Falling fertility in Indonesia: success in national family planning

This publication summarizes the findings of the National Indonesia Contraceptive Prevalence Survey (NICPS), which revealed a rapid decline in Indonesia's fertility rate. This article also describes how the successful Indonesia family planning program is designed and maintained. Since 1975, fertility rates have dropped from 5.5 to 3.3 children per woman. Those practicing contraception during the same period has risen from 400,000 couples to 17 million. Contraceptive education is high (e.g. 95% of all married Indonesian woman are familiar with a modern contraceptive method). The Indonesia family planning program cooperates with other government activities designed to improve people's health and welfare. It emphasizes access to contraceptive methods and promoting the idea small family. The program was structured to us extensive community involvement, and cultural beliefs were incorporated into program policy; Islamic leaders were consulted before program implementation. The program is flexible so that the differing needs of each region can be effectively met by the family planning program. The future main goal will be to contain a potential population boom when the 40% of the present population which is under 15 years of age becomes reproductively mature.     

Kenya's record population growth: a dilemma of development

The causes and implications of Kenya's 4% rate of natural increase and fertility rate of 8.1 births per woman were examined. Attention was directed to the following: pronatalist pressures; inadvertent pronatalist impact of development; women's education and employment and fertility; population growth and pressures; mortality decline and population growth; fertility levels and differentials; fertility desires; the family planning program; and family planning knowledge, attitudes, and practice. Kenya's development success has worked to push up the population growth rate. Improved health care and nutrition halved infant mortality from 160 to 87 deaths/1000 live births between 1958 and 1977 and a marked increase in primary school enrollment may be factors in the birthrate increase to 53/1000 population. At this time fertility is highest among women with 1-4 years of education. The 1977-1978 Kenya Fertility Survey showed that only 5.8% of married women were using modern contraception, indicating that the national family planning program, established in 1967, has made little progress. Program difficulties have included shortages of staff, supplies and easily accessible clinic as well as an almost universal desire on the part of Kenyans for families of at least 7 children. Children are viewed as essential to survival and status to the rural population.     

Mexico's population policy turnaround

Until 1972 Mexico's officials seemed to believe that the annual population growth rate of 3.5% was not really a problem as long as the economic development rate could be kept ahead of the population growth rate. The General Law of Population of 1947 was actually promoting population growth. It was only during the 1960s that elite opinion shifted, and privately funded family planning programs became increasingly active. By 1972 the population had reached 54 million, from 20 million in 1940. President Echevarria, till then a traditional pronatalist, announced in 1972 the creation of a national family planning program, and, in 1974, the creation of a national population council. Since then the Mexican government has embarked on ambitious programs of mass communication and sex education to make the population receptive to its new attitudes. The plans have worked: by mid-1979 estimates put the population growth rate at 2.9%, within sight of the 2.5% target set for 1982 by new president Lopez Portillo. According to a survey conducted by the National Fertility Survey, by late 1976 41.50% of Mexican women of childbearing age were practicing contraception. Within the 41.50% of active contraceptors, 14.9% use the pill, and 7.8% the IUD. New channels of information and of contraceptive delivery are being explored to reach Mexico's widely scattered rural population, and to bring the average family size down to 2 children from the average of 6.5 children per woman for 1973-1975. The government goal is of a 1% population increase by the year 2000.     

New strategies for slowing population growth

Growth of world population over the next 100 years, until the year 2100, will produce an estimated 11.5 billion people. The past focus on reducing rapid population growth exclusively through family planning has not been sufficient. Population policy needs to be broadened to include health care, education, and poverty reduction. The population policy recommendations of Population Council Vice-President John Bongaarts and Senior Associate Judith Bruce were to reduce unwanted pregnancies by expanding services that promote reproductive choice and better health, to reduce the demand for large families by creating favorable conditions for small families, and to invest in adolescents. The Population Council 1994 publication "Population Growth and Our Caring Capacity" outlined these issues. Another similar article by John Bongaarts appeared in the journal "Science" in 1994. In developing countries, excluding China, about 25% of all births are unwanted; 25 million abortions are performed for unwanted pregnancies. The provision of comprehensive family planning programs will go a long way toward achieving a reduction in unwanted pregnancies. In addition, changes are needed in male control over female sexuality and fertility and in cultural beliefs that are obstacles to use of contraception. Stabilization of population at 2 children per family will not occur unless there is a desire for small families. In most less developed countries, large family sizes are preferred. Governments have an opportunity to adopt policies that reduce economic and social risks of having small families. This can be accomplished through the widespread education of children, a reduction in infant and child mortality, improvement in the economic and social and legal status of women, and provision of equitable gender relations in marriage and child rearing. The rights of children to be wanted, planned, and adequately cared for need to be supported. These aforementioned measures will help to reduce fertility, provide support for small families, and justify investment in social development. Population momentum will keep population growing for some time even with replacement level fertility. Investment in adolescents through enhancement of self-esteem and promotion of later childbearing can lengthen the span between generations and slow population momentum. Population policies will be more effective when human rights are protected.     

