was done Fauzia Hoodbhoy was per- a nongovernmental organization that has been operat- demographic surveys between 1965 and sonnel manager at the Aga Khan Health Service, Karachi, ing private maternity homes and community health ser- 1991 suggest that overall, Pakistani fam- Pakistan. The work on which this article was based was vices in Karachi since 1924. Currently, AKHSP operates ilies have been slower to adopt family supported by the Canadian International Development three maternity homes, where approximately 5,700 de- Agency Awards for , and substantial support liveries occur each year, and a number of community planning practices than their South also was received from the Department of Community health centers that support prenatal care and and neighbors: By 1991, approximately 12% of Health Sciences, , and the Aga Khan child health care. Pakistani couples were attempting to limit Health Service.

38 International Family Planning Perspectives households from a wide range of socio- sure the security of the survey , since the index (defined as persons per room, ex- economic circumstances. survey was conducted in a wide variety of cluding kitchen, bath or toilet, verandah locations, some with known political ten- and storage space). Per capita income, based Sampling sions. The supervisors were instructed to ob- on the indirect estimation of wages and oc- The goal of the survey was to include a serve at least one interview by each inter- cupations of household members, was 833 random sample of 3,000 households, 1,000 viewer per day, correct deficiencies in per month* (799 in the harbor area from within the 75% catchment area of obtaining informed consent and report daily and 1,287 in the residential area). The av- each of the three AKHSP maternity homes. any problems in data coding or quality. Data erage household owned 4.9 durable goods The (or, where addresses were were analyzed using Epi Info 6.04 software. (4.1 among households in the harbor area imprecise, the neighborhoods) of the 500 and 5.9 among those in the residential area); most recent users of each of the three ma- Results 56% owned radios and 86% owned televi- ternity homes were plotted on neighbor- The survey included 3,301 households. In sions (proportions similar to those report- hood and city maps. A geographical study 176 households (5%), no one was at home ed in the 1994–1995 PCPS). boundary was then drawn containing 75% to be interviewed on either visit, and in 228 Mean family size was 6.4 persons. of the maternity home clients, and 75 sur- households (7%), occupants refused to par- Crowding index was 2.8 persons per room, vey sites (25 surrounding each maternity ticipate. A common reason for refusal was although this index varied by area: In the home) were allocated among neighbor- fear of robbery; refusal rates were highest older, more congested harbor area, the hoods, in proportion to the number of in the wealthiest areas. From the remain- mean crowding index was 3.5, and in the clients from each area. Within each neigh- ing households, 2,651 ever-married more affluent residential area, it was 2.1. borhood, survey-site starting points were women were interviewed. The overall re- The educational attainment of respon- plotted randomly on city maps using a sponse rate among households in which dents in the survey was high compared numbered grid, and from an index house- at least one member was at home was 93%. with the national average for urban areas. hold at each site, the 40 nearest households Among men, 15% had received no edu- were included in the survey sample. Survey Reliability cation, 19% had completed primary Households that refused to participate in A random 5% of respondents (n=125) were , 20% had completed the study were replaced with adjacent revisited within two days of the original and 46% had at least a secondary educa- households until the target number of survey, and a subsample of questions were tion. Among women, 28% had no educa- households at the site was reached. repeated in order to assess reliability. tion, 26% had attained a primary educa- Agreement between the original sample tion, 18% had completed middle school Data Collection and the retest subsample concerning the and 28% had attained an education at or There were no criteria for excluding house- number of persons living in the household above the secondary level.