Hidden barriers

PAKISTAN is the fifth most populous country in the world. Nearly seven million babies are born in Pakistan each year — approximately 19,000 every day. The urgency of family planning is difficult to exaggerate. Yet the scale of the crisis can tempt us into believing that the solution is simple: create awareness, provide contraceptives and persuade couples to have fewer children. The reality in Pakistan is far more complicated.

When my organisation began facilitating family planning services in villages in Larkana district, we initially referred women to a government reproductive health services centre in Larkana city. There, they could receive contraceptives or undergo tubal ligation, a permanent method commonly described as having one’s ‘tubes tied’. The services were free. At one stage, women were even offered a few hundred rupees as an incentive to undergo tubal ligation. On paper, the system appeared accessible. In practice, getting through it could become a test of endurance.

A woman would travel from her village to Larkana, only to be told that she first needed a medical test. She would have it done and return a week later. This time, she might be told that the doctor was absent and she should come again. On her next visit, there could be another administrative or medical impediment. For a middle-class urban patient, a postponed appointment is an inconvenience.

For a poor rural woman, it may end the process altogether. Every visit requires transport money, permission or cooperation from her family, arrangements for the children left at home and the sacrifice of an entire working day. She may need someone to accompany her. If she or her husband is a daily-wage worker, the household also loses income.

Family planning programmes must be designed around the woman’s complete journey.

We then changed our approach. Instead of referring women and expecting them to negotiate the system themselves, we began taking them through the process. Our team picks up the woman from her village in our vehicle and takes her to the facility. We handle documentation and consultation so that the procedure appears less daunting and is completed that day. We also provide nutritional support and take her back home. A team member visits the following day to check on her recovery and ensure that she receives the pain relief, antibiotics or other medicines prescribed by the doctor. Further visits are made for wound care and the removal of sutures.

This is what access actually looks like in a rural setting. The procedure may be free, but reaching it is not. Someone must bridge the distance between the village and the hospital, help the woman navigate the institution and remain responsible for her aftercare. We were once told that the Population Welfare Department had vehicles available to transport women. Yet that arrangement never worked reliably for our patients. We were told the vehicle has been deployed elsewhere, needs repair or will only come if several women meet at one location. A vehicle listed in a departmental inventory is meaningless if a woman cannot depend upon it on the day she needs it.

Transport and bureaucracy, however, are only part of the difficulty. The deeper barriers are social. We encountered cases in which doctors refused to perform tubal ligations on women who had no sons, only one son, or a son younger than 10. When questioned, the doctors described cases in which a woman underwent sterilisation and later lost her only son to illness or an accident. Her family then expected her to produce another boy. If she could no longer conceive, her husband might marry again, diminishing her status and security within the household. Some women later returned, desperate to have the sterilisation reversed. Reversal is complex, expensive, available only at specialised centres and does not guarantee that fertility will be restored.

These concerns reveal the cruel consequences of son preference and women’s dependence within marriage. But they also raise a difficult question: should a doctor protect a woman from a possible future injustice by denying her control over her body today? Surely, the answer cannot be a blanket refusal based on the number or ages of her sons.

The appropriate response is careful, private and informed counselling. A woman should understand that tubal ligation is intended to be permanent. She should also receive information about long-acting reversible methods. Community health workers and doctors must ensure that her decision is voluntary and free from pressure. Once an adult woman understands the implications and gives informed consent, her reproductive choice should not depend upon whether she has produced a son.

Modern contraceptive use among married Pakistani women remains low, while around one in six has an unmet need for family planning. Distance, cost, unreliable services, the need for permission or accompaniment and limited decision-making power all reduce contraceptive uptake.

We will not overcome these barriers through awareness campaigns alone. Family planning programmes must be designed around the woman’s complete journey. Who will counsel her in terms she understands? Who will take her to the hospital? Who will ensure that the doctor is present, the tests are completed and her chosen method is available? Who will bring her home and respond if she develops a complication? Unless these questions have reliable answers, we do not have a functioning family planning programme. We have services on paper and women stranded many miles away from them.

Pakistan’s population challenge is urgent. But urgency must not produce coercion or an assembly-line approach to women’s bodies. The last mile of family planning is covered only when a woman can make an informed choice, reach dependable care and return home safely. Until we build that bridge, we should not be surprised when women fail to cross it.

The writer is a rural development specialist, writer and social entrepreneur.

[email protected]

Published in Dawn, September 9th, 2026