Communique of the State Family Planning Commission on a nationwide fertility sampling survey of every person per thousand

In 1982, the Chinese State Family Planning Commission conducted a nationwide fertility survey of 1 person/1000 in 28 provinces, municipalities, and autonomous regions. 815 sample units were selected and 310,462 women aged 15-67 were interviewed, 99.9% of those identified. 252,094 (24.77%) were of childbearing age (15-49) with 24.76% 15-19 years old. Among women of fertile age, 31.46% were unmarried, 64.53% were married to their 1st husbands, 2.89% were remarried, .19% were divorced, and .94% were widowed. Average age of 1st marriage increased from 18.4 in the 1940s to 22.8 in 1981. Total fertility rate dropped from 5.44 in the 1940s to 2.63 in 1981. In 1981, the birth rate was 85/1000 women of fertile age. Fertility was much higher among minority nationalities. 118 million of China's 170 million married couples of reproductive age (69.46%) use birth control at present; 50.2% use the IUD, 25.4% tubal ligation, 10.0% vasectomy, 8.2% oral contraceptives, and 2.0% condoms. About 21 million married women should have begun using contraception but have not. 14 million or 42.3% of 33 million 1 child couples have pledged to have only 1 child. If the fertility level of 1981 is maintained and the average woman continues to have 2.63 children, 2.91 in rural areas, China's population will reach 1.2 billion by 1993 and will exceed 1.3 billion by 2000. The Central Committee has a target population of 1.2 billion by 2000.     

How female education affects reproductive behavior in urban Pakistan

Although Pakistan remains in a pretransitional stage (contraceptive prevalence of only 11.9% among married women in 1992), urban women with post-primary levels of education are spearheading the gradual move toward fertility transition. Data collected in the city of Karachi in 1987 were used to determine whether the inverse association between fertility and female education is attributable to child supply variables, demand factors, or fertility regulation costs. Karachi, with its high concentration of women with secondary educations employed in professional occupations, has a contraceptive prevalence rate of 31%. Among women married for less than 20 years, a 10-year increment in education predicts that a woman will average two-fifths of a child less than other women in the previous 5 years. Regression analysis identified 4 significant intervening variables in the education-fertility relationship: marriage duration, net family income, formal sector employment, and age at first marriage. Education appears to affect fertility because it promotes a later age at marriage and thus reduces life-time exposure to the risk of childbearing, induces women to marry men with higher incomes (a phenomenon that either reduces the cost of fertility regulation or the demand for children), leads women to become employed in the formal sector (leading to a reduction in the demand for children), and has other unspecified effects on women's values or opportunities that are captured by their birth cohort. When these intervening variables are held constant, women's attitude toward family planning loses its impact on fertility, as do women's domestic autonomy and their expectations of self-support in old age. These findings lend support to increased investments in female education in urban Pakistan as a means of limiting the childbearing of married women. Although it is not clear if investment in female education would have the same effect in rural Pakistan, such action is important from a human and economic development perspective.     

The World Fertility Survey: charting global childbearing

Interviewing some 350,000 women in 42 developing countries and 20 developed countries representing nearly 40% of the world's population, the World Fertility Survey (WFS) is in a unique position to document the historic 1970s slowdown in global population growth. This Bulletin describes efforts begun in 1972 to ensure high quality, internationally comparable, accessible data, the data's importance for policymakers, planners and researchers, and major findings available by early 1982 from directly assisted WFS surveys in 29 developing countries and contraceptive use data from WFS-type surveys in 16 developed countries. Marital fertility has declined in all developing regions except Africa but still averages from 4.6 children/woman in Latin America to 6.7 in Africa, while preferred family size ranges from 3.0 children in Turkey to 8.9 in Senegal--far above the average 2.2-2.5 children/woman needed to end developing countries' population growth in the long run. However, women ages 15-19 prefer nearly 2 children fewer than the oldest women ages 45-49; 3.8 vs. 5.7 on the average. Nearly 1/2 (48%) of married women surveyed in 27 countreis said they wanted no more children. Preventing all unwanted births would reduce birth rates up to 15 births/1000 population in these countries. Overall, 32% of married, fecund women in developing countries are using contraception compared to an average 72% in 16 developed countries. Education, literacy, and more available family planning services increase contraceptive use. Age at marriage is rising in Asia, but this factor alone has little effect on fertility. Infant mortality is higher in many developing countries than previously thought. Breastfeeding is an important restraint on fertility in most developing countries but is declining among more educated, employed, and urban women which could raise fertility if not compensated for by gains in contraceptive use.     

