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Byline: Nabila Amin, Nigar Johar, Syed Fawad Mashhadi and Mehwish Ara Shams

Keywords: Family planning, Modern contraception, Population, Women health and empowerment.


Women's empowerment is critical in achieving the sustainable development goals (SDG) in development of any society in addition to being a basic human right. The women in under developed and developing countries with low income have far more pregnancies than the developed countries which puts their lives to risk due to more pregnancy related complications 1. Besides, women who are empowered have better control over their own and their children's health which ultimately leads to better quality of health care and improved health and social outcome indices. A number of recent studies in different parts of the world have shown that maternal autonomy in healthcare seeking behaviour is directly related to women's empowerment 2-5. To reduce the maternal mortality rate,the most effective and substantive known approach is family planning.

The use of contraceptives as part of FP is cost effective intervention to accomplish the Sustainable Development Goals (SDGs) in progress of a country towards development outcomes 6. The current population of Pakistan is 219,100,790 as of 2 Feb 2020 based on the latest United Nations estimates. Pakistan population is equivalent to 2.83% of the total world population and by population ranks number 5 in the list of countries 7. The country's development is greatly hampered by the its increasing population growth. Population growth can be reduced to one birth for one woman by increasing the use of contraceptives from 15 to 17% 8.

In unindustrialized states, women have second-rate positions in all facets of decisionmaking which greatly affects the use of contraceptives. The reproductive healthcare initiatives in Pakistan began in 1950s at public and private setup, despite all these efforts the country has highest fertility and low contraceptive use rates among its neighbours. They concluded that to address the issue enhanced efforts are needed, including the sufficient counselling skills of healthcare workers and increased contraceptive supplies availability. They also emphasised the need of maternal autonomy as the influence of mother in law and husbands has a significant impact on decision making 9.

There is very less knowledge about how the independence of young Pakistani women in household decision making affects the utilization of modern contraceptives (MC). This study was focused on determining the status of utilization of modern contraceptive methods in rural and urban areas of Pakistan as well as in various socio-economic groups governed by different education levels. Another objective of the study was to determine; either women's independent household decision making, or the couple's joint participation is more influential in MCU.


A cross-sectional study design was adopted to collect data from 360 patients reporting to the Gynae and Obstetrics department Pak Emirates Military Hospital, Rawalpindi from August 2018 to August 2019. Sample size was calculated using Raosoft sample size calculator. IERB (A/28//EC-29/19) approval was obtained and informed consent taken from all the patients. Women having primary and secondary infertility were excluded from the study.

Demographic data such as age, socio economic status, level of education, no of children, household decision making and place of residence were categorised into ranges and expressed in percentages. The number of couples using certain method of contraception was also expressed in percentages. SPSS 25 was used for statistical analysis. The statistical significance of one variable over other was determined by applying one way ANOVA test. A p-value of less than or equal to 0.05 was considered statistically significant.

Table-I: Socio demographic profile of respondents (n=360).

Age of Subjects(Years)###n(%)




Husbands Age(years)





Age of The Subject at Marriage(Years)





Education Level





Place of Residence



Table-II: Autonomy of young women in household decision making.

Visited by family planning worker in last 6




Gave family planning method###2(0.6)

Talked and gave method###6(1.7)


Number of Living Children






Desire for More Children

Wants within 2 years###78(21.7)

Wants after 2 + year###14(3.9)

Wants, unsure about thinking###24(6.7)


Wants no more###208(57.8)

Husband's Desire For Children

Both wanted same###261(72.5)

Husband wanted more###28(7.8)

Husband wanted fewer###2(0.6)

Don't know###69(19.2)

Person Who Usually Decides On Large

Household Purchase

Respondent alone###35(9.7)

Respondent and husband jointly###147(40.8)

Husband alone###118(32.8)

Someone else###60(16.7)

Final Say On: Child Health Care

Respondent alone###66(18.3)

Respondent and husband jointly###170(47.2)

Husband alone###116(32.2)

Someone else###7(1.9)



A total of 360 women fulfilling the inclusion criteria were included in the study. Majority of the women, 255 (70.8%), were of 25-35 years of age while only 87 (24.2%) were in 15-25 years of age group. A majority of the husbands of the subjects, 292 (81%), were within 25-35 years of age while only 8 (2.2%) were in 15-25 years of age. All the women in the study sample were literate with 104 (28.9%) having a highest level of secondary degree. Of 360 respondents, 286 (79.5%) belonged to a low socioeconomic group while 74 (20.6%) belonged to middle socioeconomic group. Most of the women i.e. 191 (53%) lived in the urban areas while 251 (69.7%) of the husbands were engaged in manual occupation (table-I). A majority of the women, 310 (86.1%), were not visited by a family planning worker in the last six months.

Out of 360 women, 179 (49.7%) had 3-5 living children while only 17 (4.7%) had more than 6 living children. Majority of the women 208 (57.8%) did not show any desire for more children while a substantial percentage of the sample i.e 78 (21.7%) showed a desire for more children within 2 years (table-II). According to 261 (72.5%) both husband and wife wanted same number of children while in only 2 (0.6%) cases husband wanted fewer children.