† On average, holds from the survey. Where a household and the number of ever-married women men had received 10 years of education contained no ever-married women 54 years younger than 55 occurred in 94% and 96% and women 7.7 years. of age or younger, the interview consisted of cases, respectively. Birth year of the re- Forty-one percent of respondents spoke only of a brief demographic survey of spondent’s youngest child was the same ; 8% spoke Sindhi; 12% Gujerati; 7% household members. At least one return in 94% of cases, and birth year of the re- Balochi; 6% Punjabi; 8% Katchi; 3% Push- visit was made to each survey site to re- spondent was similar in 89% of cases. In to; and 15% other . Seventy-three contact households where no one was at 85% of cases, respondents agreed as to the percent were Suni and 25% were home or where adult women members birthplace of the youngest child, while Shia. Fewer than 1% each of respondents were absent at the time of the first visit. their reports on the identity of the person were Hindu, Christian or Parsee. Household data were usually provided by most responsible for choosing this facili- women, or by men in the absence of women ty agreed in 67% of cases. Agreement re- Fertility respondents. No proxy respondents were garding current pregnancy status occurred The crude birthrate for the sample was 23.2 used for the women’s questionnaire. in 98% of cases. Eighty-one percent of re- births per 1,000 population, a rate much The survey was conducted over six sponses regarding current use of any fam- lower than the estimate from the 1990–1991 weeks in January and February 1994. Data ily planning method were the same: Re- PDHS either for Karachi (36.2 births per were collected with a nine-page ques- spondents reported current use at both 1,000) or for the country as a whole (35.0 tionnaire in Urdu and English that re- survey points in 29% of cases; in 15% of per 1,000). The crude birthrate was higher quested information on household com- cases, respondents said “no” on the first near the harbor (26.7 per 1,000) than in the position and wealth, maternal and occasion and “yes” on the second, while residential area (19.3 per 1,000). The gen- paternal education, and the complete re- in 4% of cases they said “yes” on the first eral fertility rate of 98.3 births per 1,000 productive history of each ever-married visit and “no” on the second—a net bias women aged 15–49 also was lower than the woman younger than 55. Additional ques- of 11% in affirming use of family planning rate reported in the PDHS for Karachi tions covered tetanus toxoid immuniza- on the second but not the first visit. Among (173.5 per 1,000) or for the country as a tion, place of prenatal and delivery care, respondents who reported contraceptive whole (177.0 per 1,000). and family planning knowledge and use. use on both occasions, agreement con- Two survey teams, each consisting of a cerning the method used was 93%. *At the time of data collection, 31 Pakistani rupees were driver and vehicle, a male supervisor, a fe- equivalent to one U.S. dollar. male supervisor and eight interviewers, Sample Demographics fielded the questionnaire. Three days were Socioeconomic status of the survey sample †Corresponding figures for residents of in the PDHS were 27%, 27%, 13% and 32%, respectively, for spent training in the classroom and two was measured by three indices: reported oc- males and 38%, 29%, 12% and 22% for females. Nation- were spent pilot-testing the survey. The dri- cupation, ownership of durable household al levels of educational attainment were substantially ver and male supervisor were present to en- goods (an index of 10 items) and crowding lower: 68%, 20%, 5% and 7%.

Volume 25, Number 1, 1999 39 Fertility and Family Planning Trends in Karachi, Pakistan

varied by method, with 63% of respon- Table 1. Total fertility rate (TFR), age-specific fertility rate and general fertility rate among ever- married women aged 15–49, 1976–1991, Karachi, Pakistan dents aware of oral contraceptives, 57% familiar with the condom and 58% famil- Age-group 1976 1981 1986 1991 iar with the progesterone injection. In TFR†(SE) 5.68 (5.19, 6.15) 4.69 (4.38, 4.99) 3.94 (3.74, 4.14) 3.03 (2.91, 3.14) comparison, the 1990–1991 PDHS report- 15–19 100.0 75.9 60.2 31.5 ed that 77% of the national sample and 20–24 234.3 223.9 182.5 151.7 25–29 277.7 233.9 227.5 183.5 94% of the urban sample knew of at least 30–34 193.5 189.3 161.1 133.3 one modern method of family planning. 35–39 194.6 80.6 85.3 61.9 Table 2 presents the proportion of ever- 40–44 na 102.7 38.7 21.3 45–49 na na 32.4 4.8 married women who knew of at least one General modern method, stratified by age, edu- fertility rate 190.3 156.6 132.6 98.3 cation, socioeconomic status and migrant

