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In our summer-long series Beginnings, we've been exploring maternal health and childbirth around the world. Today, we go to Pakistan, home to one of Asia's fastest growing populations. There, family planning is an uncomfortable topic fraught with religious overtones. And some couples now find themselves torn between terrible choices: Defy their local spiritual leaders or raise more children than they can afford.

NPR's Julie McCarthy begins our report in the eastern Pakistani city Lahore.

(SOUNDBITE OF CALL TO PRAYER)

JULIE MCCARTHY: Pakistan is a powder keg. Its galloping growth rate, according to a new government survey, is producing nearly four million babies every year and most are born into poverty. The World Bank says 60 percent of Pakistanis live on less than $2 a day. Yet clerics in religiously conservative Pakistan tell the Muslim majority that the Quran instructs women to keep bearing as many babies as possible. The message from the mullahs is that contraception is generally haram, or a sin.

Muhammad Zakaria is the mufti of Lahore's oldest Islamic religious school, Jamia Islamia. He says modern family planning is a Western convention that offends Islam.

MUHAMMAD ZAKARIYA: (Through Translator) Family planning is wrong and un-Islamic if it is practiced routinely. If it permanently stops a woman from becoming pregnant it is harmful and illegal.

MCCARTHY: But a woman can temporarily put off becoming pregnant. The mufti says the Quran encourages mothers to space their pregnancies and to breastfeed their babies for prolonged periods. One verse states...

UNIDENTIFIED MAN #1: Mothers shall nurse their children two complete years for whoever desires to complete the nursing term.

MCCARTHY: If a new pregnancy would interfere with breastfeeding and the health of a nursing child, Islam allows a woman to temporarily stop having babies. During that period, the mufti says Islam can be interpreted to mean the man may also use condoms and the rhythm method.

Mufti Zakaria says being poor should in no way limit having babies. He quotes the Quran saying, God will provide the resources and no one will starve.

ZAKARIYA: (Through Translator) There are clear instructions in the Holy Quran, in which Allah says: We give you food and we will also give food to your children. Food is not your responsibility, but God's.

MCCARTHY: The mufti says the Quran instructs that children must not be deprived of a proper upbringing. However, in Pakistan at least one in every three children under five is underweight. And according to government data, malnutrition is widespread among mothers. All of which compels this question to the mufti.

Aren't you consigning millions of people to a pretty miserable life, when you say don't worry, the resources are there. Clearly the resources in Pakistan today are not there.

ZAKARIYA: (Foreign language spoken)

MCCARTHY: Every society has its own value system, he says. You should not judge us by yours. Children in the West lead a luxurious life. Earth is their heaven. Our children should not be compared with them. Muslims, the mufti says, don't pay much heed to the mundane pleasures of this world. Our reward will come in the next life.

ZAKARIYA: (Foreign language spoken)

MCCARTHY: The mufti adds that the West has taken modern contraception too far, removing the fear of getting pregnant and therefore removing women's sexual inhibitions. In Pakistan if a women's fear is removed says the mufti, she will stray into bad behavior and offend God.

Seventy percent of married women in Pakistan, according to the government, use no birth control method at all. And the government is ineffectual in promoting family planning says Dr. Yasmin Raashid, a leader in obstetrics and gynecology in Pakistan. But she says if properly followed, the Quran's teachings about spacing pregnancies would automatically mean smaller families. Consider that a woman's best childbearing years are between 20 and 40.

Dr. YASMIN RAASHID: And 20 and 30s, of course, is the safest time to produce children. If you look at it, then if you have a spacing between of, let's say, four years or three years between each child, they would not be producing more than three or four children.

MCCARTHY: Dr. Raashid says more than anything else illiteracy undermines family planning in Pakistan.

RAASHID: Educated mothers limit their families. There's no problem. The tragedy in our country is the majority of the women in Pakistan are not educated.

MCCARTHY: Raashid she says educating young girls is the best policy for reducing the country's high fertility rate and for achieving smaller, healthier families. She cites Sri Lanka, where the literacy rate is 91 percent. There the fertility rate, or the average number of children a woman has in her lifetime, is 2.3, compared to Pakistan where it is 3.9. In Pakistan, infant mortality is nearly six times higher than Sri Lanka, a smaller, poorer country.

RAASHID: And the only thing that you see different there is that women are educated there. They know about their rights. They know what has to be done where their children are concerned. They know what to do where their own health is concerned. You educate the women of Pakistan and we would have the same results.

UNIDENTIFIED GROUP: (Speaking foreign language)

MCCARTHY: In Pakistan, less than one percent of GDP is spent on health care. Government hospitals lack qualified staff and medicine. Private hospitals like the United Christian Hospital in Lahore, where Dr. Raashid is the chief physician, are underfunded. In her hospital nursery, soap is scarce. But a newborn baby boy with a shock of black hair does have the benefit of an incubator where he lies sleeping.