Organization and implementation of China's national sampling survey on fertility and birth control

The Planning and Statistical Department of the State Family Planning Commission of China in July 1988 implemented a fertility and birth control survey in China on 2.16 million married women ages 15-57 using stratified, systematic, clustered, and non-proportionate sampling. 3 questionnaires were used: household, married women, and sample unit covering basic status, family planning status, general characteristics of pregnancy and contraception, population flow, deaths since 1981, and socioeconomic status. The authors suggest several international cooperative research projects including: design of fertility and contraception survey; Chinese population growth; Chinese population dynamics; dynamics of marital and family status; fertility; contraception and birth control; mortality; migration; status of the nationalities of China; population development; regional fertility status; and others. Data from the survey will be available in June 1989.     

Sub-Saharan Africa: population pressures on development

The population of sub-Saharan Africa, estimated at 434 million in 1984, is expected to reach 1.4 billion by 2025. The birth rate, currently 48/1000 population, continues to increase, and the death rate, 17/1000, is declining. Rapid population growth has curtailed government efforts to provide adequate nutrition, preserve the land base essential for future development, meet the demand for jobs, education, and health services, and address overcrowding in urban areas. Low education, rural residence, and low incomes are key contributors to the area's high fertility. Other factors include women's restricted roles, early age at marriage, a need for children as a source of security and support in old age, and limited knowledge of and access to modern methods of contraception. Average desired family size, which is higher than actual family size in most countries, is 6-9 children. Although government leaders have expressed ambivalence toward development of population policies and family planning programs as a result of the identification of such programs with Western aid donors, the policy climat is gradually changing. By mid-1984, at least 13 of the 42 countries in the region had indicated that they consider current fertility rates too high and support government and/or private family planning programs to reduce fertility. In addition, 26 countries in the region provide some government family planning services, usually integrated with maternal and child health programs. However, 10 countries in the region do not support family planning services for any reason. Unfortunately, sub-Saharan Africa has not yet produced a family planning program with a measurable effect on fertility that could serve as a model for other countries in the region. Social and economic change is central to any hope of fertility reduction in sub-Saharan Africa. Lower infant and child mortality rates, rising incomes, higher education, greater economic and social opportunities for women, and increased security would provide a climate more conducive to fertility decline. Given the limited demand, great sensitivity must be shown in implementing family planning programs.     

Thinking about several problems of the research of our family planning strategy]

On the basis of 1982 census data, it is estimated that from 1987-1997 13 million women will enter the age of marriage and child-bearing each year. The tasks of keeping the population size around 1.2 billion by the year 2000 is arduous. Great efforts have to be made to continue encouraging one child/couple, and to pursue the current plans and policies and maintain strict control over fertility. Keeping population growth in pace with economic growth, environment, ecological balance, availability of per capita resources, education programs, employment capability, health services, maternal and child care, social welfare and social security should be a component of the long term development strategy of the country. Family planning is a comprehensive program which involves long cycles and complicated factors, viewpoints of expediency in guiding policy and program formulation for short term benefits are inappropriate. The emphasis of family planning program strategy should be placed on the rural areas where the majority of population reside. Specifically, the major aspects of strategic thrusts should be the linkage between policy implementation and reception, between family planning publicity and changes of ideation on fertility; the integrated urban and rural program management relating to migration and differentiation of policy towards minority population and areas in different economic development stages. In order to achieve the above strategies, several measures are proposed. (1) strengthening family planning program and organization structure; (2) providing information on population and contraception; (3) establishing family planning program network for infiltration effects; (4) using government financing, taxation, loan, social welfare and penalty to regulate fertility motivations; (5) improving the system of target allocation and data reporting to facilitate program implementation; (6) strengthening population projection and policy research; (7) and strengthening training of family planning personnel to improve program efficiency.     

