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Contraceptive prevalence and Contraceptive

use among
factors influencing utilization Pakistani
women
among women in Pakistan: a focus
on gender-based violence 119
Thao Thi Nguyen and Sarah Neal Received 21 May 2021
Revised 15 July 2021
Social Statistics and Demography, University of Southampton, Southampton, UK Accepted 23 July 2021

Abstract
Purpose – In this study, the authors determined the prevalence of contraceptive use among Pakistani women
and assessed factors influencing the utilization of contraception with a particular focus on the experience of
gender-based violence.
Design/methodology/approach – The dataset used in this study was the Pakistan Demographic Health
Survey 2018, which includes married women only. Bivariate analysis and multivariate logistic regression were
used to investigate the association between contraceptive use and a number of explanatory variables including
experience of gender-based violence.
Findings – From 2006 to 2018, the contraceptive prevalence rate (CPR) and the use of modern contraceptive
methods increased slowly. The findings of this study demonstrated that higher educational level and wealth
index increased the likelihood of contraceptive uptake and the use of modern contraception. Media exposure to
family planning and spousal communication were protective factors that encouraged women to use
contraception, including modern contraception, to avoid unwanted pregnancy. Women who experienced
gender-based violence (GBV) were more likely to use contraception than women who did not experience GBV.
Research limitations/implications – The use of secondary data limited the variety of important variable
that should be investigated including knowledge of women on SRH, the attitude of women toward SRH and
family planning, the skills of a healthcare provider on counseling family planning, and other barrier variables
such as transportation and willingness to pay for contraceptive methods. 10;The sensitivity of the topic is
considered as another challenge when collecting data. Women might be hesitant to share about their GBV
experience. The experience to GBV is also hard to define and depends on the feeling of each person, especially
emotional violence.
Originality/value – This paper is one of the very few studies to examine the association between GBV and
contraceptive use, and thus is valuable in opening up debate about the links between these two factors.
Keywords Contraceptive, Gender-based violence, Pakistan
Paper type Research paper

1. Introduction
Sexual and reproductive health (SRH) is one of the major global health challenges in many
countries in the world, especially for women. In the United Nations’ Sustainable Development
Goals (SDGs), SRH care is mentioned in Goal 3 which seeks to ensure that there is universal

