Showing posts by Elizabeth Leahy Madsen.
-
Iran’s Surprising and Shortsighted Shift on Family Planning
›August 8, 2012 // By Elizabeth Leahy Madsen
In late July, Iran’s government announced that it would no longer fund family planning programs, a dramatic reversal following 20 years of support. The change is especially abrupt for a country that has been lauded as a family planning success story, with thorough rural health services and an educated female population contributing to one of the swiftest demographic transitions in history.
-
Book Review: ‘World Population Policies’ Offers Sweeping Overview of a Complex Field
›July 2, 2012 // By Elizabeth Leahy MadsenWith much attention in the international family planning community directed to the impending anniversary of the 1994 International Conference on Population and Development and the closing date of the Millennium Development Goals, the fact that 2012 is the 60th anniversary of two other milestones in population programming may have escaped notice. In 1952, the International Planned Parenthood Federation was created, and India became the first country to formulate a national policy to reduce population growth.
These and many other landmarks are highlighted in World Population Policies: Their Origin, Evolution and Impact, a new book by demographer John May that reviews several decades of policies, advocacy, and program interventions addressing the full range of diverse demographic trends seen globally.May, who spent more than two decades working on population issues at the World Bank and other international institutions before recently assuming a fellowship at the Center for Global Development, is well-positioned to provide such an ambitious overview. Although the breadth of material included in the book means that some topics receive less coverage than a specialist might wish, it serves as a sound introduction to this diverse field, and offers some particularly interesting case studies.
The book’s main chapters begin with a summary of current population trends, including a comprehensive array of figures and statistics about population size, distribution, and projections. Some important concepts, such as the demographic transition and dividend, are perhaps covered too quickly, and in such cases the book would have benefited from more than a handful of figures, charts, and graphs. May classifies regions and countries as demographic “hotspots,” where the number of people outstrips available resources, and “coldspots,” which have too few residents. He makes an ambitious suggestion that high-density countries facing resource challenges, such as Bangladesh, should consider promoting rapid fertility decline below replacement level to stop population growth, then reverse course and increase to a rate that promotes a stable population – but such a reversal from low fertility is a feat that has stymied several countries in Europe and East Asia.
Evolution of the “Population Movement”
In addition to summarizing the ways that demographic issues have been framed in the past several decades, May briefly describes the long-running debate between demographers and economists about the ways in which population is theorized to affect economic development.
Three points in this chapter were particularly striking: First, the concept of family planning as a human right dates from well before the 1994 International Conference on Population and Development. In 1968, the Tehran International Conference on Human Rights defined the ability to choose family size and spacing as a fundamental right; still, some programs, such as India’s under the Emergency-era government of the late 1970s, adopted coercive practices. Second, population policies are not limited to official initiatives targeting fertility, mortality, and migration, but also encompass implicit or “passive” policy measures that arise without advance planning or that have an unintended effect on demographic trends. Related to this, May suggests that “contextual variables” such as education, health, gender, culture, and religion can have a greater impact on population policies’ effectiveness and demographic outcomes than government structures or funding.
Although population policies are most often designed at the national level, May’s discussion of the “population movement” highlights the influence of international networks and donors on such policies. By the late 1960s, the U.S. Agency for International Development had begun funding family planning programs overseas, and the United Nations Population Fund (UNFPA) was active. Although the United States has become less dominant over time, population programming remains a Northern-driven movement.
Beginning with a meeting in Belgrade in 1965, a series of international population conferences successfully raised the prominence of population issues on the global development agenda and built consensus around international goals, while also becoming increasingly political.
May’s cautions about such conferences are timely given this month’s London Family Planning Summit: “Consensus-building through international conferences and their preparatory meetings is often inefficient as a process, whereas such events could be used to promote learning among policymakers and experts…The gap between the conferences’ resolutions and the actual policies implemented at country level is important to remember” (110).
Growth and Aging Distinguish the Demographic Divide
In his chapter focusing on the developing world, May notes that population policies have become broader in the nearly 20 years since the Cairo conference, incorporating a reproductive rights framework while also addressing new issues such as the environment, HIV/AIDS, and poverty. But under this more holistic approach, national policies are susceptible to becoming overly diffuse, with an ambitious agenda not matched by concrete action plans.