Barriers to contraceptive use among Pakistani couples

Despite the existence of a family planning program in Pakistan since 1965 and widespread knowledge among Pakistanis about contraception, there is a high level of unmet need for family planning. One recent survey found that while 53% of married women express the desire to avoid pregnancy, less than 20% use contraception. A recent Population Council study conducted in urban and rural areas of Punjab province investigated personal beliefs, family circumstances, social norms, and gender relations among 1310 married women and 554 of their husbands. The unmet need for contraception was highest among women over age 30 years, those with more living children, less educated women, and women living in rural areas. The study found that while most Pakistanis approve of family planning, obstacles to contraceptive use exist in most marriages. 97% of respondents who wanted another child wished for a boy. That preference for sons influences contraceptive use behavior. The fear of social disapproval of contraceptive use, perceived opposition from in-laws and husbands, and fear of health side effects and divine punishment were major reasons identified against contraceptive use. Female contraceptive users were more autonomous and likely to make domestic decisions without consulting their husbands, while husbands defer to social and cultural norms.     

Effects of education on reproductive behavior: lessons from Pakistan

Evidence from the Pakistan Demographic and Health Survey 1990/91 (PDHS) and a 1987 study by Zeba A. Sathar and Karen Oppenheim on women's fertility in Karachi and the impact of educational status, corroborates the correlation between improved education for women and fertility decline. PDHS revealed that current fertility is 5.4 children/ever married woman by the end of the reproductive period. 12% currently use a contraceptive method compared to 49% in India, 40% in Bangladesh, and 62% in Sri Lanka. The social environment of high illiteracy, low educational attainment, poverty, high infant and child and maternal mortality, son preference, and low status of women leads to high fertility. Fertility rates vary by educational status; i.e., women with no formal education have 2 more children than women with at least some secondary education. Education also affects infant and child mortality and morbidity. Literacy is 31% for women and 43% for men. 30% of all males and 20% of all females have attended primary school. Although most women know at least 1 contraceptive method, it is the urban educated woman who is twice as likely to know a source of supply and 5 times more likely to be a user. The Karachi study found that lower fertility among better educated urban women is an unintended consequence of women's schooling and deliberate effort to limit the number of children they have. Education-related fertility differentials could not be explained by the length of time women are at risk of becoming pregnant (late marriage age). Fertility limitation may be motivated by the predominant involvement in the formal work force and higher income. The policy implications are the increasing female schooling is a good investment in lowering fertility; broader improvements also need to be made in economic opportunities for women, particularly in the formal sector. Other needs are for increasing availability and accessibility of contraceptive and family planning services and increasing availability and accessibility of contraceptive and family planning services and increasing knowledge of contraception. The investment will impact development and demography and is an adjunct to child health an survival.     

Case study: fertility decline in Iran

Iran has experienced one of the most successful family planning programs in the developing world, with 64 percent decline in total fertility rate (TFR) between 1986 and 2000. This paper focuses on Iranians’ unique experience with implementation of a national family planning program. Recognition of sensitive moral and ethical aspects of population issues resulted in successful collaboration of technical experts and religious leaders. Involvement of local health workers, women health volunteers and rural midwives led to great community participation. Demographic and Health Survey (DHS) data in 2000 indicated a TFR of 2.0 births per women and 74 percent contraceptive use among married women. This case study will help policy makers and researchers in Moslem countries and other developing countries with high fertility rate to consider a successful family program as a realistic concept with positive impacts on nation’s health and human development.     

Fertility decline in Bangladesh: an emerging family planning success story

Bangladesh has a population of 115 million people, and the economic growth rate of 3.7% during the 1980s was undermined by rapid population growth. The annual population growth rate was 3% in the 1960s and early 1970s, 2.5% between 1981-91 decreasing to 2.3% in 1991. The average of number of children is 4.6/woman compared with 7 in the 1960s. Infant mortality dropped from 150/1000 births in 1976 to 118/1000 in 1991. Life expectancy rose from 47 to 54 years. The 1991 Contraceptive Prevalence Survey showed that 39.9% of married women under 50 use contraceptives in 1991 vs. 18.6% in 1981. The use of modern methods increased from 10.9% in 1981 to 31.2% in 1991, while traditional methods rose from 7.7% to 8.7%. Sterilization was most prevalent in 1981. 29,000 female family planning (FP) workers were aggressively engaged in dispensing FP services in 1990. The Social Marketing Company sells pills, condoms, and oral rehydration salts through 130,000 retail outlets. The 1989 Contraceptive Prevalence Survey showed that 40% of pill and condom users obtained them from this network, and 95.4% of women knew about 4 methods of contraception. In 1990 there were 120 private organizations providing contraceptive services. Some of the components of the government FP program include field worker distribution door-to-door of injectable contraceptives (50% injectable usage rate in the Matlab project); recordkeeping activities; a satellite clinic network with access to contraceptive services; and decentralization through the Upazila (subdistrict) approach. The logistics system of FP has improved the warehousing, transportation, and management information system. Foreign aid (mainly USAID) financing of contraceptives helped avert 14.4 million births between 1974-90. The increase of contraceptive prevalence to 50% by 1997 would avert another 21.9 million births during 1991-96 (replacement fertility requires 70% prevalence.     

