Zeba A. Sathar

The effect of gender differences in primary school access type and quality on the decision to enroll in rural Pakistan.

The article explores the effect of primary school access, type (public vs. private), and quality on parents’ decision to enroll their children in rural Pakistan using a 1997 survey. The authors find that, for girls, living in a village with an all‐girls’ public school makes a significant difference in the likelihood of enrollment. The quality of the girls’ school is also a significant factor influencing parents’ decision to enroll their girls. Boys’ overall levels of enrollment are unaffected by access and quality; parents, however, are more likely to select private schooling for their boys and girls when a private school is locally available. In contrast to earlier findings for urban Pakistan, we do not find that a greater availability of private school alternatives would significantly increase overall primary school enrollment; instead, it would primarily affect the distribution of enrollment between the private and public sector.

Women's Status and Fertility Change in Pakistan

Female education workforce participation and age at marriage are argued to be imperfect but workable indicators of womens status in Pakistan. All 3 measures are shown to be significant determinants of fertility in a survey of 1979-80. Similarly age at marriage is related to female education and in urban areas to workforce participation. In addition the education for the next generation of mothers is shown to depend on parental education and in urban areas the discrimination against girls education diminishes as the occupational and educational level of their parents increases. These differentials and their implications for future change are masked by the absence of national fertility decline. (authors) (summaries in ENG FRE SPA)

Social stigma and disclosure about induced abortion: results from an exploratory study.

It is well recognised that unsafe abortions have significant implications for womens physical health; however, womens perceptions and experiences with abortion-related stigma and disclosure about abortion are not well understood. This paper examines the presence and intensity of abortion stigma in five countries, and seeks to understand how stigma is perceived and experienced by women who terminate an unintended pregnancy and influences her subsequent disclosure behaviours. The paper is based upon focus groups and semi-structured in-depth interviews conducted with women and men in Mexico, Nigeria, Pakistan, Peru and the United States (USA) in 2006. The stigma of abortion was perceived similarly in both legally liberal and restrictive settings although it was more evident in countries where abortion is highly restricted. Personal accounts of experienced stigma were limited, although participants cited numerous social consequences of having an abortion. Abortion-related stigma played an important role in disclosure of individual abortion behaviour.

Women work and reproduction in Karachi.

A survey of 1000 women in Karachi was undertaken to measure the effect of both education and employment on womens fertility and status (their relative autonomy within the family and perceived economic independence). Results show that womens status improves with 10 or more years of education and with employment in professional or other salaried positions outside the home; however having less than 10 years of schooling and working in low-paying service sector jobs or in income- earning activities at home shows little effect. Employment in professional or higher paying jobs appeared to have more effect than education on lowering womens fertility in the 5 years prior to the survey. (authors)

Schooling Opportunities for Girls as a Stimulus for Fertility Change in Rural Pakistan

This paper tests Caldwells mass schooling hypothesis in the context of rural Pakistan. His hypothesis was that the onset of the fertility transition is closely linked to the achievement of “mass formal schooling” of boys and girls. Punjab and Northeast Frontier Provinces (NWFP) were selected for this study because they appear to be on the leading edge of the demographic transition--a transition that has only recently begun--as suggested by rapid recent increases in contraceptive practice. The study covered a range of rural villages or communities with very different socioeconomic and schooling conditions in order to examine the effects of both school access and quality on family-building behavior in Pakistan. The study concludes that gender equity in the schooling environment as measured by the number of public primary schools for girls in the community or by the ratio of the number of girls’ schools to boys’ schools has a statistically significant effect on the probability that a woman will express a desire to stop childbearing and by extension on the probability that she will operationalize those desires by practicing contraception. Indeed the achievement of gender equity in primary school access in rural Punjab and NWFP could lead to a 14-15 percentage point rise in contraceptive use in villages where no girls’ public primary school currently exists and an 8 percentage point rise in villages with one primary school for girls. This is entirely supportive of the Caldwell argument that mass schooling is an important determinant of fertility change particularly when girls are included. It would appear that fertility change will be more difficult and will come much more slowly when girls are left behind. (authors)

Reducing Unmet Need and Unwanted Childbearing: Evidence from a Panel Survey in Pakistan