†The standard error (SE) for the TFR was estimated using binomial assumption for the age-specific rates, and ignoring possible covari- status. The data show that knowledge was ance between successive age-specific fertility rates. Note: The column headings 1976, 1981, and 1986 refer to the midpoints of five-year higher among women aged 25–39 intervals. TFRs for 1991 were calculated from a six-year average of births in 1988–1993. Data were partially truncated in 1976 and 1981, and TFRs for these dates were calculated using age-specific fertility rates for the closest time period for which data were available. (81–82%) than among women aged 15–19 (68%), and was higher among women with any education (80–85%) than among By examining the number of reported 5.7 births per woman in 1976 to 3.0 in 1991. women with none (68%). births by age-group according to birth co- Declines in age-specific fertility over time Among married, nonpregnant women hort, we estimated general fertility rates, are most marked among women aged in the study population, 45% reported cur- age-specific fertility rates and TFRs for the 15–19 and those aged 35 and older: Among rent use of any family planning method, study population over approximately 20 women in these age-groups, current fer- and 42% reported use of a modern years. (Due to the age structure of the sur- tility rates were less than one-third of those method. Prevalence of modern method vey population, however, these results are 20 years prior. use was lower among women who were partially truncated for the years 1976 and poor (35%) than among those of higher so- 1981.) There was a strong, consistent down- Proximate Determinants of Fertility cioeconomic status (41–43%), and was also ward trend in these fertility measures over According to the 1991 PDHS, the average lower among women who lacked educa- time. The general fertility rate appears to age at first increased tion (29%) than among women having have decreased from 190 births per 1,000 from 16.7 in 1961 to 21.7 in 1990–1991. The any education (43–44%). Adolescent in 1976 to 157 per 1,000 in 1981, 133 per mean age at first marriage among ever- women (16%) and women older than 45 1,000 in 1986 and 98 per 1,000 in 1991 (Table married respondents was 19.5 years. (29%) were less likely than women aged 1). The TFR also has fallen, from a mean of Among women aged 15–19 at the time of 20–44 (33–45%) to use a modern method. the survey, however, only 5.4% were cur- Rural migrants had lower rates of mod- Table 2. Percentage of ever-married, non- rently married, suggesting that age at first ern method use than did those who were pregnant women aged 15–49 reporting knowl- marriage may be increasing; 40% of those Karachi residents (32% vs. 40%). edge and current use of modern contracep- aged 20–24 were ever-married, as were Tubal ligation was the most prevalent tive methods, by selected characteristics (N=2,620) 71% of those aged 25–29, 86% of those modern method of long-term family plan- aged 30–34 and 90% of those aged 35–39. ning (27%), and the condom was the most Characteristics Knowledge Current (Corresponding figures from the 1991 prevalent short-term modern method use† PDHS were 24%, 60%, 83%, 92% and 92%, (40%). Twelve percent of respondents re- Total 78.9 41.6 respectively.) ported current use of the IUD, 8% cur- Age The prevalence and duration of breast- rently used oral contraceptives, 7% relied 15–19 (ref) 67.7 16.1 feeding is an important determinant of fer- on the implant and about 5% used the in- 20–24 78.8* 32.7* tility in populations with a low prevalence jectable (not shown). 25–29 81.5* 40.0* 30–34 81.7* 44.6* of contraceptive use. Ninety percent of the In all age-groups, the likelihood of mod- 35–39 80.6* 44.6* 559 infants born to women in this sample ern method use rose with the number of 40–44 74.9 44.8 * ≥45 72.5 29.4 between 1989 and 1991* were breastfed; living children. Overall, only 2% of mar- 65% were breastfed for six months or ried, nonpregnant women with no living Education (in years) more, and 52% were breastfed for 12 children were using a modern method of 0 (ref) 68.5 28.5 1–4 81.8* 42.9* months or more. The mean duration of family planning, compared with 26% of 5–10 80.4* 42.9* breastfeeding was 13.6 months, and the women with one child, 42% of those with ≥11 84.6* 43.6* median duration was 12 months. two children and 50% of women with Migrant three children. Modern method use did no (ref) 79.7 40.3 Family Planning Knowledge and Use not increase with further increases in par- yes 76.1 31.6* Knowledge of contraceptive methods was ity, however. Socioeconomic status‡ assessed with open-ended questions fol- Among all ever-married women in the Low (ref) 72.6 35.1 lowed by prompting. Virtually all respon- survey population, 54% reported that they Medium 82.2* 41.4* High 85.5* 42.5* dents (99%) reported knowing of either a had ever used a contraceptive method. We modern or traditional method of family used a historical birth-cohort analysis to *Difference from reference category is statistically significant at p<.05. †Among married, nonpregnant women. ‡Socioeconomic planning: Four out of five (79%) knew of status was categorized according to number of durable goods at least one modern method, and 47% *To avoid bias resulting from the use of truncated data owned by household, with low=0–4, medium=5–7 and high=8–10. or difficulty with recall, breastfeeding was assessed only Note: ref=reference category. knew of at least one traditional method. for women’s most recent births occurring before Janu- Knowledge of modern contraceptives ary 1992 and after December 1988.

