Abstract

In Pakistan, rapid population growth and the non-use of contraception is a social problem. The present study focused on social, religious, and cultural factors that influence the use of contraception in the country, especially in study district Mardan In the present study, researchers used a quantitative research approach with a cross-sectional research design. In the study, a multistage sampling technique was used, and through a simple random sampling technique, 384 married women aged 15-49 years were selected from Mardan. The study applied descriptive and inferential statistics to draw a linear relationship. The major statistical result shows that Mullas (Islamic religious leaders) discouraged modern contraception use with OR 5.381, CI 2.423-11.950.  It is concluded that Islam influences the use of contraception.  It is recommended that religious leaders should be actively involved in family planning programs in Pakistan.

Key Words

Use of Family Planning Methods, Use of Contraception, Married Women, Islamic Interpretation, Mardan

Introduction

The annual population growth is 2.4 percent for the period 1998-to 2017 in Pakistan (Ali, 2021; Pakistan Bureau of Statistics [PBS], 2017). According to the National Institute of Population Studies (NIPS), the fertility rate per woman was 31 percent higher than expected (NIPS, 2019). According to the survey report, the fertility rate in the country is 3.6 per woman. In addition, in Pakistan, 34 percent of married women are using contraception, with a high percentage in urban as compared to rural areas (43% vs 29%). It is also an alarming situation in Pakistan that the use of contraceptive methods declined in the last five years to 26% in 2012-13 and 25% in 2017-18 (NIPS, 2019).

The rapid population growth can be attributed to many factors. The contraceptive prevalence rate in Pakistan is the lowest in South Asia and has stagnated at 35% in the past few years. One in five married women in Pakistan is unable to obtain effective family planning methods if they want to avoid pregnancy, and the number and interval of family planning. The low contraceptive prevalence rate may be further attributed to weak service delivery systems, markets, and cultural norms. (Agha, S. 2019).

In 2019, it was statistically shown that 62 percent of 15-49 years old women worldwide are using contraceptive methods for family planning, while the user of contraception is 56 percent. In modern countries, due to the availability of contraception, the use is high as compared to other countries (67% vs 29%, respectively). Limiting the size of households in less-developed countries is a top priority because, according to the current UN forecast of the world's population prospects in 2019, the Least Developed Countries (LDCs) have grown at a rate of 2.3% per year since 2015. The growth rate in the least Developed Countries as compare to the other countries in the world is 2.5 times higher than 1.08 percent (Haupt & Kane, 2019).

According to a PDHS report, the contraceptive use rate of Pakistani women increased with the age of married women. It is observed that 10% of women in the 15-19 age group and 48% of women in the 35-39 age group use contraceptive technology to plan their families (Asif, MF, & Pervaiz, Z. 2019).

In recent years, the birth rate has been declining, but the contraceptive use rate in Pakistan is often low. It is speculated that the main reasons for people's reluctance to family planning are lack of knowledge and difficulty in accessing medical centers. It is estimated that only 10% of the population lives in the government family planning center. These obstacles have led to an unmet need for family planning in Pakistan. It is shown that around the world, 222 million married women who belong to developing countries want to delay and even avoid childbirth but interestingly, they are not using any contraception to do so. There are various factors involved in not using contraception; few methods are available, contraception is not easily available due to lack of knowledge fear among married women, cultural and religious support to large family size, non-availability of family planning services and gender-based attitude toward use of contraception. Such condition promotes unsafe abortions, which are estimated at 21 million per year in developing countries with a large number (Casterline, J. B., & Sinding, S. W. 2018).

Pakistani society is patriarchal in its structure where women live in their husband's family after marriage. In families the main decision-makers are the husband and other men family members in a joint and extended family in the country. It is highlighted in research studies that low levels of communication and sharing found between married couple related to reproductive and health care services in joint families. Married women with a subordinate position in the family and dependency on their husband's decision found with low use of contraception in the country. In joint families, married women's reproductive and sexuality is also influenced by mother in law in the family (Jejeebhoy, S. J., & Sathar, Z. A.2018).