© Thao Thi Nguyen and Sarah Neal. Published in Fulbright Review of Economics and Policy. Published
by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC
BY 4.0) license. Anyone may reproduce, distribute, translate and create derivative works of this article
(for both commercial and non-commercial purposes), subject to full attribution to the original publication
and authors. The full terms of this license may be seen at [Link]
Fulbright Review of Economics
legalcode and Policy
This paper was based on Nguyen Thi Thao’s master’s dissertation at Southampton University in the Vol. 1 No. 1, 2021
pp. 119-134
United Kingdom. The dataset for this study came from the 2018 Pakistan Demographic Health Survey. Emerald Publishing Limited
Permission to use the data set was given on 6 May 2020, and it was downloaded from the PDHS program e-ISSN: 2635-0181
p-ISSN: 2635-0173
website ([Link]) on 22 June 2020. DOI 10.1108/FREP-05-2021-0032
FREP access to sexual and reproductive healthcare services, including family planning, information
1,1 and education.
Violence against women, also known as gender-based violence (GBV), is “now widely
recognized as a serious human rights abuse” as well as “an important public health problem
that concerns all sectors of society” (World Health Organization [WHO], 2005; Hong Nguyen
et al., 2012). The adverse health consequences of GBV for women’s health are not limited to
physical and mental well-being but also encompass their reproductive health (WHO, 2005;
120 Sarkar, 2008; Hong Nguyen et al., 2012;). In addition, considerable research has been
conducted which revealed negative effects of GBV on sexual autonomy, unwanted pregnancy
and induced abortion (Emenike, Lawoko, & Dalal, 2008; Silverman, Gupta, Decker, Kapur, &
Raj, 2007).
Pakistan is one of the countries with the highest imbalance of gendered power that
favors men because of the patriarchal system (Hadi, 2017). Under the prevailing social
norms, women are considered men’s dependents (Mumtaz, Salway, Shanner, Bhatti, &
Laing, 2011). Women’s decision-making is limited, and they have little independence in
determining their economic and social identity (Mumtaz et al., 2011). All these
limitations make women more vulnerable to violence. They suffer from many abnormal,
harmful or abusive practices, such as rape, sexual assault, forced marriage and
domestic violence (Hadi, 2017). Education for girls and women is also inadequate, with
evidence of low levels of literacy among women (45%) compared to men (69%; Saqib &
Ahmad, 2014).
In Pakistan, gender disparity is evident in the country’s ranking of 141 out of 142 countries
with respect to economic opportunities for and political participation of women (Hadi, 2017).
According to the United Nations Development Programme’s (UNDP) 2014 gender inequality
index, Pakistan ranks 120 out of 150 countries. Gender disparity weakens women’s position
in society and family, making them more vulnerable to violence (Hadi, 2017). GBV may limit
women’s control over their fertility, thus reducing contraception use or interrupting the
effective use of contraceptive methods (Hindin, Kishor, & Ansara, 2008; Miller, Jordan,
Levenson, & Silverman, 2010; Pallitto, Campbell, & O’Campo, 2005). Eliminating all forms of
violence against all women and girls in the public and private spheres is the main objective of
the SDGs under Goal 5: Gender Equality, and specific in target 5.2: Eliminate all forms of
violence against all women and girls in the public and private spheres, including trafficking
and sexual and other types of exploitation.
SRH care for women in Pakistan is still a significant issue that needs more involvement by
the government, civil society organizations (CSOs) and other stakeholders for improvement.
The percentage of women accessing family planning is still low, particularly modern
methods. According to the Pakistani Demographic and Health Survey (PDHS) program
report, in 2013, only 35% of married women of reproductive age used some form of
contraception, and only 26% of them used a modern method (PDHS, 2013). Compared to other
countries in the region, Pakistan has a lower utilization rate of modern methods; for example,
the rate is 43% in Nepal and 52% in Bangladesh (Howse & Nanitashvili, 2014). This might
account for Pakistan’s high total fertility rate of 3.8 children per woman (PDHS, 2013).
According to the 2012–2013 PDHS, the prevalence of sexually active women who do not
use contraception was 46%, with about 37% of these women residing in urban areas and
53.2% in rural areas (Aslam, Zaheer, Qureshi, Aslam, & Shafique, 2016). Among women
living in urban areas, women who had higher education were more likely to use contraceptive
methods. Approximately 55% of women with no education used contraception, while more
than 70% of women with higher education used family planning and around 67% of women
with secondary education used contraception (Aslam et al., 2016). This trend was similar to
what was observed for women living in rural areas. Nearly 58% of women with higher
education used family planning methods, while only more than 42% of women with no Contraceptive
education used contraception (Aslam et al., 2016). use among
Three types of contraceptive methods are used in Pakistan: traditional, folkloric and
modern methods. Modern methods include the pill, male condom, intrauterine device (IUD),
Pakistani
injectable implant, emergency contraceptive, and female and male sterilization. Traditional women
methods are rhythm and withdrawal (PDHS, 2013). Folkloric contraceptive methods refer to
local methods and spiritual methods of unproven effectiveness, for example, amulets, herbs
and beads (Namasivayam, Lovell, Namutamba, & Schluter, 2020). From 1990 to 2013, the 121
percentage of women using traditional and folkloric methods was stable, less than 10%.
However, the percentage of women using modern methods increased significantly from
approximately 20% to nearly 50% (PDHS, 2013; Imran, Nasir, & ZaidI, 2015).
To improve maternal health and increase contraception use among women in Pakistan,
more research should be conducted to understand the factors that influence women’s health
as well as protect women from violence. Some studies in different contexts have been
conducted to prove an association between violence against women and contraceptive
utilization. Gomez (2011) found a negative association between intimate partner violence and
current contraception use. Paul (2010) reported that Pakistani men who perpetrate domestic
violence indicated that they use economic control as a tool for a sense of power and threatened
the independence of their wives. This might be one of the barriers that limit women’s access to
contraception. However, in Bangladesh, the impact of GBV on contraception use was positive
in Dalal et al. ’s (2012) study. They found that women who experienced physical violence were
1.93 times more likely to use contraceptive methods (Dalal, Andrews, & Dawad, 2012).
In this study, we determined the prevalence of contraception use among Pakistani women
and with a focus on GBV and assessed the factors influencing contraception use. The
following research questions guided the study: What is the prevalence of contraception use
among women in Pakistan? What are the factors that influence contraception use among
women in Pakistan? In particular, is experience of GBV associated either positively or
negatively with contraception use?

2. Methodology
2.1 Data source
Data were extracted from the 2017–2018 PPDHS of married women, including information on
women’s background, reproduction, contraception, fertility preferences, husband’s
background and domestic violence. Data from 2,789 women who (1) completed the
domestic violence module (2) were not pregnant at the time of the survey, and (3) their current
marriage is their first marriage were used for analysis.
The 2017–18 PDHS followed a stratified two-stage sample design. The stratification was
achieved by separating each of the eight regions into urban and rural areas. The 2017–18
PDHS included all ever-married women age 15–49. Those who were either permanent
residents of the selected households or visitors who stayed in the households the night before
the survey were eligible to be interviewed. In these households, one eligible woman in each
household was randomly selected to be asked additional questions about domestic violence.