Pakistans high unmet need for contraception and low contraceptive prevalence remain a challenge, especially in light of the countrys expected contribution to the FP2020 goal of expanding family planning services to an additional 120 million women with unmet need. Analysis of panel data from 14 Pakistani districts suggests that efforts to reduce unmet need should also focus on empowering women who are currently practicing contraception to achieve their own reproductive intentions through continuation of contraceptive use of any method. Providing women with better quality of care and encouraging method switching would bridge the gap that exists when women are between methods and thus would reduce unwanted births. This finding is generalizable to other countries that, like Pakistan, are highly dependent on short-acting modern and traditional methods. The approach of preventing attrition among current contraceptive users would be at least as effective as persuading nonusers to adopt a method for the first time.

The much-awaited fertility decline in Pakistan: wishful thinking or reality?

The Pakistan Demographic and Health Survey (PDHS) from 1990-1991 showed a decline in the total fertility rate (TFR) from 6.3 lifetime births per woman in 1975 to 5.5 births during the 6 years before the survey. A similar decline in fertility was claimed more than a decade earlier and then refuted as it seemed to have been based on a data artifact. According to various surveys the TFR for the 1980s ranged from 6.0 to 6.9 and there is no consensus on fertility levels in Pakistan. Fertility did not change much before the late 1980s when a decline may have begun. The final year of the PDS yielded a TFR of 6.5 in 1988. In contrast the PDHS indicated a TFR of 5.5 for 1985-1991 and a TFR of 5.2 for 1990-1991. If the TFR from the Pakistan Contraceptive Prevalence Survey (PCPS) is considered representative for 1984-1985 the TFR in Pakistan had fallen by about 0.5 in 6 years. The PDHS report attributes this decline mainly to the rising female age at marriage. The comparison of age-specific fertility rates for 1970-1975 with those for 1985-1991 as reported in the 1975 PFS and the 1991 PDHS respectively indicated that fertility had declined most among 15-19 year olds. The ratio of age-specific fertility rates for the 15-19 year age group during 1985-1991 was 1/3 lower than that of the same age group for 1970-1975. At the same time fertility levels among all other age-groups except women 45-49 years old seem to have fallen 4-15% since 1975. Data from the 1990-1991 PDHS like those of the 1975 PFS have presented evidence of a change in fertility that seems unlikely unless contraceptive use has been severely underreported in this survey. Fertility could be lowered quite rapidly from a TFR of 5-6 to a TFR of about 4 children per woman if the means to control fertility were made more attractive accessible and effective.

Managing unplanned pregnancies in five countries: Perspectives on contraception and abortion decisions

Why is induced abortion common in environments in which modern contraception is readily available? This study analyses qualitative data collected from focus group discussions and in-depth interviews with women and men from low-income areas in five countries – the United States, Nigeria, Pakistan, Peru and Mexico – to better understand how couples manage their pregnancy risk. Across all settings, women and men rarely weigh the advantages and disadvantages of contraception and abortion before beginning a sexual relationship or engaging in sexual intercourse. Contraception is viewed independently of abortion, and the two are linked only when the former is invoked as a preferred means to avoiding repeat abortion. For women, contraceptive methods are viewed as suspect because of perceived side effects, while abortion experience, often at significant personal risk to them, raises the spectre of social stigma and motivates better practice of contraception. In all settings, male partners figure importantly in pregnancy decisions and management. Although there are inherent study limitations of small sample sizes, the narratives reveal psychosocial barriers to effective contraceptive use and identify nodal points in pregnancy decision-making that can structure future investigations.

Induced Abortions and Unintended Pregnancies in Pakistan

During the past decade, unmet need for family planning has remained high in Pakistan and gains in contraceptive prevalence have been small. Drawing upon data from a 2012 national study on postabortion-care complications and a methodology developed by the Guttmacher Institute for estimating abortion incidence, we estimate that there were 2.2 million abortions in Pakistan in 2012, an annual abortion rate of 50 per 1,000 women. A previous study estimated an abortion rate of 27 per 1,000 women in 2002. After taking into consideration the earlier studys underestimation of abortion incidence, we conclude that the abortion rate has likely increased substantially between 2002 and 2012. Varying contraceptive-use patterns and abortion rates are found among the provinces, with higher abortion rates in Baluchistan and Sindh than in Khyber Pakhtunkhwa and Punjab. This suggests that strategies for coping with the other wise uniformly high unintended pregnancy rates will differ among provinces. The need for an accelerated and fortified family planning program is greater than ever, as is the need to implement strategies to improve the quality and coverage of postabortion services.