The challenges expand to policy implementation as well. Kenya is profiled as emblematic of the difficulties facing population programs in fast-growing sub-Saharan Africa, particularly political disinterest, mismanagement, opposition from some religious groups, and commodity shortages. But when implemented well, such policies can be very successful. The book offers a thorough summary of research findings on the common features of effective family planning programs (such as leadership, monitoring performance data, and opening access to contraceptive methods at lower levels of the health system), as well as their demographic impact. Several country examples are cited to show that family planning programs reduce lifetime fertility rates by 0.5 to 1.5 children per woman, while also benefiting individual and social health, income, and well-being.
While population policies have been often effective at shaping demographic trends in high-fertility settings, even in changing cultural norms about family size, May notes that their impact has been notably weaker in reversing the trajectory of declining fertility in developed countries. While countries such as France have maintained a fertility rate close to, albeit still below, replacement level thanks to generous paid parental leave, housing initiatives and public child care facilities, policies that try to boost low fertility through financial compensation have been particularly ineffective.
Developed countries are less likely to have formal population policies and tend to address demographic issues through incentives and disincentives implemented by multiple agencies. Aging and immigration are receiving greater attention in such countries, along with low fertility rates. Population aging raises policy concerns that are both economic and social, and May focuses largely on the benefit of reducing incentives for early retirement. He notes that thanks to improvements in health and life expectancy, “today’s 65-year-old persons are young compared to their counterparts” of previous generations (180). Despite their economic soundness, government efforts to raise retirement ages are widely unpopular, and France’s newly elected president has promised to cut the retirement age from 62 to 60 for some workers.
What Comes Next
Some observations are intriguing and could have been further detailed. For example, May notes a recent “fragmentation” of organizations working on population issues, and suggests that “too many institutions and NGOs appear to support their own limited mandates as they also struggle for resources that are less abundant” (5). Decentralization and integration within health systems is a growing trend that could have been discussed in more detail, along with the legacy of pronatalist laws and attitudes by colonial powers in Africa, the effect of recent European efforts to tighten immigration policies, and the achievements of forums designed for collaboration on population policy issues (for example, the United Nations Commission on Population and Development or the Reproductive Health Supplies Coalition).
Looking towards the future, May foresees continued integration of demography with related development issues, such as poverty reduction and equitable growth, gender and youth perspectives, environmental issues, and conflict prevention. He notes a few challenges, including sub-Saharan Africa’s lag in fertility decline and the overall ineffectiveness of policies aimed at addressing the pressures of urbanization on infrastructure and resources.
In high-fertility settings, May recommends that instead of framing reproductive health writ large, policies should more specifically target family planning and women’s empowerment, including education and income-generation opportunities as well as legal rights. Bangladesh is presented as a model for other countries, as a setting where cultural change and economic development laid the groundwork for successful family planning outreach efforts. Most of all, May entreats government leaders to maintain a policy focus on population issues, regardless of where they stand in the demographic divide.
Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.
Photo Credit: “Crowded Shopping District,” courtesy of flickr user EnvironmentBlog. -
The Year Ahead in Political Demography: Top Issues to Watch
›June 8, 2012 // By Elizabeth Leahy Madsen2011 and the first half of 2012 have been a remarkable period for political demography, with theories about the relationships between age structure and governance validated in real time by the events of the Arab Spring. Although such game-changers are rarely predictable, the year ahead promises to be eventful as well, with new demographic research and major policy initiatives on the horizon. Below are brief assessments of some of the top issues to watch between now and next summer.
1. The Evolving Story of the Arab Spring
The Arab Spring was anticipated by few observers, but for a handful of political demographers it was a watershed of sorts. As readers of this blog know, political demography research shows that countries with very young age structures are prone both to higher incidence of civil conflict and – most relevant to the outcomes of the Arab Spring – to undemocratic governance. This nuance escaped many observers of the region’s drama. Violence and conflict erupted not from raging citizens in the streets but from military and militia forces unleashed by autocrats unwilling to cede their grip on power. Young people, and their fellow protestors of all ages, were acting as a force for positive change in their demonstrations against corrupt and unrepresentative leadership. The difference in outcomes across the region, according to Richard Cincotta, can be attributed to the fact that as age structures mature, elites become less willing to trade their political freedoms to autocratic leaders in exchange for the promise of security and stability.