40 International Family Planning Perspectives approximate time trends in ever-use of of nonpermanent methods of family plan- birth year of infants and 89% for birth year family planning in the study population. ning, the largest proportions (62% of con- of (without net age bias). How- The results show a marked trend of in- dom users and 58% of pill users) cited a ever, bias in favor of reporting addition- creasing use over time: Whereas 37% of pharmacy or market as their source; fewer al knowledge and use of family planning women born in 1940–1944 reported ever than 10% obtained their method from gov- methods on retesting was apparent, and having used contraceptives (95% confi- ernment clinics. Among women using the not unexpected, considering the sensitiv- dence interval, 29–45%), this proportion IUD, the implant or the injectable, the pro- ity of the subject in Pakistan. increased to 48% among the 1945–1949 portions using private medical or gov- While every effort was made to assure birth cohort and to 64% among the ernment sources were evenly distributed the comfort and privacy of respondents 1950–1954 birth cohort (95% confidence among the different methods. during questioning (e.g., family planning intervals, 42–55% and 59–70%, respec- questions were asked at the end of the tively). Among women currently aged Discussion questionnaire, when rapport with the in- 35–39 (the 1955–1959 birth cohort), 60% Our study has two important limitations terviewer was highest), there is evidence had ever used contraceptives (95% confi- that affect the interpretation of the results: from these data that some “shy” users dence interval, 55–64%). This slight de- data quality and reliability; and the so- (15% in this sample) do not immediately crease, in comparison to the prevalence in cioeconomic and educational status of the report either knowledge or use to inter- the previous birth cohort, probably reflects study population. viewers. The net positive bias16 of 11% (the that women in this age-group are still be- First, while every effort was made to re- increase in the percentage of women who coming first-time method users. duce bias in the data—through training, stated they were currently using family close supervision and use of historical planning from the first to the second in- Fertility Preference and Unmet Need event and age charts—it is probable that terview) leads us to conclude that our re- Women in the sample were asked: “Is your some bias was incorporated. ported estimate of current modern fami- family now as large as you would like it Historically, survey results from Pakistan ly planning use (42%) is in fact a to be, or do you wish more children?” Of have been skewed by the custom among substantial underestimate. If we were to the 2,355 currently married, nonpregnant of overstating the ages of chil- add the estimate of the proportion of respondents, 22% stated that they wanted dren (spuriously lowering fertility rates)13 women who are “shy” users, the level of more children, 71% said they had their de- and the tendency of interviewers to inflate current use might be closer to 53%. sired number of children, 5% responded the ages of children to avoid having to ask To our knowledge, the reliability of fam- that the size of their family was the “will additional questions.14 In our survey, for ily planning questions in other studies of Allah,” and 3% did not respond or did example, for the year 1989, 435 births were conducted in Pakistan has not been rou- not know. Fertility preference was strong- reported—an unexpectedly low number, tinely assessed; it is possible that due to ly related to the number of living children: and 46 fewer than the average of the two respondent bias, family planning knowl- Some 67% of women with two children prior and subsequent years. This number edge and use in Pakistan has been sub- and 84% of those with three children stat- falls outside the 95% confidence interval stantially underestimated. Clearly, future ed they had achieved their desired fami- for random variation (445–525 births). A studies of family planning in Pakistan, as ly size, while among women with four or possible explanation is interviewer bias: In- elsewhere, should report reliability mea- five children, this proportion increased to terviews reporting births that occurred sures routinely. 