2.2 Data analysis

Descriptive analyses including frequencies, cross-tabulations and Pearson chi-square test
were conducted to demonstrate a primary understanding of the data and to prepare for
binary logistic regression. Multivariate binary logistic regression was used to identify the
association between independent variables and dependent variables. The two main
dependent variables in this study were Current contraception use and Type of
FREP contraceptive method. Current contraception use was defined as “Yes” and “No.” Type of
1,1 contraceptive method was categorized as “modern methods” and “traditional methods.”
Independent variables which had significant associations with dependent variables from the
results of the Pearson chi-square test were included in the logistic regression models. The
final model included Age groups, Region, Women’s education level, Wealth index, Media
exposure on family planning, Number of living sons, Number of living daughters and
Experience of any type of GBV.
122

3. Results
3.1 The prevalence of contraception use among Pakistani women
After a decade (from 2006 to 2018), there was a slight increase from 29.6% to 35.7% in the
prevalence of current contraception use among Pakistani women. From 2012 to 2018, the
percentage of women using any contraception at the time of interviewing was stable around
35% as shown in Figure 1 (PDHS, 2008, 2013, 2019).
There was an increase in use of traditional and modern methods from 2006 to 2018;
however, the percentage of women who currently use modern contraception was stable at
around 26% from 2012 to 2018 (PDHS, 2008, 2013, 2019). The increase in use of modern
methods was slow with only about 5% after 10 years as shown in Figure 1.
The prevalence of contraception use among different groups is shown in Table 1. In
general, women aged 30–44 years had a higher tendency to use contraception than younger
age groups (36.7% vs 17.1%, p-value < 0.001). Moreover, 14.4% of women aged 30–34 years
used traditional methods, but only 4.4% in the age 15–19 years. These differences in
contraception use and modern methods among age groups were statistically significant at p-
value < 0.001. A higher number of urban women used contraception than rural women,
irrespective of whether the contraceptives used were modern (32.2% vs 26.8%) or
traditional methods (14.9% vs 7.8%, respectively). There was a statistically significant
difference in contraception use among regions in Pakistan (p-value < 0.001). Islamabad
Capital Territory (ICT) and Punjab had higher percentage of women using contraception
than Sindh, Khyber Pakhtunkhwa (KPK), Balochistan and Federally Administered Tribal
Areas (FATA).
In terms of the wealth index variable, wealthier women had a higher tendency to use
contraception and modern contraceptive methods than poorer women (p-value < 0.001).
About 53% of the richest women used contraception compared to only 24.3% of the poorest
women. More than 35% of the richest women used modern contraceptive methods, compared
to only about 20% of the poorest women.

100%
70.4 64.6 64.3
80%

60%

40%
9.3 9.7
7.9
Figure 1. 20%
The prevalence of 21.7 26.1 26
contraceptive 0%
utilization among 2006 - 2007 2012 - 2013 2017 - 2018
Pakistani women from
2006–2007 to Modern method Tradional Methods No methods
2017–2018
Source(s): Author’s work, PDHS, 2018
 Current contraception use Types of contraceptive method
No Yes Total p- No method Traditional Modern Total p-
Independent variables (n 5 1683) (n 5 1106) (n 5 2789) value (n 5 1683) (n 5 295) (n 5 811) (n 5 2789) value

Age groups <0.001 <0.001

15–19 (n 5 91) 86.8 13.2 100 86.8 4.4 8.8 100
20–24 (n 5 423) 77.3 22.7 100 77.3 5.6 17.1 100
25–29 (n 5 531) 65.7 34.3 100 65.7 8.3 26.0 100
30–34 (n 5 548) 52.0 48.0 100 52.0 14.4 33.6 100
35–39 (n 5 482) 51.7 48.3 100 51.7 11.6 36.7 100
40–44 (n 5 346) 47.1 52.9 100 47.1 16.2 36.7 100
45–49 (n 5 360) 62.2 37.8 100 62.2 9.2 28.6 100
Type of place of residence <0.001 <0.001
Urban (n 5 1086) 52.5 47.5 100 52.5 14.9 32.6 100
Rural (n 5 1703) 65.4 34.6 100 65.4 7.8 26.8 100
Region <0.001 <0.001
Punjab (n 5 1482) 57.1 42.9 100 57.1 11.7 31.2 100
Sindh (n 5 675) 61.8 38.2 100 61.8 10.4 27.9 100
KPK (n 5 422) 64.8 35.2 100 64.8 6.9 28.4 100
Balochistan (n 5 138) 74.1 25.9 100 74.6 10.1 15.2 100
ICT (n 5 24) 39.1 60.9 100 39.1 13.0 47.8 100
FATA (n 5 48) 70.8 29.2 100 69.4 14.3 16.3 100
Wealth index <0.001 <0.001
Poorest (n 5 481) 75.7 24.3 100 75.7 3.9 20.3 100
Poorer (n 5 550) 66.6 33.4 100 66.7 6.9 26.4 100
Middle (n 5 562) 60.0 40.0 100 59.9 9.4 30.7 100
Richer (n 5 558) 56.4 43.6 100 56.5 12.9 30.6 100
Richest (n 5 637) 47.1 52.9 100 47.1 17.7 35.2 100

(continued )
Pakistani
women

123
use among
Contraceptive

Prevalence of
contraception use
Table 1.