When considered with this important distinction in mind, the initial events following the uprising in Tunisia that quickly spread across the region played out in a neatly linear fashion. Among the five countries where revolt took root, those with the earliest success in ousting autocratic leaders also had the most mature age structures and the least youthful populations.
In Tunisia, with a median population age of 29, one month passed between a fruit seller’s self-immolation and Zine El Abedine Ben Ali’s flight to exile. In Egypt and Libya, where median age is close to 25 years (identified by Cincotta as a threshold when countries are at least 50 percent likely to be democratic), Hosni Mubarak and Moammar Gaddafi took three weeks and eight months, respectively, to lose their titles. Ali Abdullah Saleh in Yemen (median age 17), took one year to be convinced to formally resign, while in Syria (median age 21), the 15-month uprising continues to be brutally repressed by Bashar Assad’s forces.
Of course, overthrowing a dictator, while inspiring and liberating to those whose rights have been repressed, is only the first step in achieving democracy. In the coming year, the countries that have already taken steps toward solidifying regime change will face continued tests as internal tensions surface. Even in Tunisia, recent clashes signal that political divisions and economic uncertainty have not been resolved. With potentially divisive elections ahead in Egypt and Libya, a holdover from the Saleh regime leading Yemen, and Syria’s fate unknown, the coming year should offer political demographers further evidence of the soundness of the age structure and democracy thesis.
2. New Commitments to Family Planning
Reproductive health and demography go hand-in-hand, and two milestones for family planning advocates are fast approaching: the 20th anniversary of the 1994 International Conference on Population and Development in Cairo, and the 2015 endpoint of the Millennium Development Goals.
These historic commitments by governments will be joined by a major initiative to generate new funding and political will this summer at an international family planning summit in London on July 11. The summit will be co-hosted by the Bill and Melinda Gates Foundation (Melinda made an impassioned TEDxChange speech in support of the issue in April), and the UK’s Department for International Development, for whom family planning is a priority in efforts to reduce maternal and child mortality.
Details of the summit have yet to be finalized and publicly released, but financial commitments from donors and developing countries are anticipated toward meeting a new and ambitious goal of generating $4 billion to fund contraceptives for 120 million women in developing countries by 2020. Assuming these are new users, rather than those who would be expected by projecting recent growth in contraceptive use forward, this would represent more than half of the estimated 215 million women with an unmet need for family planning.
Why does new family planning funding matter for political demography? Rates of contraceptive use are lowest and fertility highest in countries with youthful age structures. Such population dynamics exacerbate the challenges governments face in providing education, health, and basic infrastructure services, as well as supporting an economic climate conducive to industry diversification and job creation. In turn, the likelihood of civil conflict and undemocratic governance is higher in such countries.
While policies that recognize the benefits of family planning may be solid, funding and implementation often fall woefully short. In the least developed countries, less than one-third of reproductive-age women are using any contraception, and the rate has grown by just 0.4 percentage points annually over the past decade. Meanwhile, funding from all sources is less than half the amount required to meet unmet need. If the July summit motivates a new groundswell of financial support, 2012 could incite major strides toward improvements in individual health and well-being as well as demographic momentum in the remaining high-fertility countries.
3. Demographic Diversity in Sub-Saharan Africa
The current era of global demographic diversity has been distinguished by both record-low fertility rates in parts of Europe and eastern Asia and persistently high fertility across most of western, central, and eastern Africa. More than one-quarter of women in sub-Saharan Africa would like to postpone or avoid pregnancy, but are not using contraception, demonstrating a large unmet need for family planning.
The U.S. government-funded Demographic and Health Survey (DHS) program is the largest single source for detailed data on health status and behavior in high-fertility developing countries, and in turn informs estimates and projections of demographic trends. Recently, DHS reports have been released showing that contraceptive use over the past five years is growing much faster than the regional average in Ethiopia, Malawi, and Rwanda. In turn, fertility rates have dropped, ranging from a relatively modest 0.3 children per woman in Malawi and an unprecedented 1.5 children per woman in Rwanda.