The unmet need for family planning is reported mostly in the families where her husband and mother-in-law greatly influence the size of family members. In South Asian countries, mostly women are subordinate, and they prefer family interest over their own personal interest, which promote high fertility and childbirth. In such conditions, it is realized that the husband and other in-laws influence the fertility preference of married women. Married women are mostly discouraged to discuss family planning and contraception with her husband. One of the research areas which need further exploratory research is the attitude of mother in law and other in-laws toward modern contraception, especially permanent sterilization after 3-4 children (Carter, M.2016).




Objective

1. To investigate the use of contraception and modern family planning methods among married women in District Mardan

2. To find out the influence of Islamic interpretation on the use of modern family planning methods and contraception in District Mardan




Research Question

1. The married women are using any modern family planning method and contraception?

2. Whatever religious interpretation influence the use of modern family planning methods and contraception?  

3. Whatever religious leaders talking to the general public on the use of modern family planning methods and contraception? 

Research Methodology

In the present study, researchers used a quantitative research approach with a cross-sectional research design. In the study multistage sampling technique is used to divide the study district Mardan in administrative units, namely; Tehsils and Union Councils. In the study, researchers used a simple random sampling technique to select women aged (15-49 years) in the study area. In the study, researchers used the Umer Sekaran table and selected 384 married women in the study district. It is important to state that researchers used the table because all the married women have homogeneity in their daily lives and health practices. In the study, researchers used proportionate formula for the distribution of selected 384 married women in selected tehsils. 

Figure 1

Study and Sample Population Selection

The above figure shows that the total household population of the study district is HH=311868. In the study through proportion allocation, 220 married women were selected from Tehsil Mardan, 51 married women are selected from Tehsil Katlang, and 113 married women are selected from Tehsil Takhat Bahi. Researchers developed a self-administered after extensive literature review and reviewing the existing tool used in Pakistan Demographic and Health Survey. The same tool is publicly available to use and collect data from the same nature of respondents in Pakistan. In the present study, researchers hired two women research assistants, and after orientation, they were engaged in the data collection process. The collected data are kept confidential and no one except the principal researcher is permitted to view the questionnaires. The same study is developed from the dissertation of principal author which is already approved from Graduate Study Committee and ASRB the statutory bodies of Abdul Wali Khan University Mardan. Furthermore, the researchers ensured confidentiality and privacy of the married women respondents. In the present study a verbal consent is recorded from all the respondents because the married women respondents are not permitted to sign any document without the permission of their men family members. In the present study, researchers used descriptive and inferential statistics. In descriptive statistics, researchers simply draw the frequency and percentages of socio-demographic characteristics of married women while in inferential statistics, researchers used regression analysis and cross-tabulation to draw the association and its level between dependent and independent variables.  

Results

Table 1. Socio-demographic Characteristics of Married Women Participated in the Study (N=384)

Socio-demographic Variables	f	(%)
Current age of the Married Women
15-19	88	22.9
20-24	152	39.6
25-29	124	32.3
30-34	15	3.9
35 & above	5	1.3
Age at first Pregnancy
15-18	133	34.6
19-22	169	44.0
23-26	74	19.3
27 years and above	8	2.1
Educational Qualification of the Women
Illiterate	72	18.8
Primary	58	15.1
Middle	40	10.4
Matriculation	80	20.8
Intermediate	33	8.6
Bachelor	37	9.6
Master & Above	64	16.7
Occupation of the Women
Housewife	248	64.6
Government Job	26	6.8
Private Job	110	28.6
Type of the Family
Nuclear	258	67.2
Joint	126	32.8
Residential Area
Urban	12	3.1
Rural	372	96.9

 




