Family planning has been a contentious issue in Pakistan, the sixth most populous country in the world -- home to an estimated population of 192 million, growing at the rate of 1.92 per cent. At this rate, the population is expected to reach levels as high as 343 million by 2050, rendering the future of its populace vulnerable in the wake of shrinking resources.

The recent awareness campaign on tv and in print, by the Population Welfare Department of Sindh incorporated religious text to talk about breastfeeding as both the responsibility of the mother and a natural way of birth spacing. The tagline, on the other hand, talks about a totally different issue -- not birth spacing or breastfeeding; the tagline reads "small family - easy life".

The circuit is incomplete and the message vague at best. Given that merely 38 per cent of babies in Pakistan are fed breast milk exclusively during their first six months -- is the ad an attempt at tackling the country’s abysmal breastfeeding rate? Or, is it a call to limit the family size for better quality of life as the tagline suggests?

The assumption, perhaps, is that by practising birth spacing, eventually family size will be smaller -- in a country where the minimum marriageable age for women is 16, there is reason to doubt if the former will lead to the latter. Though the issue has been taken up in the National Assembly and there is pressure to push marriageable age up to 18 years for women, the debate is a sensitive one.

The ambassador for the population awareness campaign is a member of the Islamic clergy -- one who very recently vociferously opposed the Women Protection Bill, deeming it a departure from our social and cultural values and criticised the incumbent government for aping the West.

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"There have been two demographic and health surveys -- one was in 2006-7 and the other in 2013-14. The surveyed women were asked all kinds of questions. Hardly anyone quoted religion as the reason for not using contraception. So, you don’t need to use the clergy to convince women, men or mothers-in-law on the matter," says veteran journalist Zubeida Mustafa.

The Pakistan Demographic and Health Survey (PDHS) 2013-14 highlights that knowledge of at least one method of contraception is almost universal where modern methods are more widely known than traditional ones (almost all women know of a modern method, while 73 per cent know of a traditional method).

The survey also states that the level of contraceptive knowledge increases slightly with increased education and wealth. Among reasons why female non-users of contraception do not visit family planning service outlets, reasons fell largely in three categories -- "no need" (63 per cent), "wanted more children" (32 per cent), and "services already available at home" (16 per cent).

"Such ads have been appearing for the last forty years. When you do not inform people where they can go or where their nearest population centre is? There really isn’t even the need for such a huge and expensive campaign when people don’t even know where to go," Mustafa believes.

Nabila Malick, Director Advocacy at Rahnuma, Family Planning Association of Pakistan, says the focus should be on access to and quality of birth control instruments. Pakistan aims to bring its contraceptive prevalence rate to 55 per cent by 2020 -- at the moment, it has a contraceptive prevalence rate as low as 35 per cent and an unmet need for contraception which stands at 25 per cent. "Just by reaching out to the unmet need, the contraceptive prevalence rate can be brought up to 60 per cent."

Talking about the stigmatisation of birth control and family planning, Malick says, "There was a misconception in the community that religion prohibits family planning but it’s not there anymore. The focus should instead be on the quality of the instruments used -- even news of one woman having had a bad experience can impact the perception of the entire village," she says.

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"I wanted to get myself sterilised after having two children -- a son (now 9) and a daughter (now 14). But there was a lot of pressure to have at least two more children in case anything happened to these. So, I had two more children -- a girl and a boy aged 7 and 5 respectively. Then, I got sterilised despite the fear that there would be medical side effects. There was also some backlash but I had to do it," says 40-year-old Anwar Bibi, who comes from Chak-76 near Vehari. She complains of lack of medical facilities and employment opportunities in her area, which made her move to Lahore to improve her living standard.

On the new awareness campaign, she says "These ads don’t help. How will you convince our men and our in-laws? They want sons at any cost. One of my cousins ended up having 10 children even after her first-born was a son just because there was pressure to have another son."

Amina Ahmad, a 30-year old housewife and mother of two says, "I think the awareness campaign would be more helpful if people were told where the welfare centres were and what kind of services and products they would find there. I think no one doubts the fact that family planning is something that is allowed in Islam."

"Most methods practised are for females and there is, generally, resistance from men when it comes to birth control. There is a need to involve and integrate them in the process so they can play a positive role," says Omer Aftab, CEO of Women’s Empowerment Group, an organisation that aims to strengthen the process of socio-economic development, and empower women.

"It will be a long time before we can look at the family planning issue from the human rights’ lens where you talk of a woman’s agency. For now, we are approaching it in the traditional manner -- looking at it through the medical and the religious lens," he says.

Talking openly about family planning and birth control has been a difficult task. Advertisements in the realm often skirt the issue in the name of expediency, fearing a conservative backlash.

"Our governments, advertisers and media are unduly apprehensive about adverse reactions from citizens if advertisements promote family planning and contraceptives," says Javed Jabbar, former Chairman MNJ Communications and occasional adviser to the Pakistan office of the Population Council.

He substantiates his argument with the fact that recent surveys by international research organisations have shown that out of every ten married couples in Pakistan, three couples belonging mostly to the lower-middle class and the rural poor want to practise family planning and use contraceptives because sheer economic problems alone have made them realise that they cannot afford large family sizes but they struggle with access and advice.

Addressing the issue of appraising the effectiveness and resonance of the ad campaign, he says the measurement of success of an ad campaign has to be within a larger context of social reality and delivery of services to those most in need.

"An ad campaign is only one of several factors that are required to achieve a level of balanced population growth. Female literacy, female education, women’s participation in the organised labour force, prevention of marriages at premature ages, convenient access to family planning services and follow-up care by health providers are equally, if not far more, important," he states.

In his opinion, "there is a need to invest larger amounts in field research, in demographic studies and in assessment of communication campaigns, including the evaluation of the great importance of inter-personal communication by trained health providers, non-mass media methods used, such as community-based communication, including street theatre and local, indigenous media."

Haris Gazdar, founding partner and senior researcher at the Collective for Social Science Research in Karachi, argues that the effectiveness of the awareness campaign will be obvious in the way the public discourse evolves. "Given where the public discourse is, at the moment, an important gauge will be simply whether and to what extent conversations about family size become acceptable."

When asked about the recent Sindh government advertisement, Gazdar says, "A stray remark I picked up on the street the other day was a car mechanic talking about the campaign. He was making a light-hearted comment. This is very anecdotal, but at this stage I would measure success by asking if people actually noticed the campaign. In the past, such campaigns had messages that were so far away from the ‘elephant in the room’ that they hardly registered with people."

The story has been updated to reflect the correct designation of Javed Jabbar as the former Chairman of MNJ communications, and an occasional adviser to the Pakistan office of the Population Council.