These findings suggest that the pattern of demographic stagnation in sub-Saharan Africa may be shifting, perhaps due to governments’ and donors’ investments in family planning. However, newer survey results for Mozambique, Uganda, and Zimbabwe present a more mixed picture, with modest gains in contraceptive use in Uganda, offset by declines in the other two countries.Click here for the interactive version (non-Internet Explorer users only).
Additional recent survey results show that use of modern contraceptive methods has barely increased in Senegal (from 10 percent in 2005 to 12 percent in 2010-11). And while modern contraceptive use increased in the Republic of Congo from 13 percent in 2005 to 20 percent currently, fertility also rose slightly, from 4.8 to 5.1 children per woman.
Approximately 10 countries in sub-Saharan Africa are slated for DHS fieldwork this year, including one of the continent’s giants, the Democratic Republic of the Congo, and several of the highest-fertility countries in the region. (Outside of sub-Saharan Africa, the demographic heavyweights in this year’s group of DHS reports are Bangladesh, Indonesia, and Pakistan.)
The upcoming surveys will provide greater clarity about whether the promising signs of family planning adoption and the potential for progress through the demographic transition in Ethiopia, Malawi, and Rwanda are initiating widespread change across the continent, or whether the need for commitments such as those generated by the London summit is even stronger.
4. New Population Projections
DHS reports are critical inputs for the world’s most comprehensive and readily accessible set of demographic data, the UN Population Division’s World Population Prospects. This database is fully updated and revised biannually, in large part due to the steady stream of newly available estimates from the DHS and related sources, such as national censuses. The next revision of World Population Prospects, based on estimates for mid-year 2012, is expected to be published in spring 2013.
The previous revision of World Population Prospects was notable for its methodological overhaul. In addition to extending the projections until 2100, the Population Division shifted to a probabilistic technique (as opposed to assuming convergence at a single fertility rate of 1.85 children per woman) that generates 100,000 possible fertility trajectories for each country and selects the median as the medium fertility variant, commonly cited as the most likely projection. Still, the basic parameters remain the same: With fertility rates the strongest driver of population projections, low, medium, and high fertility variants are constructed around the assumption that countries will converge towards replacement level fertility, around 2.1 children per woman.
In some cases, this results in projections that are vastly at odds with recent trends. For example, in Japan, fertility has fallen by 38 percent, from replacement level in the early 1970s to 1.3 children per woman in 2010, but the UN projects it to immediately reverse course and begin rising to 1.8 by mid-century. If the projection holds, Japan’s population will decline relatively modestly, from 127 million to 109 million. But if fertility stays constant at current levels, the population will fall below 100 million. For low-fertility countries like Japan, all UN scenarios assume constant or rebounding fertility rates, even though continued decline may be a plausible outcome in some cases.
When next year’s projections are released, a cluster of media articles will report the projected world population for 2050. In last year’s revision, the medium fertility variant resulted in a projection of 9.3 billion, an increase from the 9.1 billion projected two years earlier based on higher projected fertility in the future. Such reports often overlook the range of population totals possible depending on fertility paths: If the global fertility rate varies by 0.5 children per woman in either direction, the total population could be more than one billion higher or lower in 2050, with an even wider range possible by 2100.
Most of the projected growth in world population, and its potential range, will be driven by the high-fertility countries concentrated in sub-Saharan Africa. Population projections for these countries vary tremendously based on fertility scenarios informed by the recent DHS results described above.
In Nigeria, Africa’s most populous country, fertility has fallen over the past 40 years, but by a gradual 15 percent. The UN projects it to drop more than twice as fast, by more than two children per woman (39 percent), in the next four decades. In any scenario, Nigeria is on track for rapid population growth, but the potential range based on fertility outcomes is wide. If fertility declines as projected in the medium variant, the country would grow from 158 million to 390 million. And although unlikely, the constant fertility projection of 504 million Nigerians in 2050 should be kept in mind given the slow pace of fertility decline to date.
Population projections are highly wonky, but their careful production and regular revision are essential for accurate planning of economic and social needs in countries around the world. While governments with dedicated census agencies, such as those in the U.S., Japan, or India, rely on internally-generated estimates, the UN projections serve as the primary indication of population trends in countries with spottier data coverage and have tremendous utility in gauging future needs for infrastructure, housing, health care across the life cycle, education, jobs, and other investments.