How female literacy affects fertility: the case of India

Recent studies indicate that there is a direct correlation between increased literacy and decreased fertility. This link was demonstrated in study that covered 90% of India's population. Studies in other developing countries have confirmed this finding. In addition, high literacy rates have been found to correspond to high infant survival rates. Researchers also found that there was little change in the relationship between literacy and fertility when they were both controlled for different levels of urbanization. The problem is that only 1 in 4 Indian women are literate. However, India's government has a program in place the goal of which is to have universal literacy. In Kerala, female literacy is the highest (65%). And at 3.4 children/women, it has 1 of the lowest fertility rates. For the 14 states studied, the total fertility rate was 5.0 children/woman, the child mortality rate was 126/1000, and the female literacy rate was 22%. In contrast in Rajasthan where female literacy is 11% (the lowest of the 14 states studied) fertility is the highest at 6.0 children/woman. No state with higher than average fertility had higher than average female literacy rates. Literate women are likely to have more surviving children because they are more aware of good health practices, and they tend to live in better circumstances. As a result, couples need fewer births to reach their desired family size.     

Adolescent fertility: worldwide concerns

There is growing concern over the adverse health, social, economic, and demographic effects of adolescent fertility. Morbidity and mortality rates ar significantly higher for teenage mothers and their infants, and early initiation of childbearing generally means truncated education, lower future family income, and larger completed family size. Adolescent fertility rates, which largely reflect marriage patterns, range from 4/1000 in Mauritania; in sub-Saharan Africa, virtually all rates are over 100. In most countries, adolescent fertility rates are declining due to rising age at marriage, increased educational and economic opportunities for young women, changes in social customs, increased use of contraception, and access to abortion. However, even if fertility rates were to decline dramatically among adolescent women in developing countries, their sheer numbers imply that their fertility will have a major impact on world population growth in the years ahead. The number of women in the world ages 15-19 years is expected to increase from 245 million in 1985 to over 320 million in the years 2020; 82% of these women live in developing countries. As a result of more and earlier premarital sexual activity, fostered by the lengthening gap between puberty and marriage, diminished parental and social controls, and increasing peer and media pressure to be sexually active, abortion and out-of-wedlock childbearing are increasing among teenagers in many developed and rapidly urbanizing developing countries. Laws and policies regarding sex education in the schools and access to family planning services by adolescents can either inhibit or support efforts to reduce adolescent fertility. Since contraceptive use is often sporadic and ineffective among adolescents, family planning services are crucial. Such programs should aim to reduce adolescents' dependence on abortion through preventive measures and increase awareness of the benefits of delayed sexual activity. Similarly, sex education should seek to provide a basis for intelligent, informed decision making. Programs tailored to reach teenagers in schools, recreational centers, and the workplace have particular potential.     

Brief

This brief article discusses population dynamics, contraception, and abortion in Shanghai, China. China's policy of rapidly developing medium and small cities and towns is coming to fruition. China now has 666 cities, of which 75 are megacities, 192 are medium-sized cities, and 399 are small cities. It is expected that there will be about 800 cities by the year 2000. Population movement of the floating population has increased. During 1990-95 the domestic migrant population was 3.02% of total population. 24.44 million (67.1%) were floating population who moved within provinces, and 11.98 million floated between provinces. Population is affected by declines in the supply of water. The Yellow River spans 5400 km and passes through nine provinces, including the two most populous provinces of Henan and Shandong. The Yellow River empties into the Yellow Sea, when the river is flowing. Since 1972, stretches of the Yellow River have run dry for as many as 683 km. The driest stretch of the river tends to be from Kaifeng City in Henan Province to its mouth at the Yellow Sea. The river bed has been dry for as many as 136 days. The lack of water from the Yellow River impacts on the millions who live along its banks near the Yellow Sea. The Shanghai Population Information Center reports that married women's abortion rate has declined and unmarried women's abortion rate has increased. An information program on contraception and contraceptive services for unmarried women is planned for completion by Spring 1998. It is hoped that the family planning program will be as successful in decreasing abortion rates among the unmarried as among the married. In the community of Pengpu New Village, Zabei District, a new family planning program was established which promotes the concept of family planning among nongovernmental organizations, the unemployed, and the floating population.     