Pakistani women
among
 1,1

124
FREP

Table 1.
Current contraception use Types of contraceptive method
No Yes Total p- No method Traditional Modern Total p-
Independent variables (n 5 1683) (n 5 1106) (n 5 2789) value (n 5 1683) (n 5 295) (n 5 811) (n 5 2789) value

Women’s education level <0.001 <0.001

No education (n 5 1401) 67.4 32.6 100 67.4 7.9 24.7 100
Primary (n 5 430) 58.1 41.9 100 58.1 10.9 30.9 100
Secondary (n 5 557) 51.5 48.5 100 51.5 13.3 35.2 100
Higher (n 5 402) 50.4 49.6 100 50.4 15.9 33.7 100
Media exposure to family planning (any) <0.001 <0.001
No (n 5 2055) 63.9 36.1 100 63.9 9.4 26.7 100
Yes (n 5 734) 50.4 49.6 100 50.4 13.9 35.7 100
Number of living children <0.001 <0.001
0 (n 5 308) 99.7 0.3 100 99.7 0.3 0.0 100
1 (n 5 389) 77.7 22.3 100 77.7 5.6 16.7 100
2 (n 5 476) 64.9 35.1 100 64.9 12.8 22.3 100
3 (n 5 455) 50.8 49.2 100 50.8 14.5 34.7 100
More than 3 (n 5 1160) 45.9 54.1 100 45.9 12.5 41.6 100
Experience of GBV (any) 0.001 0.002
No (n 5 1846) 62.5 37.5 100 62.5 10.5 27.0 100
Yes (n 5 943) 56.1 43.9 100 56.0 10.8 33.2 100
Additionally, as for education level, women with higher education used contraception in Contraceptive
general and modern contraceptive methods more than women with lower education (p-value use among
<0.001). A higher proportion of women who had heard about family planning in media
channels used contraception (49.6%) and modern methods (35.7%; p-value < 0.001). Also,
Pakistani
women who had a higher number of living children used contraception and modern methods women
more than women who had a smaller number of living children (p-value < 0.001). Women who
had a higher number of living sons had a higher tendency to use contraception than women
with a lower number of living sons. 125
As for the GBV experience variable, about 44% of women who experienced at least one
type of GBV used contraception in general, and 33.2% of women who experienced GBV used
modern methods compared to 38% and 27%, respectively, for those who had not experienced
GBV. The proportion of women who used traditional methods was similar in two groups of
women with around 10.5%. The difference in contraception use among different groups of
women who experienced at least one type of GBV was statistically significant (p-value < 0.01).

3.2 Factors associated with contraception use using binary logistic regression
The factors associated with contraception use are shown in Table 2. Results from
multivariate logistic regression showed positive association between age groups, educational
level, wealth index, exposure to family planning information in the media, number of living
children and experience of GBV with contraception use.
In general, compared to women age 15–19 years, those aged 45–49 were less likely to use
contraception in general (Odd ratio–OR: 0.241, p-value < 0.010) and modern contraceptive
methods (OR: 0.387, p-value < 0.050). Additionally, there was a positive association between
women’s education level and their use of contraception. Women who had more education
were more likely to use contraception than women who had no education (OR: 2.202, p-
value < 0.010). Women with higher education were also more likely to use modern methods
than the reference group, women who had no education (OR: 2.074, p-value < 0.010).
Furthermore, family planning communication appears to be a factor that encouraged
women to use contraception. Pakistani women who were exposed to family planning
information in media channels were more likely to use contraception in general (OR: 1.265, p-
value < 0.050) and modern methods (OR: 1.244, p-value < 0.050) than women who were not
exposed to family planning information in media channels. Besides, in comparison to the
reference group (women in the lowest household income group), a higher wealth index
increased the likelihood of contraception use and modern methods. Women in the highest
household income group were more likely to use contraception in general (OR: 4.352, p-
value < 0.010) and modern methods (OR: 2.034, p-value < 0.010) than the reference group.
The number of living children including sons and daughters had a positive association
with contraception use in general and modern methods. Women who had more than one
living son were more likely to use contraception (OR: 4.677, p-value < 0.010) and modern
methods (OR: 3.688, p-value < 0.010) than the reference group (women who did not have sons).
Women who had one daughter were also more likely to use contraception (OR: 2.822, p-
value < 0.010) and modern methods (OR: 1.884, p-value < 0.010) than the reference group
(women who did not have daughters). Interestingly, the strength of the coefficient was higher
for living sons than for living daughters. This result means that having a certain number of
living sons increases the likelihood of using contraception when compared with a certain
number of living daughters.
Experience of GBV was also a predictor that explains contraception use. Women who had
experienced violence were more likely to use contraception than women who had not
experienced violence (OR: 1.223, p-value 5 0.040). The results also showed that among
women who experienced violence, education level and wealth index had a positive association
FREP Use modern contraceptive
1,1 Current contraception use method
Variable OR 95% CI for OR OR 95% CI for OR

