Authors: Babar Tasneem Shaikh  ( Health Services Academy, Islamabad. )
Syed Khurram Azmat  ( Marie Stopes Society, Karachi. )
Arslan Mazhar  ( Health Services Academy, )

Introduction: The population of the world reached seven billion in 2012. Pakistan\\\'s population stands at more than 180 million, is growing rapidly, and has the highest unmet need for family planning (FP) in isolated rural areas. The low usage of contraception in the rural areas of Pakistan correlates with the level of isolation, poverty, illiteracy, and to a large extent, religious misinterpretations/misconceptions. Almost 25% of couples who desired FP services were not receiving them for a variety of reasons of which religion could be one, especially in the rural remote areas where the media is still not reaching and influencing mind-sets. In this scenario, the role of social marketing in bringing about attitudinal and behavioural change among users in underserved areas and gatekeepers and opinion makers in society must not be neglected.
The work in promoting FP, contraception and birth spacing requires authentic evidence from similar socio-cultural contexts and this endeavour of compiling case studies from various Islamic countries on their FP initiatives is a good step. Governments around the world, including many in the Islamic world, support FP programmes to enable individuals and couples to choose the number and timing of their children.
Methods: This paper is a review of secondary data accessed through PubMed and Google Scholar. It provides an overview of Islamic countries\\\' policies on, and support for FP and modern contraception. For this purpose, literature from Afghanistan, Bangladesh, Egypt, Indonesia, Iran, Jordan, Kuwait, Malaysia, Morocco, Nigeria, Pakistan, and Turkey was included.
Results: There are significant internal social and economic reasons to focus on FP in the Muslim world. Thus, arguments by religious scholars who see FP as an external western conspiracy aimed at curtailing the growth and strength of the Islamic world appear to be uninformed of both the socio-political and demographic realities in many Muslim countries, as well as the historical permissibility of contraception within the Islamic legacy. In fact, it can be argued that given the profound socio-economic and political difficulties in various parts of the Muslim world, a lack of FP and increasing populations would weaken and curtail the pace of overall development.
Conclusion: Private institutions and the government must collaborate in leveraging initiatives and bridging gaps for more robust advocacy with clergymen and religious scholars to support the larger cause of FP and birth spacing i.e. improving infant and maternal health in Pakistan.
Keywords: Family planning, Contraception, Islam, Pakistan.

The introduction of modern contraceptives, the restructuring of family planning (FP) programmes, and endorsements and international agreements on birth spacing, all have given new impulses to old paradigms on the subject. In this very context, Muslims and Islamic countries have always been under debate and critique. Pakistan, for instance, is one example where the FP programme has not delivered the results desired and the common perception is that it is perhaps due to religion. This is true, to some extent. The Pakistan Demographic and Health Survey (PDHS) 2006-07 showed that six percent of women were restrained from using any FP method because of religious reasons or interpretations.¹ These interpretations and misconceptions have been propagated to declare FP a sin. The major role in this regard indubitably is of the local clergymen. Nonetheless, there are several Islamic countries that have not only presented many success stories in this regard, but have achieved control over their fertility rate and population growth rate. Governments around the world including many in the Islamic world, endorse FP programmes to facilitate individuals and couples to decide for themselves the number and timing of their children. These FP programmes have carried the slogan of improving the health of women and children besides slowing down population growth in countries where an overwhelming population growth was considered a barrier to socio-economic development. It is important to note at this juncture that most Islamic countries endorsed the Programme of Action of the United Nations 1994 International Conference on Population and Development,² and the 2000 Millennium Development Summit Declaration which called for universal access to FP information and services.³ PubMed® and Google Scholar® were used as the main databases for collecting literature. This review will provide an overview of Islamic countries\\\' policies on, and support for FP and modern contraception. For this purpose, literature from Afghanistan, Bangladesh, Egypt, Indonesia, Iran, Jordan, Kuwait, Malaysia, Morocco, Nigeria, Pakistan, and Turkey was included. This is a summary of peer-reviewed articles on Islam, contraception, and FP.