(SOUNDBITE OF HOSPITAL MACHINERY)

MCCARTHY: This is one of the fortunate few, who could take advantage of being born inside a hospital. That's not the case with most children in Pakistan. It's estimated that at least 70 percent of Pakistani children are born at home, many without a skilled birthing attendant. The result: 12,000 mothers die in childbirth in Pakistan each year.

To save more mothers Dr. Raashid says Pakistan must invest in more midwives.

RAASHID: You really don't need hi-fi doctors everywhere. You need proper trained midwives. Skilled birth attendants working in the villages, I mean skilled women can go and deliver the patients at home. And at the moment, we only have 25 percent of women being delivered by skilled birth attendants.

(SOUNDBITE OF CHILDREN)

MCCARTHY: Dr. Raashid's hospital deploys lady health care workers who go door to door counseling expectant mothers on neonatal care and family planning. They work the narrow warrens of distressed and dilapidated neighborhoods of Lahore. In this congested lane, children fight, toddlers frolic, and proud parents stand in doorways showing off their infants to a stranger. The pressure on women to keep producing babies is obvious here.

(SOUNDBITE OF METAL GATE)

MCCARTHY: We step into the three-room home of Rani and Tariq, a young couple with seven children. The pair sits on a large bed in the stifling heat, cranky babies splayed around them.

ERUM AKHTAR: (Foreign language spoken)

MCCARTHY: Erum Akhtar, the health care worker, tells wife Rani about the importance of keeping her children healthy. In a barely audible voice, the diminutive mother with huge brown eyes says that she herself is sick and that she wants to stop having babies.

Rani, did you ever say to your husband, I can't do this any more? I don't want any more children. I need to stop. This is not a healthy thing to do. Did you ever say that, Rani?

RANI: (Foreign language spoken)

MCCARTHY: Yes, you did say I need to stop. When did you say that?

RANI: (Foreign language spoken)

MCCARTHY: After the sixth child, you said no more. But your husband insisted?

RANI: (Foreign language spoken)

MCCARTHY: Rani says she had five sons in a row, but her husband wanted a daughter. So they had a sixth child: the hoped-for baby girl. But her husband Tariq, who has held only sporadic jobs, wanted a second daughter. And Rani got pregnant again and again. Now in her mid-20s, Rani is expecting her eighth baby.

(SOUNDBITE OF A CRYING INFANT)

MCCARTHY: Tariq explains that he was obsessed with having daughters in a country obsessed with having sons, because he came from a family of all boys and felt deprived with no sisters. When pressed, Tariq acknowledges that he has compromised his wife's health.

TARIQ: (Foreign language spoken)

MCCARTHY: He says yes, he understands how people could think that he was irresponsible. He says he has now gotten the daughter that he wants. He's now reconciled himself to that. He said I've committed mistakes. He said, in this day and age, it's tough enough to raise two children, let alone the seven he has with another one on the way.

Three hundred miles away, the roles are reversed for another young couple.

(SOUNDBITE OF CHILDREN PLAYING)

MCCARTHY: Their village of Poukai in Pakistan's Northwest Frontier is an impoverished place where children cool off in the dirty water of a local canal, their livestock swimming alongside them.

UNIDENTIFIED GROUP: (Speaking foreign language)

MCCARTHY: In their home shared with 12 relatives, 25-year-old Khasrat and her husband, Qadar Gul, are expecting their fourth child. Khasrat says she never went to school and cannot read the Quran, but she listens to the cleric's sermons carried over loudspeakers equating contraception with a sin, a restrictive interpretation of Islam that allows few choices in family planning. Khasrat is feeling unwell with an undiagnosed pelvic pain. She is eight and a half months pregnant.

Khasrat, have you discussed with your husband the whole idea of planning the family? Four is enough, that you're not feeling well. Have you said that to your husband?

KHASRAT GUL: (Through Translator) I am the one who insisted on another boy, she says. It was my husband who wanted to stop at three.

MCCARTHY: Qadar Gul is worried about his wife's health and about feeding more mouths. He's injured and cannot work. He is also atypical because, unlike a lot of men here, he does not scorn family planning. He practiced abstinence, but his wife insisted that she wanted a brother for her older son.

QADAR GUL: (Speaking foreign language)

MCCARTHY: Qadar Gul is saying that, yes, he is different and that he thought about it. He thought about the consequences of having more children. He said we are poor. He said he's not happy with the adequacy of his housing. He said there's not enough room and he told his wife this, but he said she persevered and his wife said let it be God's will.

This faithful Muslim man struggles to respect both his cleric's command not to use contraception and his desire not to father more children. It's a deeply personal choice with profound implications for his family, and that choice writ large has profound implications for the nation. Julie McCarthy, NPR News.

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