91% and 94%, respectively. after January 1989 required the completion The urban, middle-class character of Thus, 71% of currently married non- of 10 more questions than those reporting this study population is a strong limita- pregnant women reported having births that occurred before this date. In- tion in generalizing the findings to other achieved their desired family size, yet only terviewers may have misreported birth parts of Pakistan. Clearly, this Karachi 42% reported use of a modern contracep- dates to avoid having to ask these addi- sample, deliberately chosen to reflect the tive method. This suggests that perhaps tional questions. Similar problems were catchment area of private maternity as many as one-third of married women documented in the 1991 PDHS survey. The homes, was better educated and wealth- have an unmet need for contraceptives. importance of interviewer training and ier than the average Pakistani household, close field supervision in future studies and at least slightly better off than the av- Source of Family Planning Methods cannot be overemphasized. erage urban resident. Because of differ- Overall, 26% of current contraceptive users To compensate for the misclassification ences in wealth and education, the results did not know the source of their family of births, we recalculated the most recent of this survey can not be generalized to the planning method, possibly because in Pak- fertility estimates for 1989–1993 as a country, or to Karachi as a whole. A bet- istan men tend to make family purchases. six-year average, including all births in ter interpretation of the findings is that Of those who reported a source, 23% ob- 1988; misclassified births were thus in- they are specific to this urban, largely mid- tained their method from a government cluded in the most recent interval. This re- dle-class subpopulation. source (such as a hospital or family plan- calculation led to a modest elevation of the With these caveats in mind, the main ning clinic), 24% reported a private med- estimated TFR for the interval 1988–1993, findings of the survey remain substantial ical source and 53% obtained their method from 2.96 to 3.03 lifetime births. and convincing: A dramatic change in fer- from a pharmacy or market. Our data generally can be described as tility has occurred within the study popu- Of the 262 women who had undergone showing moderate to high retest reliabil- lation over the past 20 years. We believe tubal ligation and had reported the source, ity,15 but with variation according to ques- that the effects shown—a TFR that has fall- 53% had used private medical clinics or tion type. In particular, we are concerned en from 5.7 to 3.0 births per woman, strong hospitals; the remainder said that gov- about the reliability of age reporting and internal consistency in the data and clear ernment hospitals and family planning its effect on fertility measures. In this sur- separation of the confidence intervals centers were their providers. Among users vey, agreement on retesting was 94% for around each estimate—are of a magnitude

Volume 25, Number 1, March 1999 41 Fertility and Family Planning Trends in Karachi, Pakistan that argues against an explanation based increasing proportion of the urban mid- Resumen on bias or sampling error alone. Clearly, dle-class will move to the need, Contexto: En Pakistán, las tasas globales de there are strong parallel trends toward in- are important subjects for institutional fecundidad (TGF) permanecen elevadas, la pre- creased utilization of family planning in audit and policy review. del uso de anticonceptivos es baja y urban, middle-class Karachi and a drop in hay desacuerdo con respecto a que la fecundi- fertility. The contraceptive prevalence References dad haya comenzado a declinar. Es probable que (45%) is the highest level reported from any 1. Ahmed T, Unmet need for contraception in Pakistan: si hay alguna disminución de la fecundidad en community survey in Pakistan to date, and pattern and determinants, Demography in , 1993, Pakistán, esto ocurra al principio entre las mu- 22(1):31–51; Aslam A, Pakistani prospects, Populi, edi- may even be somewhat underestimated. torial, Nov. 8–10, 1993; and Cernada GP and Ubaidur Rob jeres de clase media de las zonas urbanas. Taken together, these data suggest that for AK, Pakistan’s fertility and family planning: future di- Métodos: Se realizó una encuesta transver- this urban subgroup at least, the demo- rections, Journal of Family Welfare, 1992, 38(3):49–56. sal de 3.301 hogares en la zona urbana de Ka- graphic transition in Pakistan is underway. 