Pakistan’s Context
The most common factors associated with the unmet need for FP in Pakistan include women\'s perceptions that their mothers-in-law have different fertility goals in mind, having less than two sons or two daughters, a lack of economic independence, a lack of spousal communication on sexual matters, and religious misinterpretations.¹ It has often been emphasized that programmes to reduce unmet need should therefore target mothers-in-law and their religious interpretations about FP because they are the main decision-makers in matters related to couples\' adoption of FP, female economic independence, and encouraging spousal communication.⁴ Women\'s autonomy has also documented some significant results in accessing FP services in areas where husbands\' opposition and religious opposition are the main barriers.⁵ In another study, it was documented that it is mostly religious leaders who are against FP services and that involving them proactively in community education is extremely important to promote contraception use.⁶ Lady health workers (LHWs), for instance, have been found to be most effective in addressing religious myths and misconceptions with regard to FP. There is strong evidence that the LHW programme has succeeded in integrating FP into \'doorstep\' provision of preventive healthcare, hence addressing the issue of women\'s mobility.⁷ Other initiatives are direly needed to address the beliefs and perceptions of religious opinion givers about FP practices, and it is essential to develop the capacity of religious leaders in order to promote FP messages at the community level.⁸ Another study states that religious leaders who had more knowledge about contraception methods actually approved of FP services. Moreover, religious leaders from more educated provinces had positive views about FP methods as compared to provinces with lower literacy rates.⁹ Studying community health-seeking behaviours and conducting health systems research, of course, with religion, culture, and societal norms at their core, seems imperative in the context of Pakistan.¹⁰
Scenarios in Other Islamic Countries
South East Asia
In Bangladesh, husbands\' disapproval of FP is still a deterrent to women\'s regulation of fertility and this phenomenon highlighted the structural influences that explain fertility regulation behaviour.¹¹ Myths, false beliefs, and rumours about the use of oral contraceptive pills, for instance, are prevalent in Bangladesh. A lack of consultation with qualified FP workers and the influence of religious norms and folk stories are still key hindrances in the uptake of oral contraceptive use.¹² However, the government of Bangladesh has actively engaged Islamic scholars to advocate for maternal and child health, including FP.
Even in Afghanistan, the involvement of communities along with local opinion and religious leaders has made the promotion of FP practices in rural Afghanistan possible. Dialogues with opinion leaders, clinic staff, and household members helped in understanding cultural norms and taboos in order to innovate and test FP services in a local context. Updated contraceptive information supported with Islamic ideology and the mobilization of religious leaders helped in achieving the goals of the programme.¹³
Malaysia already had policies for a balanced, equitable, and sustainable development before the 1994 International Conference on Population and Development (ICPD). The conference gave Malaysia the opening to follow specific and more intricate issues. Reproductive health services including FP have been integrated and are available, accessible, and affordable within the existing healthcare system, both public and private. Since the government of Malaysia needed help in implementing Cairo\'s goals, regular consultations on programme design and implementation are held with all types of advocacy groups, the private sector, and community groups, including the clergy.¹⁴
In Indonesia, there has been widespread knowledge of contraceptive methods for some time. In 2002-2003, 99% of currently married women knew of one modern contraceptive method, at least. Contraception use increases with a woman\'s level of education. There is hardly any religious opposition to FP in Indonesia.¹⁵
Middle East