Region
Punjab (n 5 1482) Reference category Reference category
Sindh (n 5 675) 0.986 (0.791–1.230) 0.993 (0.792–1.245)
126 KPK (n 5 422) 0.717* (0.549–0.937) 0.886 (0.674–1.164)
Balochistan (n 5 138) 0.417** (0.263–0.662) 0.346** (0.206–0.582)
ICT (n 5 24) 1.639 (0.640–4.195) 1.884 (0.775–4.581)
FATA (n 5 48) 0.622 (0.308–1.255) 0.395* (0.173–0.904)
Age group
15–19 (n 5 91) Reference category Reference category
20–24 (n 5 423) 0.870 (0.426–1.778) 1.143 (0.507–2.577)
25–29 (n 5 531) 0.684 (0.335–1.394) 0.895 (0.398–2.012)
30–34 (n 5 548) 0.731 (0.355–1.504) 0.791 (0.348–1.798)
35–39 (n 5 482) 0.549 (0.263–1.146) 0.734 (0.320–1.688)
40–44 (n 5 346) 0.516 (0.242–1.100) 0.578 (0.247–1.355)
45–49 (n 5 360) 0.241** (0.112–0.520) 0.387* (0.164–0.917)
Women’s education level
No education (n 5 1401) Reference category Reference category
Primary (n 5 430) 1.365* (1.034–1.802) 1.372* (1.035–1.820)
Secondary (n 5 557) 1.609** (1.215–2.131) 1.677** (1.258–2.235)
Higher (n 5 402) 2.202** (1.578–3.073) 2.074** (1.476–2.914)
Exposure to media information about family planning
No (n 5 2055) Reference category Reference category
Yes (n 5 734) 1.265* (1.030–1.554) 1.244* (1.011–1.531)
Wealth index
Poorest (n 5 481) Reference category Reference category
Poorer (n 5 550) 2.007** (1.471–2.739) 1.590** (1.151–2.195)
Middle (n 5 562) 2.662** (1.937–3.659) 1.813** (1.306–2.517)
Richer (n 5 558) 2.658** (1.893–3.732) 1.564* (1.101–2.220)
Richest (n 5 637) 4.352** (3.010–6.294) 2.034** (1.396–2.964)
Number of living sons
0 (n 5 692) Reference category Reference category
1 (n 5 753) 4.677** (3.462–6.317) 3.688** (2.657–5.121)
2 (n 5 683) 9.147** (6.656–12.569) 6.081** (4.329–8.541)
3 (n 5 430) 14.322** (9.97–20.558) 13.258** (9.082–19.354)
More than 3 (n 5 231) 20.208** (13.185–30.971) 8.644** (5.569–13.417)
Number of living daughters
0 (n 5 725) Reference category Reference category
1 (n 5 824) 2.822** (2.169–3.671) 1.884** (1.428–2.486)
2 (n 5 587) 3.356** (2.508–4.491) 2.896** (2.141–3.917)
3 (n 5 326) 5.081** (3.610–7.152) 4.122** (2.915–5.827)
More than 3 (n 5 327) 5.471** (3.813–7.850) 4.374** (3.021–6.332)
Table 2.
Binary logistic Experience of GBV
regression model of No (n 5 1846) Reference category Reference category
contraceptive Yes (n 5 943) 1.223* (1.010–1.481) 1.207 (0.993–1.467)
utilization (weighted) Note(s): *p-value < 0.05; ** p-value < 0.01
with contraception use. Women with secondary education were more likely to use Contraceptive
contraception than women who had no education (OR: 2.650, p-value < 0.010; Table A1). use among
Women in the middle-income group were 2.5 times more likely to use contraceptive methods
than women in the poorest group (OR: 2.518, p-value < 0.0101; Table A1).
Pakistani
In use of modern contraceptive methods (Table A2), spousal communication and joint women
decision-making increased the likelihood of condom use (one of the most popular methods).
Women who made contraception decisions with their husband or partner were more likely to
use condoms compared to the reference group, only women decided to use contraception (OR: 127
1.648, p-value < 0.010).