2. Ministry of Population Welfare, Government of Pak- rachi, la cual recopiló información sobre los an- The high proportion of family planning istan and U.S. Agency for International Development, tecedentes reproductivos y sobre el users who obtain their supplies from pri- Accomplishments of the Population Welfare Planning Project conocimiento y prácticas de planificación fa- (1982–1993), Karachi, Pakistan: Elite Publishers, 1993. vate sources such as pharmacies or med- miliar de 2.651 mujeres que se habían casado ical clinics is notable. Although 23% of 3. National Institute of Population Studies, Pakistan, and alguna vez, de 54 años de edad o menores. Se IRD/Macro International, Pakistan Demographic and Health users who reported a source attended gov- Survey, 1990/1991, , Pakistan: National Insti- utilizó un análisis de cohortes para identificar ernment family planning clinics or hos- tute of Population Studies, 1992. las tendencias temporales de la fecundidad y pitals, the bulk of sterilizations and tem- 4. Ministry of Population Welfare, Government of Pak- del uso de anticonceptivos modernos. porary methods were obtained through istan, Pakistan Contraceptive Prevalence Survey, 1984–1985, Resultados: Las entrevistadas tenían un private sources. This finding is in agree- Islamabad, Pakistan: Ministry of Population Welfare, 1986. mejor nivel de educación y de condición so- ment with other data17 indicating that this 5. Pakistan Institute of Development Economics and In- cioeconómica que el promedio nacional. Su population uses private maternity homes ternational Labour Organization, Population, Labour Force TGF era de 3,0 hijos por mujer, la tasa gene- and Migration Survey, 1979–1980, Islamabad, Pakistan: for the majority of prenatal and delivery Pakistan Institute of Development Economics, 1981. ral de fecundidad era de 98,3 nacimientos por services. Clearly, more research into client cada 1.000 mujeres de 15–49 años y la tasa 6. NM, Pakistani Women: A Socioeconomic and De- preferences for private health care services mographic Profile, Islamabad, Pakistan: Pakistan Institute bruta de natalidad era de 23,2 nacidos por una in both maternal health and family plan- of Development Economics, 1986. población de 1.000. Tan recién en 1976, ning services is called for. 7. Sathar ZA, The much-awaited fertility decline in Pak- la TGF entre la población de la muestra había istan: wishful thinking or reality? International Family sido de 5,7 hijos por mujer. El 42% de las mu- Conclusions Planning Perspectives, 1993, 19(4):142–146. jeres casadas de 15–49 años, actualmente usan The women surveyed in this study had 8. Sathar ZA and Mason KO, How af- un método anticonceptivo moderno. Entre las lower fertility than the national population fects reproductive behavior in urban Pakistan, Asian & mujeres nacidas entre los años 1950 y 1954, Pacific Population Forum, 1993, 6(4):93–103. and showed strong declining fertility 64% había usado anticonceptivos alguna vez, trends over time. The significance of this 9. Sathar ZA, Maternal , report pre- en comparación con 37% de las nacidas entre pared for UNICEF situation analysis of women and chil- data is considerable in Pakistan, where ev- dren, Pakistan Institute of Development Economics, un- 1940 y 1944. El método más corrientemente idence of fertility change has been limited published report, 1990; and Khan A, Policy-making in usado por las entrevistadas era el condón (and controversial). At least for an urban, Pakistan’s population programme, Health Policy and Plan- (40%), seguido de la ligadura tubaria (27%) relatively well-educated subgroup, con- ning, 1996, 11(1):30–51. y el DIU (12%). En general, 53% de las usua- traceptive use and fertility appear to be 10. National Institute of Population Studies, Pakistan, rias obtuvieron su método en las farmacias o and IRD/Macro International, 1992, op. cit. (see refer- changing rapidly. The contraceptive preva- ence 3). mercados, y 24% utilizó hospitales privados lence seen in this population is not solely o clínicas. Alrededor del 71% de las mujeres 11. Ministry of Population Welfare and Population Coun- accounted for through the government’s cil, Pakistan Contraceptive Prevalence Survey 1994–95: Basic casadas y no embarazads indicaron que habí- provision of family planning supplies: Con- Findings, Islamabad, Pakistan: Ministry of Population an logrado el