In Iran, decision-makers including ministry officials and religious leaders met with technical experts and collectively agreed that the country could not adequately feed, educate, house, or provide jobs to its citizens at existing levels of population growth. Faced with these facts, they took action and developed a population policy that was incorporated into the country\'s development plan. Family planning programmes were strengthened as a building block for poverty reduction and the achievement of national development goals.¹⁶ Religious leaders have also played their role in removing community fears about contraception methods. This is the most unique and impressive approach adopted by FP programmes in Iran.¹⁷ Social stigmas such as men\'s negative behaviours towards permanent contraception, were addressed through consultative sessions with non-state actor (ulema); however, political actors played a crucial role in these endeavours.^18,19
In Egypt, the Grand Mufti, the country\'s most authoritative interpreter of Islamic law, issued a religious decree in the mid-1930 spermitting contraception, thus allowing the establishment of birth control clinics in Egyptian cities. He declared that the earliest followers of the Prophet (pbuh) practiced contraception with the knowledge of the Prophet, who did not forbid it. In 1964, Sheikh Hasan Ma\'mun encouraged the use of contraception based on the changing needs of the Muslim people. Since 1980, religious leaders have played a major role in the public education efforts of the State Information Service by speaking out on the acceptability of birth control in the eyes of Islam.20 In the 1990s, the National Population Commission made population issues part of the educational curriculum, including the religious educational curriculum.²¹
In Jordan, a lack of awareness and acceptance of contraceptives has been widely believed to be a socially constructed adherence to tradition, often with religious implications. Additionally, the doctrine of Islam has often been interpreted to forbid the use of FP methods. In fact, it is being argued that perhaps Muslim leaders\' positions on FP are not always interpreted correctly; these leaders mayin fact, be no more opposed to reproductive health programmes than are other members of society.^22,23 Traditional, familial, and religious pressures on Jordanian women were limiting factors in birth spacing. Son preferences and religious norms among Jordanian women had a strong influence on contraceptive behaviours. The involvement of religious leaders in FP programmes had a positive influence on rural Jordanian women.²⁴ Family planning programmes supported through fatwas* triggered the contraceptive uptake among Muslim communities. The government led FP programmes and the proactive role of religious leaders was effectively persuaded younger women to seek reproductive health services.²⁵
In Kuwait, women held the perception that FP is not allowed in Islam. Today, contraception is generally accepted in Kuwait and is often considered more important for child spacing than for family size limitation. Although Kuwait did not have any state-funded FP programme, the government provided free contraceptive products and methods.²⁶
Europe
In Turkey, religious leaders have a positive attitude towards contraception. The integration of religious leaders in reproductive health programmes and education on FP issues was prioritized to attain desirable fertility rates.²⁷ Family impositions and religious barriers had been important reasons for the non-use of contraception in Turkey. The effectiveness of FP programmes could only be maximized with the involvement of husbands and religious and other influential leaders in the community.²⁸ Moreover, there was a significant decline in the number of pregnancies, number of children, and spontaneous abortions over time mainly due to increases in educational and socio-cultural levels, and because of the removal of religion-related misinterpretations.^29,30
Africa
In Morocco, the low use of contraceptives by women was attributed to hindrances by religious extremists. Research in Morocco established that religious extremists played a strong role in the misinterpretation of Islam about FP. However, the economic conditions of the working-class community could not be neglected while looking at the complex decision making process of reproductive health practices. Clergymen were therefore engaged in the national programme to help achieve desired results.³¹
In Nigeria, the majority of religious leaders emphasized the importance of sexuality education in schools, yet some disagreed. It was realized that religious leaders were aware of problems related to young people\'s reproductive health. However, today, it is felt that the harmonization of sexuality education in schools according to cultural values, is needed.³²