Family planning: a missing priority in Pakistan's health sector?

According to Alex Ezeh and colleagues, “Pakistan’s failure to promote family planning in the 1970s and 1980s” has already had, and will lead to, great repercussions: a population that is anticipated to be “41% larger than Bangladesh’s” by 2050. Currently, Pakistan’s population is estimated to be more than 180 million, increasing at a rate of 1·9% per year. It is projected to be between 266 million and 342 million by 2050 (fi gure), largely to be determined by the uptake of family planning and consequent fertility decline. Pakistan has a poor record of reducing fertility: although the fertility rate has fallen from about six births per woman in 1990 to 3·6 in 2012, it is higher than that in the rest of south Asia. Family planning is perhaps the most overlooked and neglected component of women’s health in Pakistan. Contraceptive use rose sharply, from 12% to 28%, during 1991–98 (corresponding to a 2% increase per year), but the rate of increase has slowed and reached a plateau at about 30% since then. There is, however, a renewed possibility after the 18th Constitutional Amendment to focus on family planning as a means to improve maternal and child health with each newly evolving provincial health strategy. More recently, in research leading up to the London Summit on Family Planning in July, 2012, the association between the fall in fertility and a period of favourable age structures resulting from falling dependency ratios has been linked strongly to the economic wellbeing of families and macroeconomic growth. The opportunity to capture the demographic dividend in the next few decades has led to a growing realisation in Pakistan that investments in a strong family planning programme and in human development are imperative. It is now a question of matching the realisation with a strong policy and programmatic response, especially in Pakistan’s provinces. Many economists and academics still doubt that Pakistan will achieve a substantial increase in the use of family planning because of religion, social conserva tism, or preferences for larger families. Yet these apprehensions are not borne out by the evidence—there are at least three strong arguments that go against this premise. First, a quarter of women in the reproductive age group (15–49 years) in Pakistan have an unmet need for family planning. In Khyber Pakhtunkhwa and Baluchistan, the unmet need for family planning is greater than 30%. Nearly 1 million women in Pakistan seek unsafe abortions every year, a decision determined by the high level of unwanted pregnancies. Improved access to quality services will reduce the number of abortions and maternal and child deaths. Second, it is clear from inequities in unmet need for family planning and contraceptive use by income levels, and across urban and rural populations, why women who are poor have as many as two unwanted pregnancies compared with a quarter of this number for women who are not poor. The health system, unable to 9 National AIDS Control Program, Ministry of Health Islamabad. Report on rapid situation analysis of the HIV outbreak in Jalal Pur Jattan, Gujrat District. 2008. http://www.nacp.gov.pk/library/reports/Surveillance%20 &%20Research/Report%20on%20Rapid%20Situation%20Analysis%20 of%20the%20HIV%20Outbreak%20in%20Jalal%20Pur%20Jattan,%20 Gujrat%20District.pdf (accessed Sept 27, 2012). 10 Kassi M, Afghan AK, Khanani MR, Khan IA, Ali SH. Safe blood transfusion practices in blood banks of Karachi, Pakistan. Transfus Med 2011; 21: 57–62. 11 PMRC. Prevalence of hepatitis B and C in Pakistan. Islamabad: Pakistan Medical Research Council, 2009. 12 Nishtar S, Boerma T, Amjad S, et al. Pakistan’s health system: performance and prospects after the 18th Constitutional Amendment. Lancet 2013; published online May 17. http://dx.doi.org/10.1016/S0140-6736(13)60019-7. 13 Creswell J, Yasin Z, Sahu S, Khan AJ. Public–private mix in tuberculosis— authors’ reply. Lancet Infect Dis 2012; 12: 909–10. 14 Khan AJ, Khowaja S, Khan FS, et al. Engaging the private sector to increase tuberculosis case detection: an impact evaluation study. Lancet Infect Dis 2012; 12: 608–16.