número deseado de hijos. traceptives were obtained from govern- Welfare and Population Council, 1995. Conclusiones: Entre la población urbana de ment clinics or hospitals in less than a quar- 12. Sathar ZA, 1993, op. cit. (see reference 7); Sathar ZA clase media de Karachi, con niveles relativa- ter of the cases where the source was et al., Women’s status and fertility change in Pakistan, mente altas de escolaridad, hay una gran ten- known. Markets and pharmacies are com- Population and Development Review, 1994, 14(3):415–432; dencia hacia la disminución de la fecundidad and Cernada GP and Ubaidur Rob AK, 1992, op. cit. (see mon sources of the most easily accessible reference 1). y el uso de anticonceptivos. Sin embar- methods, and families frequently turn to go, aún es evidente la necesidad insatisfecha 13. Sathar ZA, 1993, op. cit. (see reference 7). private doctors for both sterilization and que existe en materia de planificación familiar. 14. National Institute of Population Studies, Pakistan, methods of birth spacing. In spite of the in- and IRD/Macro International, 1992, op. cit. (see refer- creased use of family planning reported by ence 3). Résumé Contexte: survey respondents, however, there re- 15. Fabricant SJ and Harpham T, Assessing response re- Au Pakistan, l’indice synthétique mains a considerable “unmet need” for liability of health interview surveys using reinterviews, de fécondité est élevés, la prévalence contra- family planning—perhaps as many as one- Bulletin of the Health Organization, 1993, ceptive est faible et la question de savoir si la fé- third of our respondents. 71(3/4):341–348. condité a commencé à baisser est loin d’être ré- Overall, our findings suggest that the 16. Ibid. solue. Les premiers signes de déclin de la natalité urban population of Pakistan is moving 17. Hagen CA, Maternal mortality, fertility, and the uti- y seront vraisemblablement observés parmi les toward widespread use of family plan- lization of prenatal care in Karachi, Pakistan, unpublished femmes des classes moyennes urbaines. ning. Whether government clinics will en- master’s thesis, McGill University, Montreal, Canada, Méthodes: Une enquête transversale menée 1995; and Hanley J, Hagen CA and Shiferaw T, Confi- courage user confidence by providing ser- dence intervals and sample size calculations for the Sis- auprès de 3.301 ménages de la région urbaine vices of perceived high quality, and terhood Method of estimating maternal mortality, Stud- de Karachi a recueilli des informations sur les whether the private clinics that serve an ies in Family Planning, 1996, 27(4):220–227. antécédents procréateurs et la connaissance et

42 International Family Planning Perspectives pratique du planning familial de 2.651 femmes 23,2 naissances par millier d’habitants. En lisatrices se procuraient leurs méthodes en mariées ou l’ayant été, jusqu’à l’‚ge de 54 ans. 1976 encore, l’indice synthétique de fécondi- pharmacie ou au marché, et 24% s’adressaient L’analyse de cohorte de naissances a été utili- té s’élevait à 5,7 naissances par femme. Qua- à des cliniques ou hôpitaux privés. Quelque sée pour identifier les tendances temporelles rante-deux pour cent des femmes mariées ‚gées 71% des répondantes mariées ou l’ayant été de fécondité et de recours à la contraception de 15 à 49 ans pratiquaient une méthode de et non enceintes ont déclaré avoir atteint leur moderne. contraception moderne au moment de l’en- nombre d’enfants désiré. Résultats: Les répondantes étaient plus ins- quête. De celles nées entre 1950 et 1954, 64% Conclusions: Il existe, au sein de la classe truites et de rang socio-économique supérieur avaient déjà pratiqué la contraception, par rap- moyenne relativement bien instruite du centre à la moyenne nationale. Leur indice synthé- à 37% de celles nées entre 1940 et 1944. urbain de Karachi une forte tendance au dé- tique de fécondité était de 3,0 naissances finales La méthode la plus pratiquée parmi les utili- clin de la fécondité et un recours croissant à la par femme, l’indice général de fécondité étant satrices courantes était le préservatif (40%), contraception. Un besoin considérable de plan- de 98,3 naissances par millier de femmes ‚gées suivi de la ligature des trompes (27%) et du ning familial non satisfait n’en demeure pas de 15 à 49 ans, et le taux brut de natalité, de stérilet (12%). Dans l’ensemble, 53% des uti- moins évident.

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