Sadiah Ahsan Pal  ( Department of Gynaecology, Orthopaedic Medical Institute (OMI), Karachi. )

Pakistan is currently the 6th most populated country in the world and rapidly moving to become the 4th most populated by 2050. This is very alarming, as we are already outstripping our resources, with water, gas and power shortages.
Nearly 1 in every 4 births is unplanned in Pakistan. Fifty percent of married women want pregnancy spacing or to limit their family, while 25% of married women have an unmet need of family planning.¹ This unmet need is reflected in the large number of abortions, 890,000 per year, and women hospitalized with complications every year (197,000).²
The majority of the women who have abortions in Pakistan are married, 30 years or older, with 3 or more children. Poverty is one of the major reasons for resorting to abortion, instead of using modern effective contraception. The abortions, often unsafe, risk their lives. Unsafe abortions account for 5.6% of Maternal deaths.¹
This sorry state of affairs can be gauged by this example: A grand multipara from Interior Sindh gave birth to her twenty first child during the floods that devastated Pakistan in 2011. She called her baby "Icki", (number 21). She had exhausted all the names she knew for her offsprings ! I shared this story with a group of health workers from the flood affected areas of Sindh, and asked them to guess the name of the 21st child. The majority guessed the correct name, because they had met such women before, whose children were a number!
Pakistani women are actually having more children than they want, especially in the rural areas. Though cheap, even free contraceptives are available in Pakistan, they are not reaching the user. The methods with the lowest failure rates like the combined oral contraceptive pill (COCP)/implants/injections and IUCDs (Intrauterine contraceptive device) are used by only 2% of women. Our dismal Contraceptive Prevalence Rate (CPR) is 27 %, virtually unchanged over the last decade. Compare this to other muslim countries: Iran 73 %, Turkey 73%, Morocco 63%, Indonesia 61%, Egypt 60% and Bangladesh 61%.³
Myths and misconceptions about the most effective contraceptives lie with the lay public as well as physicians Reasons cited by women who use no contraception, are that they have left it to God (28%), opposition from husband, fear of side effects and lack of knowledge. Only 5% have a perceived religious prohibition.¹
They are generally unaware of the non-contraceptive benefits of the pill and the safety and efficacy of the modern IUCDs. Even physicians are unaware of the non contraceptive benefits of the pill: decreased blood loss and osteoporosis, improved skin and hair, improved symtoms of premenstrual syndrome and dysphoric disorder, reduced risk of ovarian cancer, uterine cancer and colon cancer. The safety of the COCP was confirmed in the largest longitudinal study of 46,000 women over 40 years. It found that women on the pill live longer and are less likely to die prematurely of all causes including cancer and heart disease.⁴
We must ensure that every graduating doctor and nurse is competent to prescribe all the modern, effective contraceptive methods, including emergency contraception. Healthy Timing and Spacing of Pregnancy (HTSP) of 2 to 3 years, in order to have the best outcome for the mother and child, should also be advised.
Premarital counseling should be made compulsory by the government for all couples prior to their Nikah. This is particularly important because there is no formal sex education in our schools and colleges.
Contraception counseling (to prevent unplanned pregnancy) should be combined with health advice and screening; check Blood group (to prevent Rhesus incompatability), Rubella status (to prevent German measles in pregnancy), Thallasaemia screening (prevent Thallasaemia Major) and Human Papilloma Virus (HPV) Vaccination (to prevent cervical cancer). Similar measures, have already been implemented in Iran with success.
Health Professionals also need to focus on the antenatal and postpartum period for contraceptive counseling, when women are most receptive to advice. Once discharged after delivery, they often do not return for follow up, and hence miss the opportunity for effective family planning. This missed opportunity to prevent unplanned pregnancy can be rectified by proper counseling and if chosen, insertion of the IUCD immediately (within 10 mins) or up to 48 hours after delivery, before discharge. Due to cultural reservations and fear of divorce, Pakistani women with completed family are often unwilling for tubal ligation, even when undergoing Caesarean sections repeatedly. Intra-Caesarean IUCD insertion offers a very effective and safe alternative to tubal ligation for such women, providing highly effective, safe, reversible contraception for up to 12 years. Skilled Birth Attendants and Obstetricians need to be trained in the new technique of immediate postpartum IUCD insertion, as it is different from that of interval or 6 weeks postpartum insertion. Fundal placement of the IUCD with Kelley\'s Forceps in the larger postpartum uterus, using aseptic technique, is the key to the success of this procedure. Initial reports of follow-up from a pilot study from 2 large tertiary care government hospitals in Karachi are very encouraging, showing very low expulsion rates (2%) without any significant complications.⁵
Population planning and education is the basis of a better economic future. The most effective way of doing this would be to only have the number of children that couples can afford to have. This can be achieved by easy access and informed choice of effective modern methods of contraception, competent health professionals and greater budget allocation by our government.
Pakistan can only progress with sensible family planning.

1. 2007 Pakistan Demographic and Health Survey 2006-07. National Institute of Population Studies, Pakistan; and, Macro International, Inc.
2. Population Council. 2004. Unwanted Pregnancy and Postabortion Complications in Pakistan: Findings from a National Study.
3. World Population Data Sheet 2012, Population Reference Bureau. (Online) (Cited 2013 Dec 31). Available from URL: http://www.prb.org/Publications/Datasheets/2012/world-population-data-sheet/data-sheet.aspx.
4. Hannaford PC, Iversen L, Macfarlane TV, Elliott AM,  Angus V,  Lee AJ. Mortality among contraceptive pill users: cohort evidence from Royal College of General Practitioners\' Oral Contraception Study. BMJ 2010; 340: c927.
5. Jafarey SN, Ahsan A, Shah L. Training for & Institutionalization of Post Placental and Immediate Postpartum Insertion of Intrauterine Contraceptive Device. SOGP News & Views 2012; 22: 4.