4. Discussion
In this study, the results indicated that women age 45–49 years old were less likely to use
contraception and modern contraceptive methods. These results could be explained that
women aged 45–49 years old had a certain number of living children. They might have
infrequent intercourse with their husband or partner (Islam & Hasan, 2016). This age is also
close to the menopause period among women; thus, they might believe that it is less likely
they will get pregnant at this age (Islam & Hasan, 2016).
Women’s higher education significantly increased the likelihood of contraceptive uptake
and use of modern contraceptive methods. This finding is consistent with findings of
previous studies described in the literature review. Women’s education level is a basic
measurement of their socioeconomic status and reflects women’s autonomy (Saleem &
Bobak, 2005). Most Pakistani women residing in rural areas have less access to education or
employment opportunities than women living in urban areas (Tarar & Pulla, 2014). Rural
women are unpaid workers, expected to contribute to agricultural activities, and not allowed
to go out to earn a living (Tarar & Pulla, 2014). This makes women more dependent on their
husbands or partners; therefore, rural women’s autonomy is low, and they have less decision-
making power and rely on their husband’s decisions for seeking health services or even using
family planning (Saleem & Bobak, 2005). This explains why women in this study who have
higher education are more likely to use contraception and modern contraceptive methods
than women who have lower education. Women who have higher educational qualification
might have better knowledge of SRH. They also have higher socioeconomic status in society
with stable occupations and live in places where it is easier for them to access health facilities,
including family planning services.
Compared to women in the poorest group, higher household income increased the
likelihood of contraception use and modern contraceptive methods. This result was
consistent with previous regional studies, such as Mohsena & Kamal (2014). The wealth
index is also a basic measurement of women’s socioeconomic status. Women with a higher
wealth index usually live in better conditions and have easier access health facilities,
including family planning services (Saleem & Bobak, 2005). They can afford the cost of
contraception. Their autonomy is normally higher than that of poorer women. Thus, it is
easier for wealthier women to be involved in decision-making with their husband or partner,
and these women have more autonomy in deciding issues related to their health (Mohsena &
Kamal, 2014; Osmani, Reyer, Osmani, & Hamajima, 2015).
Women who reside in a better family condition with higher wealth index, might have
husbands or partners with higher education and economic levels. Meanwhile, the husband
normally plays an important role in deciding on health service–seeking behavior in a family.
Women who have husbands or partners with higher education used more contraception and
modern contraceptive methods than women who had husbands or partners with lower
education, according to the Pearson chi-square test in the preliminary findings from the
descriptive analysis.
FREP Media exposure to family planning was positively associated with use of contraception and
1,1 use of modern contraceptive methods. Women who were exposed to family planning in media
channels were more likely to use contraception and modern contraceptive methods compared
to women who were not exposed to information in media channels. This result was expected
and in line with the findings of the previous studies discussed in the literature review.
The development of technology has contributed to the effectiveness of health intervention
programs. Mass media campaigns are one of the strategies for increasing healthy behavior,
128 including promoting knowledge and changing attitudes toward family planning (Jacobs,
Marino, Edelman, Jensen, & Darney, 2017). Mass media including radio, television and
newspaper can reach a very large audience (Jacobs et al., 2017). Therefore, women might have
more access to family planning information and be more familiar with family planning, which
can affect their attitudes and ideas about desirable lifestyles and contraception (Goni &
Rahman, 2012). Moreover, information in official mass media channels, such as television,
radio and newspaper, is more trusted by audiences (Goni & Rahman, 2012).
The number of living sons, as well as daughters, was statistically significantly associated
with contraceptive uptake and use of modern contraceptive methods. Women who had a
higher number of living children were more likely to use contraception and modern
contraceptive methods than women who had a lower number of living children. Having a
certain number of sons increased the likelihood of using contraception and using modern
contraceptive methods when compared with living daughters.
These findings reflect a cultural preference for sons. Pakistan is one of the countries with
this cultural preference. It is influenced by the patriarchal social system in which the level of
female empowerment is lower than that of male empowerment (Facio, 2013; Nasrullah &
Bhatti, 2012). Similar to many countries in Asia, Pakistan has a patrilineal inheritance system,
and daughters are normally viewed as a heavier economic burden than sons (Channon, 2017;
Nasrullah & Bhatti, 2012), because a woman’s family has to pay a large dowry when she
marries, and the participation of women in the labor force is extremely low (Channon, 2017).
Compared to other countries with available data, Pakistan has a much higher preference for
sons than any other country, including India — where the extremely high preference for sons
results in high levels of sex-selective abortions (Channon, 2017). The preference for sons not
only affects contraceptive uptake behavior but also influences use of modern contraceptive
methods (Channon, 2015). This suggests that eliminating the preference for sons might
increase contraception use and modern contraceptive methods. It also addresses fertility
issues, avoids sex ratio imbalances and improves SRH.
The participation of men and women in decision-making regarding contraception use was
a good predictor of the use of condoms (Table A2). Women who jointly made decisions with
their husbands or partners were more likely to have their husband use a condom than women
who decided by themselves.
The results also showed that women whose husbands made most decisions regarding
contraception use were more likely to use condoms than women who joined in the decision-
making process. In the context of Pakistan, men make most of the decisions on healthcare
service seeking and women depend on their husband or partners, especially in terms of
household finance (Ali et al., 2011; Nasrullah & Bhatti, 2012; Tarar & Pulla, 2014; Zakar,
Zakar, & Kraemer, 2013). Therefore, if women are allowed by their husbands or partners to
use contraception, it would be easier to access family planning services and afford modern
contraceptive methods.
The results also show that women who experienced GBV were more likely to use
contraception than women who had not experienced violence. This finding was in line with
the finding of Dalal et al. (2012) in Bangladesh and Emenike et al. (2008) in Kenya. The higher
level of contraception use among women who experienced violence might be associated with
fear of pregnancy in unfavorable conditions (Siddique, Zakar, Farhat, & Deeba, 2019). These
findings were consistent with some evidence that abused women are likely to control their Contraceptive
bodies in term of SRH decision-making (Siddique et al., 2019). Women might be aware of the use among
consequences of their husband’s or partner’s violent behavior toward them. Therefore, the
women were more likely to take the initiative to control the number of children born in a
Pakistani
violent relationship (Dalal & Lindqvist, 2012; Siddique et al., 2019). women
Among women who experienced violence, the results showed that higher education
increased the likelihood of contraception use, and women with a higher wealth index were also
more likely to use contraception than the poorest women. Women in the KPK and Balochistan 129
regions, which are known as less developed regions with lower literacy and wealth index
compared to other regions, were less likely to use contraceptive methods to prevent unintended
pregnancy than women in Punjab, the most populous region (Rehman, Jingdong, & Hussain,
2015). This means that abused women in better living and working conditions might have a
better perspective on their unfavorable condition and be aware of the effect of their husband’s
or partner’s violent practices toward them (Siddique et al., 2019). Healthcare services, including
family planning services, might be more available and convenient for women in better living
conditions (Punjani, 2018). Therefore, these women have easier access to family planning
services to prevent unwanted pregnancy than women in worse conditions.
The rate of GBV is very high in Pakistan with about 34% of Pakistani women having
experienced at least one type of GBV. However, this led to higher contraception use among
women who experienced GBV. GBV results in many adverse health outcomes and forces
women to protect themselves in unfavorable conditions. Compared to women residing in
better living and working conditions, women who reside in less developed areas and have less
education and a lower wealth index face many problems related to their SRH, such as unmet
family planning needs and official support services about GBV when domestic violence is
considered a private issue and the government does not have an efficient mechanism to
support victims of GBV.