Table 1 illustrates the age of the married women. The data shows that 22.9% of the respondents are in the age category of 15-19 years, 39.6% of the respondents are in the age category of 20-24 years, 32.3% of the respondents are in the age category of 25-29 years, 3.9% of the respondents are in the age category of 30-34 years, while 1.3% of the respondents are in the age category of 35 and above years. According to the results, most respondents are in between the ages of 20 and 24. Table statistically shows the age of respondents at the time of their first pregnancy. The result illustrates that 20.1% of the respondents are 15-18 years of age during the time of their first pregnancy, 40.9% of the respondents are 19-22 years of age, 17.2% of the respondents are 23-26 years of age, while 21.9% of the respondents are 27 years old and above. According to the results, the majority of respondents were between the ages of 19 and 22 at the time of their first pregnancy. Table demonstrates the educational qualifications of the respondents. The data shows that 18.8% of the respondents are illiterate, 15.1% of the respondents are primary pass, 10.4% are middle pass, 20.8% are matric pass, 8.6% are intermediate pass, 9.6% are bachelor qualified while 16.7% are master and above. According to the findings, the majority of respondents are matriculants. Table shows the occupations of the respondents. The result shows that 64.6% of the respondents are housewives, 6.8% of the respondents are employed in government jobs, while 28.6% of the respondents are doing private jobs. The results demonstrate that most of the married women are housewives. The above table shows the family type of the respondents. According to the data, 67.2% of respondents are part of a nuclear family, while 32.8% are part of a joint family. However, the result reveals that the nuclear family type is more common among respondents. The above table shows the residential area of the respondent. According to the results, 3.1% of the respondents lived in cities, while 96.9% lived in rural areas. The results show that the majority of respondents live in rural areas.




 

Table 2. Knowledge, Attitude and Practices among Married Women toward use of Family Planning Methods in the Study Area (N=384)

Knowledge, Attitude and Practices Variables	f	(%)
Hear about Any Family Planning Methods
Yes	341	88.8
No	43	11.2
Hear about Modern Family Planning Methods
Yes	278	72.4
No	106	27.6
Source of Knowledge among Married Women
Health Services Provider	219	57.0
Another then Health Services Provider	165	43.0
Ever Used Family Planning Methods
Yes	264	68.8
No	120	31.3
Currently Using any Family Planning Method
Yes	207	53.9
No	177	46.1
Type of Family Planning Methods Currently Using
Traditional	112	29.2
Modern	176	45.8
Non	96	25.0
Knowledge of Husband may Influence the use of Family Planning Methods
Yes	269	70.1
No	115	29.9
Married Women Ended use of Family Planning Methods
Yes	136	35.4
No	248	64.6
Reasons of Non-use of Family Planning Methods
Against to Religion	283	73.7
Un-awareness of FPM	29	7.6
Health Complications	29	7.6
Wants more children	43	11.2

 




Table 2 shows that 88.8% of the respondents have heard about family planning, while 11.2% of the respondents have not heard about family planning. According to the findings, the vast majority of respondents had heard about the family planning. The above table shows that 72.4% of the respondents had heard about modern family planning methods, while 27.6% of the respondents had never heard about modern family planning methods. The result shows that the majority of the respondents had heard about modern family planning methods. Table shows that for 57% of the respondents, the source of information is health services providers, while for 43% of the respondents, the source of information is other than health services providers. The result shows that, for most of the respondents, the source of information was health services providers.

Table 2 shows that 68.8% of the respondents have used family planning methods, whereas 31.3% of the respondents have never used family planning methods. The findings show that the vast majority of married women have used family planning methods. The above table shows that 53.9% of the respondents said yes, they are currently using any family planning method while 46.1% of the respondents said no, they are not currently using any family planning method. The result shows that the vast majority of the respondents are currently using family planning methods. Table shows that 29.2% of the respondents had used traditional family planning methods, 45.8% of the respondents had used modern family planning methods, and 25% of the respondents had never used any methods. The results show that the majority of respondents used modern family planning methods. Table 2 shows that 70.1% of the respondents said they think that knowledge of the husband may influence the use of FPM, while 29.9% of the respondents said that knowledge of the husband may not influence the use of FPM. The vast majority of the respondents believed that the knowledge of the husband might influence the use of FPM.  Table 2 shows that 35.4% of the respondents said yes they have ended the FPM while 64.4% of the respondents said they have not ended the FPM. The result shows that most of the respondents are still using FPM. Table 2 shows that 40, 73.7% of respondents said they do not use FPM because it is against their religion. 7.6% of respondents said they do not use FPM because they are unaware of it. 7.6% of respondents said they do not use FPM because of health complications. 11.2% of respondents said they want more children and thus do not use FPM.