By no means is this an exhaustive list of factors that will affect political demography research and policy over the coming year. Other events to watch for include the Rio+20 conference on sustainable development in June, where the priority issues of jobs, energy, infrastructure, and resources will be shaped by demographic trends, and continued attention to prospects for the demographic dividend in Africa. Political demography is inherently cross-disciplinary, and the field’s researchers and practitioners will be engaged on multiple fronts in the year ahead.
Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.
Sources: Al Jazeera, Bongaarts (2008), Cincotta (2008), Cincotta (2012), Cincotta and Leahy (2006), Grist, Guttmacher Institute, MEASURE DHS, The New York Times, NPR, Population Reference Bureau, UN Population Division, The Washington Post.
Image Credit: “The Face of a Tyrant,” courtesy of flickr user freestylee (Michael Thompson); video courtesy of TED; chart created by Schuyler Null, data from UN Population Division. -
New Surveys Generate Mixed Demographic Signals for East and Southern Africa
›May 8, 2012 // By Elizabeth Leahy MadsenThe pace of fertility decline in sub-Saharan Africa will be the single most important factor in whether the global population reaches the UN’s high projection of nearly 11 billion in 2050, or remains closer to the low projection of 8 billion. In recent years, the high projection has seemed more likely, as sub-Saharan Africa has been marked by stalled fertility declines and stagnant rates of contraceptive use. Survey results released over the past year showing dramatic increases in contraceptive use in Ethiopia, Malawi, and Rwanda therefore set demographers and the family planning community abuzz, signaling that concerted efforts to improve health services had paid off and fertility rates were on the decline. But in recent months, additional surveys from Mozambique, Uganda, and Zimbabwe have shown that those positive trends are not universal.
-
Yemen: Revisiting Demography After the Arab Spring
›April 17, 2012 // By Elizabeth Leahy MadsenAlong with other countries where the Arab Spring caught hold, Yemen has been gripped by major upheaval over the past year. Although President Ali Abdullah Saleh finally ceded power in February after his administration’s violent reprisals failed to deter protesters, the country remains at a crossroads. As its political future continues to evolve, the new government must also address a range of deep-seated economic and social challenges. In addition to claiming more than 2,000 lives, the crisis has undermined Yemenis’ livelihoods and even their access to food. A recent World Food Program survey found that more than one-fifth of Yemen’s population is living in conditions of “severe food insecurity” – double the rate measured three years ago – and another fifth is facing moderate difficulty in feeding themselves and their families.
-
The Missing Links in the Demographic Dividend
›March 9, 2012 // By Elizabeth Leahy MadsenThe “demographic dividend,” a concept that marries population dynamics and development economics, is on the rise in policy circles – Rajiv Shah, Melinda Gates, and African government ministers have all discussed it recently in high-level forums. Most notably for demographers, World Bank Chief Economist Justin Yifu Lin wrote a blog post that focuses on the demographic dividend’s potential to give developing countries a powerful economic boost through declining dependency ratios and a proportionately large working-age population.
-
Afghanistan and Pakistan: Demographic Siblings? [Part Two]
›February 15, 2012 // By Elizabeth Leahy MadsenLate last year, Afghanistan’s first-ever nationally representative survey of demographic and health issues was published, providing estimates of indicators that had previously been modeled or inferred from smaller samples. My first post on the survey focused on the methodology and results, which found that Afghanistan is not as much of a demographic outlier as many observers had assumed. But perhaps the most surprising finding is how the results compare to those of Afghanistan’s neighbor, Pakistan.
The political future of each country depends largely on the other and, with Afghanistan making progress on reproductive health issues that remain stalled in Pakistan, their demographic trajectories are heading toward closer synchronization as well. In one key measure – use of contraception among married women – Afghanistan is almost identical to Pakistan. The modern contraceptive prevalence rate is 19.9 percent, slightly lower than the rate of 21.7 percent in Pakistan.
While Pakistan faces its own serious political instability, it is widely regarded as more developed than its neighbor. Afghanistan is included in the UN’s grouping of least developed countries, and Pakistan is not. Pakistan’s GDP per capita is almost twice as high. On the surface, this should suggest lower fertility. There is a general negative relationship between economic development and fertility, though demographers are quick to point out its complexities, and David Shapiro and colleagues have found that countries with larger increases in GDP actually experience slower fertility declines.