5. Limitations of the study

Although the dataset is considered nationally representative data on health, this cross-
sectional study reflects only an overview, contraceptive method uptake and use of modern
contraceptive methods among Pakistani women. The results do not show underlying causes
to explain contraception use behaviors.
The use of secondary data limited the variety of important variables that should be
investigated, including women’s knowledge of SRH, women’s attitude toward SRH and
family planning, skills of a healthcare provider in counseling family planning, and other
barrier variables, such as transportation and willingness to pay for contraception methods.
Although the survey was conducted in a large sample size, the number of participants who
met all criteria of this study was small. This might call into question the representativeness of
these findings for the population.
The sensitivity of the topic is considered another challenge when collecting data (Basu,
Jaising, & Collective, 2005). Women might be hesitant to share their GBV experience (Basu
et al., 2005). The experience of GBV is also hard to define and depends on the feeling of each
person, especially emotional violence. An additional limitation is that information on the
frequency of GBV is not provided in the data set.

6. Recommendations
Based on the findings of this study and those from previous studies, there are some
recommendations to promote contraception use and use of modern contraception methods
among Pakistani women.
FREP Because of disparity in socioeconomic conditions, women who have less education, live in
1,1 poorer regions and have a lower wealth index are less likely to access information on family
planning and health facilities. Therefore, the government of Pakistan should create a strategy
for promoting a national SRH program and enhance the availability of family planning
services in all communities to respond to the demand for family planning, especially for less
developed areas where women face many barriers, such as transportation and affordability of
contraception. Moreover, integrating comprehensive sexuality education into school
130 programs should be considered. Young people can be equipped with SRH knowledge and
skills and effective communication skills for use with spouses, children and parents at a
young age.
The position of women in society is one of the biggest concerns in health promotion
programs. When women are considered the property of men, they cannot make a
decision without permission from their husbands, fathers or brothers (Ashraf, Abrar-Ul-
Haq, & Ashraf, 2017). Therefore, women empowerment programs to promote the
position of women in family and society should be developed and integrated into the
national call for action. That improves the meaningful participation of women in the
labor force, allows them independence in the economy and grants them more power in
making decisions about their health and their bodies. Meanwhile, male involvement and
spousal communication promotion should be taken into consideration as important
components.
The government should develop an efficient mechanism to support victims of GBV. The
mechanism should ensure the safety, privacy and confidentiality of the victims. Supporters
should have a neutral attitude and be respectful to and supportive of victims.

7. Conclusions
This study aimed to identify the prevalence of contraception use among Pakistani women, as
well as assess the factors influencing the utilization of contraception with a focus on GBV.
The findings demonstrated that the experience of GBV was a good predictor in explaining
variation in contraception use. Women who experienced violence are more likely to use
contraception than women who had not experienced violence. Higher contraception use
among women who experienced violence might be associated with fear of pregnancy in
unfavorable conditions.
From the results of this study and those from previous studies, some associations between
contraception use and risk factors were identified. Policymakers can use these findings to
develop policies and national programs for improving the prevalence of contraception use
and model contraceptive methods among Pakistani women.

