When the prime minister began urging Pakistanis to watch the Turkish historical TV drama Dirilis Ertugrul (Ertugrul’s Resurrection), also described as the Muslim Game of Thrones, his reasons may have purely been to glorify the Muslim value system, the Ottomon Empire, and to counter Islamophobia.

But now that Pakistanis have got a glimpse into what Turkey’s glorious past may have been like, it may be the right time to introduce them to present day modern Turkey, even emulate and aspire to be like them in some areas.

For instance, one thing that Pakistan can learn from is how to keep its population manageable.

Just ahead of this World Population Day, the Turkish Statistical Institute has released data to show that the country’s fertility rate (the number of babies born to a woman during her reproductive cycle of ages between 15 and 49) has dropped to 1.88 from 2.38 in 2001, which is even lower than the standard replacement (when a generation replaces itself from one generation to the next) level of 2.1. On the other hand, Pakistan’s stands at a whopping 3.6 births per woman according to the latest Pakistan Demographic and Health Survey (PDHS) 2017-18, a marginal decline from 3.8 in 2012-13.

Urbanisation, women pursuing education and their active participation in the workforce are some of the reasons Turkish experts attribute to women postponing childbirth and the reason for the slowdown in the fertility rate.

In Pakistan, although women constitute 49% of Pakistan’s population, only 24% are counted in the labour force. By age 49, on an average, a Pakistani woman gives birth to more than five children, and many births are not spaced. The average birth interval is two-and-a-half years, although 37% of births still occur within 24 months of the last birth. Teenage pregnancy is rife and it is highest among girls with no education. According to the United Nations Population Fund, only 10% percent of married adolescents aged 15-19 access family planning (FP) “due to the negative attitudes from health providers and lack of targeted, youth-friendly interventions”.

A population multiplying exponentially and the need for family planning

It is only after giving birth to four kids that a woman wants to limit further pregnancies. And so, if most couples want four children, convincing them to use family planning before they reach their target may be an uphill task for the state that wants to get a handle on the population bomb and is keen on promoting the long acting reversible contraceptive (Larc) which are not only long-lasting and reversible but also safe.

There are two such methods — implants and intrauterine contraceptive devices (IUCDs), although some experts also includes injectibles (which last for three months) in Larc.

Daily wage earner Liaquat is happy with his brood of four. Married for seven years and never using a contraceptive he and his wife Sapna have four children — two daughters and two sons (aged four years, three years, and two years, with a fourth one just five months old).

“My family is complete,” he says, adding that their last baby would have been their fifth had their first born, not died soon after birth. He had not worked out exactly how he was going to feed so many mouths with the paltry Rs 1,500 per day that he earned, but was not overly worried.

It was during the antenatal before the last birth that Sapna’s doctor convinced them to get an IUCD inserted into her uterus while she was still on the delivery table.

With more and more women delivering at hospitals (the latest PDHS says it is 66%) it perhaps gives healthcare providers that perfect but small window of opportunity to promote this method.

Sapna and Liaquat may wish to have four children but health experts fear that if couples continue to have unplanned babies, and so many of them, Pakistan’s population will double from 207 million to 440 million by 2055.

And if Pakistan’s population continues to grow at the current rate of 2.3% annually and the economy fails to keep pace with it, that will spread country’s resources too thin. This may mean longer power outages, more kids out of school, and more malnourished children.

“No one seems committed to resolve the issue,” says Dr Azra Ahsan, gynecologist and obstetrician with over two decades of experience.

Why are not enough women interested?

When asked about her position on Larc, Dr Ahsan, who is president of the non-profit Aman (Association for Mothers & Newborns), found it to be a sure shot way of tackling Pakistan’s runaway population. The woman will be stress-free for as long as 12 years in the case of an IUCD and for five years with an implant.”

But fewer women seem interested.

Dr Ahsan blames both governments which every now and then make some noise but “fail to take any concrete action” as well as people from her own fraternity — the health care providers (HCPs) “who do not think an exploding population is an issue or that counseling and providing family planning is their responsibility”.

Dr Yasmeen Qazi, senior advocacy consultant to the Bill and Melinda Gates Foundation, added that “a weak governance of the FP programme managed by two vertical ministries of health and population” in provinces was failing to reach women and couples in need of FP.

Explaining how the FP programme was being affected by the two ministries, Dr Qazi said that health ministries were not interested in FP since it has not been their mandate traditionally though they have larger and stronger health teams and providers. She added that the population ministries, on the other hand, are fully focused on FP but are small in size and do not have either the capacity or the budgets to handle the issue.

She adds that Sindh was the only province where health and population had one secretary reporting directly to Minister for Health and Population Welfare Dr Azra Pechuho.

Women and unborn babies are the losers in this skewed scheme of things. “It often results in mistimed and unwanted pregnancies with high abortion rates,” says Dr Qazi, to which Dr Ahsan adds: “Almost half of all pregnancies in Pakistan are unintended and the couples just resort to abortion instead of planning their family.”

Dr Ahsan adds that she counsels women “with their best interest in mind, considering their medical conditions”. And then they refuse advice based on their social and cultural considerations and beliefs.

“I feel extremely frustrated,” says Dr Ahsan.

Misconceptions surrounding Larc

Mariam Jawad, 34, gave birth to a third son just two weeks back. It was a difficult time since she had tested positive for Covid-19 and had been in quarantine until a few days before giving birth. Her husband was still in quarantine when she went to the hospital for delivery. “I felt very lonely and my doctor had counseled me to get an IUCD inserted since I was in the hospital and for which I, too, quite convinced”, but at the last minute she got cold feet and declined.

Part of the reason for her reluctance were side effects that people had told her about, including “weight gain and hormones in your body”. In addition, after she heard that “two people got pregnant with the coil”, she got even more wary. However, she never cleared up the confusion in her mind with her obstetrician.

Dr Ahsan admits that minor weight gain can happen with hormonal contraceptives but not with IUDs.

But more than patients who don’t have a medical education, Dr Ahsan is baffled by doctors who are staunch believers in the plethora of myths and misconceptions that abound around modern methods of contraceptives. “Doctors come to me with questions like: will using contraceptives lead to weight gain, infertility or even cancer?” she says, adding that “family planning is just not taught in medical colleges.”

Dr Qazi, has for years been advocating for “addressing and responding to misinformation and confusion about contraceptives’ use” to enable positive demand for FP, she says. But then, the government must also ensure an uninterrupted supply of contraceptives that “reaches the last mile” along with high quality of services.

For this to happen, the foolproof strategy Dr Qazi has in mind involves girls and women leading “the change that they want” from and at the grassroots and those sitting in “positions of power to influence positively on laws and policies concerning women’s health and rights”.

But for now, it is the pandemic, that has stalled many FP programs across the country. When the government announced a lockdown back in April, it closed FP centers too and women were unable to get FP supplies, or access antenatal or delivery care. For example, the data for People’s Primary Healthcare Initiative in Sindh, which manages 1140 primary healthcare facilities of the province on Larc, shows a sharp dip. The number of IUCDs inserted in January and February was 6,240 and 8,997 respectively but slipped to 4,398 in March. Implants showed a similar trend. In January and February of 2020, the number of implants consumed was 6,036, in February 2020, it was 14,026, and in March 2020, a total of 5,094 implants were used.