Fertility and Family Planning Trends in Karachi, Pakistan by Catherine A
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Fertility and Family Planning Trends in Karachi, Pakistan 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 the nation- available data is that there has been no al average. Their total fertility rate was 3.0 lifetime births per woman, the general 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 Khan 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 area, as of the family planning program in number of children born to women aged many other private and government hos- CPakistan,1 a country 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 city. As Karachi grew, and as national surveys: The total fertility rate increasing age at first marriage, 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 harbor. Thus, the sur- 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 territory 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 population growth 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, Prince George, Canada. 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, Aga Khan 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 Canadians, and substantial support liveries occur each year, and a number of community planning practices than their South Asian also was received from the Department of Community health centers that support prenatal care and mother and neighbors: By 1991, approximately 12% of Health Sciences, Aga Khan University, 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 staff, 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 rupees 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 addresses (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 school, 20% had completed middle school 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.