Economic development and fertility decline: lessons from Asia's newly industrialized countries

The general thesis that economic development and fertility decline are interrelated is substantiated in literature that discusses the successes of the newly industrialized countries of Hong Kong, Korea, Singapore, and Taiwan. When countries are developing rapidly, family planning accelerates the rate of fertility change, particularly among the poor uneducated rural population. Relying on economic and social development is not enough. National policy in Hong Kong, Singapore, Korea, and Taiwan recognized that population growth drains resources and the family planning programs operating since the 1960s contributed to a drop from 5 children/woman to 2 by 1988, and 70% of married couples used contraception. Coupled with this, age at marriage rose, contraception became more available, and educational and employment opportunities increased. Economically, the growth rate in the 1980's was 6-10% annually, with growth in the manufacturing and service sectors and export trade. Close economic ties evolved between governments and private sectors. Social development programs had been fully funded and gains evident in education, living standards, health care and nutrition, and life expectancy. The success of family planning is attributed to encouraging contraceptive awareness and use. Fertility reduction may occur with social and economic development, but no developing countries have reduced fertility without family planning. The relative importance of family planning may change over time, and reducing the cost through government sponsored family planning programs and encouraging the acceptability of contraceptive usage.     

India's population in transition

This demographic profile of India addresses fertility, family planning, and economic issues. India is described as a country shifting from economic policies of self-reliance to active involvement in international trade. Wealth has increased, particularly at higher educational levels, yet 25% still live below the official poverty line and almost 66% of Indian women are illiterate. The government program in family planning, which was instituted during the early 1950s, did not change the rate of natural increase, which remained stable at 2.2% over the past 30 years. 1993 marked the first time the growth rate decline to under 2%. The growth rate in 1995 was 1.9%. The total population is expected double in 36 years. Only Nigeria, Pakistan, and Bangladesh had a higher growth rate and higher fertility in 1995. India is geographically diverse (with the northern Himalayan mountain zone, the central alluvial plains, the western desert region, and the southern peninsula with forest, mountains, and plains). There are regional differences in the fertility rates, which range from replacement level in Kerala and Goa to 5.5 children in Uttar Pradesh. Fertility is expected to decline throughout India due to the slower pace of childbearing among women over the age of 35 years, the increase in contraceptive use, and increases in marriage age. Increased educational levels in India and its state variations are related to lower fertility. Literacy campaigns are considered to be effective means of increasing the educational levels of women. Urbanization is not expected to markedly affect fertility levels. Urban population, which is concentrated in a few large cities, remains a small proportion of total population. Greater shifts are evident in the transition from agriculture to other wage labor. Fertility is expected to decline as women's share of labor force activity increases. The major determinant of fertility decline in India is use of family planning, which has improved in access and use during the 1980s. If India is to keep a stable population under 1.6 billion in the future, Indians may have to accept only one child per family.     

Withdrawal in Pakistan: new insight into an old method

Although family planning programs pay almost no attention to the validity of coitus interruptus (withdrawal), it is a traditional method of family planning widely used to regulate fertility in Pakistan. Large-scale quantitative studies conducted in recent years in Pakistan by the Population Council have indicated that withdrawal is the most popular temporary method of fertility regulation in the country, second among all methods only to female sterilization. Pakistani couples use withdrawal mainly because they believe that modern methods are unsafe for women and unreliable. They have some fears and misconceptions about modern methods. The method may work well in Pakistan also because users seem to feel that they own it. Withdrawal is therefore a reasonable option given Pakistanis' beliefs and circumstances. Those who use withdrawal in Pakistan practice the technique with considerable efficacy and tend to continue using it. Furthermore, couples which use withdrawal have discussed their family planning preferences and decided together to use the method. However, in order to improve the use of modern methods of contraception, information provision, counseling, and interpersonal communication must be improved.