Religion remains a central issue in the discourse on FP and contraception despite the assiduous efforts of state programmes on FP and birth spacing and the proactive advocacy role played by non-government organizations (NGOs). The Quran does not disallow birth control, nor does it forbid a husband or wife from spacing pregnancies or limiting the number of children. Thus, the great majority of Islamic jurists believe that FP is permissible in Islam.³³ The silence of the Quran on the subject of contraception could not be a matter of omission by God, as he is "All-Knowing" and Islam is understood to be an eternal religion and a code of life. The proponents of FP also note that coitus interruptus or withdrawal was practiced in the epoch of the Prophet (pbuh) by his Companions.³⁴ The Quranic teaching for mothers to breastfeed their children for two years must be understood with its precise philosophy i.e. to allow women to have rest and restore their anatomical, physiological, and hormonal system before another pregnancy.³⁵ In its true spirit, Islam is considerate of FP as spacing pregnancies and curtailing the number of pregnancies makes mothers more physically fit and fathers more financially at ease. None of these actions contravene any prohibition in the Quran or in the Prophet\\\'s (pbuh) tradition (Sunnah). If redundant fertility leads to a definite health nuisance for mothers and children, or economic hardship and discomfiture for fathers, or the helplessness of parents to raise their children properly, Muslims would be allowed to regulate their fertility in order to reduce these hardships.
The organized FP programmes of Egypt and Iran are noteworthy. Both often involve religious leaders in their FP campaigns. Egypt is home to Al-Azhar Mosque and Al-Azhar University, two renowned centres of Islamic teaching. These centres have frequently dispatched fatwas in favour of modern contraception and the Egyptian government has used them in its thriving FP campaigns.³⁶ As a consequence, contraceptives are available in Egypt in all government primary healthcare facilities. Since the reinstatement of Iran\\\'s national FP programme, the Ministry of Health and Medical Education in Tehran has regularly issued fatwas to its provincial offices and down to the lower strata of the health network to remove any doubts that health providers or clients may have about the permissibility of FP and contraception in Islam. Health clinics must display the fatwas for their clients as a ready reference. Moreover, the issuing of fatwas on FP is not the monopoly of the ministry of Health office in Tehran; these rulings can be sought from local clergies, as well.³⁷ However, there is a stern pre-requisite in this case - the capacity building of religious leaders. It is absolutely imperative that religious leaders and local clergymen possess accurate and appropriate information and skills to help their followers make informed choices on matters related to health and wellbeing, particularly on matters related to FP and birth spacing. There is a need to mobilize and sensitize these stakeholders to play their parts as a matter of social responsibility towards saving women from unwanted pregnancies and improving children\\\'s health.
For a country like Pakistan, the enormity of this emergency of population overgrowth coupled with illiteracy and poverty has emerged as a menace to the social system. It is a major impediment in the path of all efforts to improve living standards.³⁸ It is strongly suggested for all future interventions encompassing FP as their mainstay, to advocate the concept for the betterment of mother\\\'s and children\\\'s health. The concept of spacing children means the practice of contraception in order to allow a rational time period between the births of any two children: the point being that each child receives ample attention in its upbringing. A mother\\\'s full attention is required in the difficult task of nourishing, training, and educating a child. It is very difficult to provide this essential care and attention for each child if a baby is born every year. Moreover, according to Islamic jurisprudence, fatwas, and the case studies of various Islamic countries, it can be deduced that if another pregnancy would seriously affect the care and upbringing of an existing child, then reversible methods of birth control may be practiced. Family planning has always been tainted by its association with population control — the discredited attempts by various countries to reduce their populations through coercion. Hence, this approach has damaged the programme\\\'s overall spirit. Today, it is about global population planning where the number has crossed seven billion. Future interventions must provide FP, birth spacing, and general mother and child health services to women and girls around the world to eventually change the course of their lives. That is what will make the paradigm of FP transformational. In this regard, social marketing has shown successful results in bringing about behaviour change towards the uptake of birth spacing methods in Pakistan and elsewhere. However, since the coverage of social marketing was limited to urban and peri-urban areas of the country, the desired result of fertility control was not achieved, especially amongst rural women.

The issue of FP and contraception in Islam has become a grave concern because of unprecedented population growth around the globe; Indonesia and Pakistan are major contributors. Other Islamic developing countries present maternal and child health indicators which are not on track to achieve the millennium development goals (MDGs) set for 2015. Having recognized that Islam is still the mainstay in the debate on FP and contraception in Islamic countries, religious leaders, ulema, scholars, think tanks, and even local clergymen should be disseminating the correct information and actively engaging in advocacy for the promotion of birth spacing for the improvement of maternal and child health outcomes. Improving literacy rates through investment in girls\\\' education is another proven strategy to improve reproductive behaviours. This becomes even more relevant for the developing countries listed in this paper where maternal and child health indicators cannot be compared with those of the developed world.

This manuscript was written with the technical, administrative, logistic, and financial support of the Marie Stopes Society (MSS), Pakistan. The authors are indebted to Dr. Mohsina Bilgrami, country director, MSS who provided direction and oversight for this work.
Conflicts of interest
There are no conflicts of interest.

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