As far as women's decision making in household purchases is concerned majority 147 (40.8%) revealed that respondents and husbands jointly made the household purchases while in 118 (32.8%) only the husbands made these purchases. Out of 360 respondents 170 subjects (47.2%) said that both husbands and wife made decisions for the health of their children, while in 116 (32.2%) husbands alone made such decisions. Details are shown in table-II. Regarding modern contraceptive usage, 106 (29.4%) of the respondents used combined oral contraceptive pills (COCP) while 66 (18.3%) did not use any contraceptive method (fig-1).

Socioeconomic status showed a statistically strong association (p=0.035) with using modern contraceptives. Educationstatus showed a statistically strong association with desire for more children (p=0.004), usage of modern contraceptives (p=0.004), respondents role in household decision making (p=0.041) and respondent's role in decision making for child health (p=0.021). However, place of residence did not show any association with use of modern contraceptives (p>0.05) as almost equal number of women rearing from rural (n=137) and urban (n=157) areas used modern contraceptives (fig-2).


The universaldecreeof the Sustainable Development Goals to be achieved by 2030 is to guarantee gender parity and to advance women's health. The United Nations believes that in order to improve women's health both gender equality and family planning are of fundamental importance 10. Family planning has traditionally been an argumentative subject in Pakistan. The overall contraceptive use in Pakistan is dismally small at 35%, and to make the matters worse the traditional contraceptive method are the main contributors among the method-mix 11. The economic empowerment and reproductive empowerment have known to be directly related in women all around world. In US it was found that the easy access of contraceptives promoted women to have better careers and financial independence 12.

However in third world countries the case might be different; women with more children have known to be more involved in family income generation 5. Modern contraceptive devices, which have proven to be exceedingly effective method only account for a slow-rising 26% of use in Pakistan which is further lowest in the underserved areas (<20%) 8,11. In a recent study conducted in Nigeria it was concluded that in reproductive-aged women modern contraceptive adoption, continuation, and discontinuation is associated with gender norms 13. In our study there were cases where decisions were taken by someone else such as husband's family. In Pakistani patriarchal society men are considered superior and major decisions are made by them.

This affects the autonomy of women and making decisions becomes even harder for her when family intervenes 14. Socioeconomic status has a significant impact on modern contraceptive usage because people in lower middle class usually do not have strong educational background. Educated women working in good working environments can handle situations in better way and thus are more empowered 15. In a study comprising Bangladeshi population,it was found that a significant factor contributing to increase the likelihood of MCU is spousal joint participation in household decision making. Therefore, the development of negotiation skills in young people should be the main focus ofpolicy makers by creating educational and employment opportunities 16. A study carried out on rural Indian population pointed towards an association of spousal communication about contraceptive use with female empowerment and recommended devising of approaches for empowering women to advance better reproductive health issues 17.

In our study level of education showed a statistically strong association with desire for more children (p=0.004). Similar to study carried out in Nepal Women's empowerment was significantly associated with socioeconomic status and educational status of women and their husbands 18. In another study in Ghana, evidence was found that lesser awareness and disbelieves were the main cause of low use of MC. Emphasizing the practical use of modern contraceptive use and its benefits along with clearing out the misconceptions regarding its negative thoughts and harmfulness can make a difference and reduce the husband's disapproval 19. In a study conducted in 2019 in Pakistan by Sana and Farooq, it was concluded that women in Pakistan are still dependant on their male partners for decision making.

Educated women are less dependent but still the hold of husband over their lives is not completely absent. The nature of autonomy differs among women as a woman might be independent in her decisions regarding children's and her own health, household purchases but she can't decide the number of children for herself 20.

In a similar study in Oman, it was found that Omani woman are good in making ecomic decisions but still they have to encounter "social power" of the patriarchal society. Women with better socioeconomic state and education were more aware of their rights 21. Above mentioned studies like this one agree that socio economic profile of women is most important for women empowerment and autonomy. It can lead to improved quality of lives of family and contribution of women in economy as well 22,23.


There is a need to elevate women's status in Pakistan through more directed and tactical interventions in reproductive health initiatives and family planning programs by promoting women's independence and autonomy. The health care and family planning workers need to more vigilant and be sufficiently trained with more counselling skills to clear out misconceptions and create awareness about benefits of family planning. More involvement in household decision making for women should be encouragedso that modern contraception usage can be increased. Modern contraceptives should be made more accessible for common people to increase their usage.


It was found that in a substantial number of couples, decision for usage of modern contraceptives was mutual. Similarly, household decisions such as household purchases, children's health were also taken mutually by most of the couples. Socioeconomic status and education had a strong association with the desire for more children. Women empowerment and educational status has statistically strong association with use of modern contraception irrespective of the place of residence of the respondents. However, a very alarming finding was that most of the women have not had an encounter with family planning worker in last six months despite the fact that most of the women in the study did not have desire to have more children.


This study has no conflict of interest to be declared by any author.


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Author:Nabila Amin, Nigar Johar, Syed Fawad Mashhadi and Mehwish Ara Shams
Publication:Pakistan Armed Forces Medical Journal
Geographic Code:9PAKI
Date:Jun 30, 2020

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