 

Table 3. Association of Islamic Teachings and its Influences on Ever Used of Family Planning Methods among Married Women Aged 15 to 49 years (N=384)

 

Variable Religious Factors	Ever used any Family Planning Methods		OR, 95% C.I	P. Value
	Yes Frequency (%)	No Frequency (%)
Whether Religious Thoughts Encourage the use of FPM
Yes	75(67.6%)	36(32.4%)	1.000
No	189(69.2%)	84(30.8%)	5.381(2.423-11.950)	.001
Whether Religious Leaders Talked About the FPM in Your Area
Yes	78(57.4%)	58(42.6%)	1.000
No	186(75.0%)	62(25.0%)	.361(.210-.621)	.001
Does Religious Leaders Encourage the use of FPM
Yes	70(56.0%)	55(44.0%)	1.000
No	194(74.9%)	65(25.1%)	.264(.127-.546)	.001
Any Resistance From Religious Leaders to use of FPM
Yes	139(69.8%)	60(30.2%)	.899(.584-1.385)	.630
No	125(67.6%)	60(32.4%)	1.00
Any Religious Booklets Available for FP in the Area
Yes	130(71.8%)	51(28.2%)	1.000
No	134(66.0%)	69(34.0%)	1.823(1.072-3.099)	.027
Any Religious Talk Shows on TV/Radio for Support of FP
Yes	124(63.9%)	70(36.1%)	.466(.270-.803)	.006
No	140(73.7%)	50(26.3%)	1.000
Whether Feeding of Child Encourage FP
Yes	238(71.7%)	94(28.3%)	3.041(1.544-5.991)	.001
No	26(50.0%)	26(50.0%)	1.000

 




The cross-tabulation of Islamic teaching and dichotomous variable (ever used any family planning methods) shows that out of the total sample population. Out of the total sample size of the study, 189(69.2%) of Women not confirmed that religious thoughts encourage the use of FPM, while 84(30.8%) of them confirmed in this regard. The odd ratio of no confirmation to religious thoughts encourages the use of FPM for not ever used any family planning methods is 5.381 times greater than the reference category. No confirming religious thoughts encourage the use of FPM is statistically significant to their not used contraception. The confidence interval value of their statistical significance is (2.423-11.950).

Out of the total sample size of the study, 186(75.0%) of Women not confirmed that Religious leaders talked about the FPM in their area, while 62(25.0%) of them confirmed in this regard. The odd ratio of no confirmation to Religious leaders talked about the FPM in their area for not ever used any family planning methods is .361 times lesser than the reference category. No confirmation to Religious leaders talked about the FPM in their area is statistically significant to no use of contraception. The confidence interval value of their statistical significance is (.210-.621).

Out of the total sample size of the study, 194(74.9%) of Women not confirmed that religious leaders encourage the use of FPM, while 65(25.1%) of them confirmed in this regard. The odd ratio of no confirmation to religious leaders encourage the use of FPM for not ever using any family planning methods is .264 times lesser than the reference category. No confirmation to religious leaders encourage the use of FPM is statistically significant to their no use of modern methods of family planning. The confidence interval value of their statistical significance is (.127-.546).

Out of the total sample size of the study, 139(69.8%) of Women resisted from Religious leaders to use FPM, while 60(30.2%) of them confirmed in this regard. Women resisted from Religious leaders to use FPM is statistically insignificant to their not use of contraceptives.