Pakistan’s fertility rate of 4.1 children per woman is in fact 20 percent lower than Afghanistan’s, but the similarities in contraceptive use, which is one of the direct determinants of fertility, suggest that this gap could be shrinking. If Afghanistan’s median age at marriage (18 compared to 20 in Pakistan) was higher and more women were educated (76 percent of women have never been to school compared to 65 percent in Pakistan), the two fertility rates might be closer.
Pakistan’s Entrenched Challenge
Why are these indicators closer than might be expected? Relative to the other countries in South Asia, Pakistan has had considerably less success in promoting family planning use. Bangladesh has a per capita income about half that of India and one-quarter that of Sri Lanka, yet the three countries’ fertility rates are identical. Nepal has the lowest income in the region – even slightly below Afghanistan – yet more than 40 percent of married women use modern contraception and fertility is three children per woman. And then there is Pakistan. Despite a per capita income 90 percent that of India, only 22 percent of married women use modern contraception and fertility remains persistently high at over four children per woman.
The weaknesses of Pakistan’s family planning program have been well-documented. Government commitment has been lacking and cultural expectations and gender inequities are a powerful force to promote large family size. The country’s most recent DHS report cited disengagement with the program among local agencies, low levels of outreach into communities, and weak health sector support as likely causes for the stagnation of contraceptive use. In summer 2011, the Pakistani government abolished the federal Ministry of Health and empowered provincial governments with all responsibilities for health services. This transfer of authority could pay dividends by increasing local ownership of health care, but some in and outside Pakistan have raised concerns about the loss of regulatory oversight and information sharing entailed in total decentralization.
Compared to the Afghanistan survey, the most recent Pakistan Demographic and Health Survey provides more detail on women’s motivations and preferences regarding fertility and family planning. Overall, 55 percent of married women in Pakistan have a “demand” for family planning; that is, they wish to avoid pregnancy or report that their most recent pregnancy or birth was mistimed or unwanted. More than half of these women are using family planning, while the remaining 25 percent of married women have an “unmet need.”
Unintended pregnancies and births play a major role in shaping Pakistan’s demographic trajectory. The DHS survey finds that 24 percent of births occur earlier than women would like or were not wanted at all. If unwanted births were prevented, Pakistan’s fertility rate would be 3.1 children per woman rather than 4.1. Yet 30 percent of married women are using no contraceptive method and do not intend to in the future. The most common reasons for not intending to use family planning are that fertility is “up to God” and that the woman or her husband is opposed to it.
Linked Destinies
Just as Afghanistan and Pakistan’s political circumstances have become more entwined, their demographic paths are more closely in parallel than we might have expected. For Afghanistan, given the myriad challenges in the socioeconomic, political, cultural, and geographic environments, this is good news; for Pakistan, where efforts to meet family planning needs have fallen short of capacity, it is not. While Afghanistan is doing better than expected, Pakistan should be doing better.
Regardless, both countries are at an important juncture. With very young age structures and the attendant pressures on employment and government stability, each government must reduce unmet need for family planning or face mounting difficulties to providing for their populations in the future. In addition to rolling out health services, turning the share of women without education from a majority into zero would be an excellent way to start.
Elizabeth Leahy Madsen is a consultant on political demography for the Wilson Center’s Environmental Change and Security Program and senior technical advisor at Futures Group.
Sources: Afghanistan Ministry of Public Health, Bongaarts (2008, 1978), Cincotta (2009), Embassy of Afghanistan, Haub (2009), International Monetary Fund, MEASURE DHS, Nishtar (2011), Population Action International, Savedoff (2011), Shapiro et al. (2011), UN-OHRLLS, UN Population Division, U.S. Census Bureau, The Washington Post.
Image Credit: Chart arranged by Elizabeth Leahy Madsen, data from MEASURE DHS. -
Afghanistan’s First Demographic and Health Survey Reveals Surprises [Part One]
›February 14, 2012 // By Elizabeth Leahy MadsenLate last year, Afghanistan’s first-ever nationally representative survey of demographic and health issues was published, providing estimates of indicators that had previously been modeled or inferred from smaller samples. It shows that Afghan women have an average of five children each, lower than most experts had anticipated, and that their rate of modern contraceptive use is just slightly lower than that of women in neighboring Pakistan.