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Corresponding author
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Appendices Contraceptive
use among
Pakistani
Variable Coefficient Wald statistic OR 95% confidence interval (CI) for OR women
Women’s education level
No education Reference category
Primary 0.470 4.114 1.600* (1.016, 2.520) 133
Secondary 0.974 14.197 2.650** (1.596, 4.398)
Higher 1.063 10.249 2.896** (1.510, 5.554)
Age group
15–19 Reference category
20–24 0.297 0.286 0.743 (0.251, 2.202)
25–29 0.714 1.749 0.490 (0.170, 1.411)
30–34 0.552 1.021 0.576 (0.197, 1.680)
35–39 0.773 1.898 0.462 (0.154, 1.386)
40–44 0.951 2.674 0.386 (0.123, 1.208)
45–49 1.292 4.873 0.275* (0.087, 0.865)
Wealth index
Poorest Reference category
Poorer 0.613 5.756 1.846* (1.119, 3.047)
Middle 0.924 12.487 2.518** (1.509, 4.203)
Richer 0.761 6.670 2.141** (1.201, 3.816)
Richest 0.976 8.779 2.653** (1.391, 5.060)
Region
Punjab Reference category
Sindh 0.221 0.816 1.247 (0.772, 2.014)
KPK 0.426 4.421 0.653* (0.439, 0.972)
Balochistan 0.902 7.647 0.406** (0.214, 0.769)
ICT 0.417 0.217 1.518 (0.262, 8.787)
FATA 0.633 1.767 0.531 (0.209, 1.350)
Exposure to media information about family planning
No Reference category
Yes 0.296 2.365 1.345 (0.922, 1.962)
Number of living sons
0 Reference category
1 1.670 31.895 5.310** (2.975, 9.479)
2 2.519 67.133 12.414** (6.796, 22.676)
3 2.671 64.095 14.453** (7.516, 27.793)
More than 3 2.999 64.497 20.069** (9.653, 41.725)
Number of living daughters
0 Reference category
1 1.075 17.309 2.929** (1.765, 4.859) Table A1.
Binary logistic
2 1.610 33.829 5.002** (2.908, 8.604)
regression: current
3 1.975 40.307 7.208** (3.917, 13.263) contraception use
More than 3 1.937 36.682 6.938** (3.707, 12.987) among women who
Note(s): *p-value < 0.05; **p-value < 0.01; Nagelkerke R2 5 0.334. Classification table overall percentage 5 had experienced
71.2. Hosmer and Lemeshow Test (χ 2 5 14.536, p-value 5 0.069) violence
FREP Variable Coefficient Wald statistic OR 95% CI for OR
1,1
Women’s education level
No education Reference category
Primary 0.362 2.127 1.437 (0.883, 2.337)
Secondary 0.554 5.395 1.740* (1.090, 2.776)
Higher 0.248 0.773 1.281 (0.737, 2.226)
134 Age group
15–19 Reference category
20–24 0.249 0.123 1.282 (0.319, 5.154)
25–29 0.157 0.050 0.855 (0.217, 3.367)
30–34 0.506 0.511 0.603 (0.151, 2.414)
35–39 0.374 0.270 0.688 (0.168, 2.817)
40–44 1.457 3.778 0.233 (0.054, 1.012)
45–49 0.911 1.457 0.402 (0.092, 1.765)
Wealth index
Poorest Reference category
Poorer 0.955 5.797 2.598* (1.194, 5.653)
Middle 1.127 8.404 3.085** (1.440, 6.608)
Richer 1.472 13.344 4.357** (1.978, 9.597)
Richest 1.068 6.636 2.908** (1.291, 6.552)
Region
Punjab Reference category
Sindh 0.484 5.893 0.616 (0.417, 0.911)
KPK 0.855 13.317 2.351 (1.486, 3.722)
Balochistan 0.078 0.028 1.081 (0.432, 2.705)
ICT 0.569 0.943 1.767 (0.560, 5.580)
FATA 0.858 0.817 0.424 (0.066, 2.726)
Experience of GBV
No Reference category
Yes 0.499 9.299 1.648** (1.195, 2.271)
Exposure to media information about family planning
No Reference category
Yes 0.423 6.346 1.527* (1.098, 2.122)
Number of living sons
0 Reference category
1 0.050 0.028 0.951 (0.529, 1.710)
2 0.690 4.813 0.502* (0.271, 0.929)
3 0.508 2.131 0.601 (0.304, 1.190)
More than 3 1.643 12.675 0.193** (0.078, 0.478)
Number of living daughters
0 Reference category
1 0.579 5.896 0.561* (0.352, 0.894)
2 0.742 7.401 0.476** (0.279, 0.813)
3 0.787 6.791 0.455** (0.252, 0.823)
More than 3 0.841 6.110 0.431* (0.221, 0.840)
Decision-makers for contraception use
Table A2.
Binary logistic Mostly respondent Reference category
regression: condom use Mostly husband/partner 1.461 6.923 2.956* (1.285, 12.788)
among women who Joint decision 1.084 6.498 1.648** (1.195, 6.803)
used contraception at Note(s): *p-value < 0.05; ** p-value < 0.01; Nagelkerke R2 5 0.313. Classification table overall percentage 5
the time of the survey 75.3. Hosmer and Lemeshow Test (χ 2 5 10.212, p-value 5 0.250)