Out of the total sample size of the study, 134(66.0%) of Women not confirmed any Religious Booklets available for FP in the area, while 69(34.0%) of them confirmed in this regard. The odd ratio of no confirmation to any Religious Booklets available for FP in the area for no use of contraception is 1.823 times greater than the reference category. No confirmation to any Religious Booklets available for FP in the area is statistically significant to their not ever used any family planning methods. The confidence interval value of their statistical significance is (1.072-3.099).

Out of the total sample size of the study, 124(63.9%) of Women confirmed that Religious talk shows on TV/Radio for support of FP, while 70(36.1%) of them not confirmed in this regard. The odd ratio of confirmation to Religious talk shows on TV/Radio for support of FP for not ever using any family planning methods is .466 times lesser than the reference category. Confirmation to Religious talk shows on TV/Radio for support of FP is statistically significant to their not contraception use among married women. The confidence interval value of their statistical significance is (.270-.803).

Out of the total sample size of the study, 238(71.7%) of Women confirmed Feeding of children encourage FP, while 94(28.3%) of them not confirmed in this regard. The odd ratio of confirmation to Feeding of children encourages FP for not ever used any family planning methods is 3.041 times greater than the reference category. Confirmation to Feeding of children encourage FP is statistically significant to their not used any contraception. The confidence interval value of their statistical significance is (1.544-5.991).

Discussion

In the present research study the researchers mainly focused on association between religious interpretation and religious leader’s attitude toward use of modern contraception in the study district Mardan, Khyber Pakhtunkhwa province of Pakistan. It is discussed in the study that religious leaders have enough knowledge about family planning methods, family planning program in Pakistan and some modern contraception. Pakistan Demographic and Health Survey report (2017-2018) stated that 98 percent to 99 percent of married couple in the country having knowledge about any family planning method (NIPS, 2019). It is statistically shown that religious leaders avoid talking about the use of modern contraception and family planning methods. Another study also discussed that mostly religious leader discussing that in Islam large family size is encouraged to increase Muslim Ummah (Varley, 2012; Hoodfar, 2000). Islamic scholars clearly stated that there is natural space period between two children which is the feeding duration of a child by mother for maximum two years It is shown in the present study that religious avoid to talk on the issue of rapid population growth and family planning among married couple. In a study, it is discussed that religious leaders are delivering religious lectures during Jummah prayers and in different other religious occasions, but no religious leader talking on the issue with the general masses (Shafiqullah, 2018). The present study identified a very important issue that no such published reading material is available related to family planning with Islamic interpretation in favor. It is discussed that one of the influential and acceptable ways to encourage family planning in Pakistan is the religious favorable interpretation which is not available in the country (Campbell, 2006). In the present study, it is shown that religious talk shows and on-air programs on radio are greatly influence the use of family planning methods in the country. It is also discussed in other studies that TV Talk Shows and Radio programs are the easy way to communicate and educate married couple especially women regarding family planning and contraception (Tasciotti, 2022). Another study discussed that religious scholars avoid talking on family planning to the public but the easy way is to start regular electronic media programs related to family planning and its benefits for married couple, family and overall society (Ali, 2005). 

Conclusion

It is concluded that most of the married women and their family members have knowledge of modern family planning methods but they avoided to use modern family planning methods. The results indicated that various socio-cultural and religious factors are responsible for the underutilization of modern contraceptives and other family planning methods. It is concluded that religious leaders and their interpretation of family planning play a vital role in underutilization of contraception among married women. There are no religious programs on air on radio and television to educate married women on the use and benefit of family planning. Further, it is also concluded that religious leaders are not talking about family planning issues in religious sermons. The present study recommended that religious leaders should play a vital role in encouraging the use of contraceptives among married couple for to control the family size in their religious sermons. The civil society organizations are required to start an awareness program at the community level to educate married women and men about the social and economic challenges due to large family size and also share with married women about health challenges due to continues pregnancies. The study also recommended that government should start religious talk shows on TV and on-air radio programs for general public awareness. They are required to engage religious leaders in such programs.  It is also recommended that lessons related to family planning program, its benefit and current challenges due to rapid population growth should be included in school level curriculum. 

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