Pakistan's problems with militancy, a fragile economy and natural disasters such as the 2010 floods have often been discussed, but an even greater threat may be posed by the sheer numbers of people in the country.
According to official figures, the projected population for 2015 is 191 million, up from the current figure of 170 million, making it the sixth most populated nation on earth. By 2050 it is expected to climb into fourth place.
This is bad news for a country that has struggled to provide its people with adequate food, healthcare or education. Malnutrition rates are high and are linked to 50 per cent of infant and child deaths; there is one doctor for every 1,183 people; and the literacy rate of 57 per cent is among the lowest in South Asia, says a report by IRIN, the UN information unit.
"There is now increasing evidence that investments, among others, in education, health, including reproductive health, women's empowerment and slower population growth contribute towards poverty reduction. In general, it has also been found that where there is rapid population growth and high fertility rates, poverty incidence is also highest," Rabbi Royan, the UN Population Fund (UNFPA) representative in Pakistan said.
More mouths to feed
"More people of course means a further drain on resources," Sikander Lodhi, an economic analyst said. "Resources are already stretched to the limit," he said.
The same principle holds true within individual households.
"Allah has given us eight children. We are fortunate," said Rafiq Muhammad, 50, a laborer who earns around Rs5, 000 (US$59) a month. His wife, Parveen Bibi said: "It is very hard to feed everyone. We do not even get one proper meal a day."
"People believe large families mean more earning hands; but they do not realise they also mean more eating mouths," said Rehana Nazeer, a service delivery manager at the Lahore-based Family Planning Association of Pakistan. She said that the "closed, conservative nature of society" and also problems in tending to the health needs of women in rural areas on hormone-based contraception had led to difficulties in promoting birth control.
"If a woman develops a bleeding problem, she cannot get to a doctor on her own. Her husband or other man in the family must take a day off work to take her," Nazeer said.
Lack of awareness about contraception
According to the Demographic Health Survey of Pakistan, conducted in 2006-07 by the Ministry of Population Welfare, while 96 per cent of women who have ever been married are aware of at least one family planning method, fewer than half have ever used one, and less than 30 per cent of married women currently use a contraceptive. The survey also shows 25 per cent of married couples would like to use contraception but are not doing so, mainly because they lack access to advice or contraceptives.
"Many women would like to practice birth control, but their husbands dislike the idea," Farhat Bibi, a lady health worker said. Run by the government's National Programme for Family Planning and Primary Health Care, the lady health workers' scheme was started in 1994 to reach out to rural communities and cater to the needs of women and children in particular.
"We offer advice on contraception, but some women are too scared of their husbands to even consider these methods," she said. The belief that God determined family size, and in some cases that women on the pill may be tempted to have sex outside marriage - confident they would not become pregnant – play a key role in harbouring this attitude, Farhat said.
These factors explain why Pakistan has struggled to promote family size. Though the fertility rate has declined gradually over the last 15 years, according to the Demographic Survey, the fertility rate of 4.1 children per woman means the population continues to grow, with an increased strain placed on dwindling resources, including water.
"The high number of pregnancies also means women in particular, and children, suffer more health problems and this further drains resources," said Samina Iqbal, a doctor who told IRIN: "I always advise my female patients to stick to one or two children, but they face acute family pressure to have more."
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