sexual and reproductive health. according to the world health organization and population action international, as of 2007, "only 16 percent of women receive at least four antenatal care visits during pregnancy, fewer than one-third of births are attended by skilled health personnel, and the maternal mortality ratio, at 320 maternal deaths per 100,000 live births, remains high." current policy dating from 2002, pakistan's current family planning policy reflects the government's concern with rising population trends and poverty. the policy's goals include reducing population growth (from 2.1 percent in 2002 to 1.3 by 2020), reducing fertility through voluntary family planning (from 4 births per woman in 2004 to 2.1 births per woman by 2020), and as a signatory to the programme of action developed at the international conference on population and development in cairo in 1994, pakistan pledged to provide universal access to family planning by 2010. also in pakistan's poverty reduction strategy paper is the objective of increasing contraceptive use 57 percent by 2012. at present there is no federal ministry of health or population welfare and therefore no population policy. however, at the time of writing, khyber pakhtunkhwa, sindh and punjab are working on individual health and population strategies. an analysis of this policy showed that while the government of pakistan spent us$652 million funds under this policy between 2000 and 2009 (unfpa), there was hardly any change in cpr which was 30% in 2000 and remained unchanged in 2006. it is also important to note that other elements of population development such as education, capacity building, economic development, climate etc. were notably absent from this policy. in 2009 the ministry of population sought to revise the population policy. however, under the 18th amendment to the constitution, the ministry was devolved and its responsibilities were shifted to provincial population welfare departments. in 2013 some of the provinces - notably punjab - reported that they were developing their own population policies. family planning in 2000s in 2006–07, the pakistan demographic health survey of pakistan (pdhs 2006-7) showed that approximately 30% of married women of reproductive age (mwra) were using some form of family planning. of these 8% used a traditional and 22% used a modern method. approximately 25% had an unmet for family planning, of this around 2/3rd was for limiting and the rest for spacing. these translate into 7 million fp (family planning) users, 5 million users of modern methods and 6 million with an unmet need. since a large number of modern method users are sterilized and received the service in a previous year, the actual number women availing any fp service were just under 3 million or less than half of those with an unmet need. the dhs also dispelled the popular notion that religious reasons keep families from using family planning. in the dhs less than 10% of fp nonusers cited a religious reason for their non-use. using data from the pdhs 2006-7, approximately 35% of fp users received their fp services from the public sector, 12% from ngos and private providers and the overwhelming 52% bought their methods over the counter from shops, making fp services largely subject to market forces. the government spends on average around rs. 4 billion (us$42 million) a year on fp but nearly 90% of this goes towards salaries and overheads and commodities account for 7-14% of these funds. since the pdhs 2006-7, operations of ngos have increased but it appears that according to the supply data there has been no increase in supply of fp commodities and that entry of the ngo marie stopes society into fp services has displaced clients from other private sector, perhaps those that previously self procured commodities. additionally, it appears that the if the amount of commodities that are being reported by the pakistan bureau of statistics in its "annual contraceptive prevalence reports" is accurate, the overall increase in population may mean that the cpr for modern methods may have actually declined. even when one adjusts for underreporting for private sector and ngo services, it is likely that the current cpr may actually be unchanged from the pdhs 2006-7. a more accurate picture will emerge with the release of the data from the pakistan demographic and health survey 2012. family planning after 2010 a brief version of the pakistan demographic and health survey 2012 was released in october 2013. it showed that the overall cpr had climbed to 33.4% of which approximately 25% was from modern methods. in essence it showed that the overall increase in cpr since the previous dhs had been around 1% per annum overall and around 0.5% in modern methods. extrapolating these results to estimated populations suggest that there are 8.8 million users of any fp, 5.5 million users of modern methods and 3.65 million women who avail fp services in any given year. thus only around 14% of all married women of reproductive age (mwra) access fp services in a given year. this represents an increase of 700,000 users since the last dhs; around 2/3 of this difference may be attributed to increased population and nearly all these were supplied by ngos. the preliminary dhs report does not report sources of fp services but analysis of government's contraceptive prevalence report suggests that 44% avail public sector services and that the role of ngos has increased from 11% in 2006-7 to around 40%. the total change in users of fp services between 2006 and 2012 was around 700,000 women. this is exactly equal to the increase in number of women served by ngos (supported by donors such as usaid, dfid, kfw, giz, david and lucile packard foundation etc.); while the overall quantum services by the government and those that self procure commodities from stores remained the same. community health workers in the 1990s, two agencies in pakistan started village-based community health worker programs in pakistan. the ministry of population welfare started planning a program in 1992 based on a similar program in bangladesh. this program recruited married women, with at least 10 years of schooling, that lived in rural areas, and trained them to provide family planning services to their communities. the aim of these services was to reduce the fertility rate and slow population growth. the ministry of health (pakistan) started a similar program in 1994 called "lady health workers." this program emphasized maternal and child health, and also delivered family planning services. both groups of women provide door to door health and family planning services, supplied with oral and injectable contraceptives and condoms to distribute to their communities. one study in 2002 showed that in areas with 2 or more community-based workers there was a 7% increase in the use of modern, reversible contraceptive methods. an evaluation of the lady health worker program showed only a marginal improvement in fp among health indicators the populations served of around 5-6%. in 2006 there were 96,000 lady health workers.