Righteous planning

Shehryar Nabi reports on the changing religious attitudes towards contraception in Pakistan, as experienced by reproductive healthcare workers

Righteous planning
Tabassum Sattar, the head of a Family Welfare Centre in Nankana Sahib District, Punjab, visits remote villages to provide medical consultations. Part of her job is to distribute contraceptives to women who cannot afford to have more children. These include condoms, birth control pills, intrauterine devices and injections. She also discusses the option of a sterilisation procedure.

Occasionally, Sattar encounters opposition to the use of contraceptives on the grounds that they are un-Islamic. She responds by saying the Prophet (pbuh) used birth control methods on his animals.
"She had six children and the seventh was on its way. Most of her children had some disability"

“He (pbuh) put stones in the uterus of a camel to prevent it from having more children,” she tells the doubters.

Her attitude resonates with a decisive shift in the mainstream Islamic position on birth control in Pakistan. In June, religious leaders convened by the United Nations Population Fund and the Population Council - a non-profit that conducts family planning research - issued a declaration supporting all methods of birth-spacing on a Qur’anic basis. In November, they shared a stage with government officials at the Population Summit in Islamabad to endorse the need for family planning and the responsibility of ulema to send out a positive message on birth control.

Maulana Shahdad Mujadadi, who conducts family planning training workshops in Punjab for ulema on behalf of the Population Welfare Department, observes that a minority of participants still oppose birth control.

“I feel that the 10 percent who oppose family planning are just sticking with whatever they were taught by their elders. They haven’t done any research of their own,” he said.

Family planning first appeared on the national agenda in the 1950s
Family planning first appeared on the national agenda in the 1950s

Fewer women across Pakistan are seeing a conflict between family planning and religion. According to Demographic and Health Surveys, the number of women who cited religion as the reason they did not use contraception fell from 13 to 5 percent between 1990 and 2007.

Over a third of Pakistanis currently practice some form of contraception, a low figure compared to other countries in the region. At the same time, Pakistan’s fertility rate is the highest in South Asia. Research has linked having large families without birth spacing to increased health risks for mothers and their children. For every 1,000 births, 67 newborns in Pakistan die within a year - the highest rate of any South Asian country. The Population Council estimates that every year, over 500,000 children under the age of five die from health complications because their families are unable to provide for them; and nearly 14,000 mothers die from pregnancy-related complications.

Sattar saw for herself the toll that a lack of birth-spacing can have on poor families when she consulted a very weak, pregnant woman.

“Her condition was very depressing for us to see. She already had six children and the seventh child was on its way. The husband was a slacker with no proper job to sustain the family. Most of her children had some sort of disability,” she said.

Ali Mir, Director of Programs for the Population Council, has been organising religious leaders throughout Pakistan to form a consensus in favor of family planning. He says the notion that contraception disrupted the family - a sacred institution in Islam - stalled momentum for expanding contraceptive access in Pakistan, which first appeared on the government’s national agenda in the 1950s.
6 million couples want to take up methods of family planning, but lack the necessary services

“Religious leaders did not support this idea because [they thought] you are interfering with the basic premise that God is providing for everyone,” said Mir.

The stance of religious figures left an impression on the public. A survey in 2000 showed that most men perceived religious leaders as widely opposed to birth control and 29 percent of men thought that religion forbids it. The majority also agreed that the involvement of religious leaders in family planning services was important for increasing their consumption.

Shaukat Masih, a male employee at the Family Welfare Centre in Nankana Sahib, remembers what it was like to try motivating people to use contraceptives when he first started his work 40 years ago - in an environment that was hostile to family planning.

“People used to make fun of us. In fact they used to throw stones at us. So we used to go the field, spending most of the time shielding ourselves from the abuses hurled at us and just come back,” he recalled.

Religious controversy over birth control stems from verses 17:31 and 6:151 of the Qur’an – both of which prohibit killing children out of poverty. They have been interpreted as an Islamic justification to forbid the use of contraceptives. Opponents also cite a hadith that says the Prophet (pbuh) would be proud of his ummah, and that limiting the size of the family would betray that pride.

Pakistan has the highest infant mortality rates in South Asia
Pakistan has the highest infant mortality rates in South Asia

Political arguments against contraception have been lodged as well, claiming that birth control is an agenda of foreign governments to limit the size of the Muslim population.

Mir says that opponents have wrongly equated contraception with murder, and that birth control is in fact permitted in Scripture. He cites verse 2:233 of the Qur’an, which states that mothers may nurse their children for two years after birth. As breastfeeding has been shown to prevent pregnancy, this could be interpreted as a Qur’anic approval of birth control. And he notes that when the ‘method of withdrawal’ (coitus interruptus) was mentioned in the hadith, it was not prohibited by the Prophet (pbuh).

The main argument put forth by advocates of family planning is that ensuring the wellbeing of the mother is a religious duty.

“Contraception is not in violation of Islamic principles given that mothers have a high status,” said Hassan Malik, General Manager of Technical Services at the Marie Stopes Society, an organisation that provides reproductive health services in Pakistan.

One reason for the relatively high birth-rates has been the religious opposition to contraceptives
One reason for the relatively high birth-rates has been the religious opposition to contraceptives

Now that a consensus has been formed over this message, Mir says, the next step is to spread it to the local level.

It has already reached the village of Perray Wali in central Punjab, where local maulvi sahib Qari Gazanfar has noticed discussions of family planning at Islamic conferences. He advocates for birth control based on the idea that healthy families capable of providing for children would produce an ummah the Prophet (pbuh) would approve of.

“If you bring a child into this world, you should raise the child well. Produce such children that people of other faiths will want to say the kalma (profession of Islamic faith),” he says.

Religious figures who support family planning still disagree on a few issues, particularly on the subject of sterilisation. Critics of sterilisation regard it as mutilation of the body, which is forbidden in the Qur’an. But Mir remains firm that these procedures do not contradict Islam because if they do cause any bodily harm, they are reversible.

Family planning professionals agree that addressing Pakistan’s reproductive health challenges will not be limited to religious interpretation. Malik stresses that clearing misconceptions about birth control must be followed through by providing services, because obstacles such as cost, transport, unskilled birth attendance and unequipped health centres continue to persist, especially for poor rural communities.

“We have almost 6 million couples who have an unmet need. These people want to take up methods of family planning, but they do not have the necessary services,” he says.

Mir anticipates that mobilising religious advocacy will open the door to proactive family planning policies and normalize for every family the notion that the health of mothers and children is a high priority.