Shazia Shahid, a community health educator, went to the tiny house to speak with the slight young woman about birth control. It was morning, a good time because the woman’s husband was out working. But the woman shrank behind a green veil — and behind her wizened mother-in-law, who smiled but made clear that she saw no need to discuss the topic.

It was a typical exchange in this remote village, and in much of the nation. In fits and starts, public and private agencies in Pakistan are advocating contraception to curb the country’s surging population, prevent deaths during childbirth and help provide better lives for those who are born. But in this deeply conservative society, women themselves are often the least able to decide, and the people who can — husbands, mullahs, mothers-in-law — still prize many children, particularly boys.

It is a desire that Pakistan can ill afford. The sixth most populous country in a world that recently surpassed 7 billion inhabitants, Pakistan has South Asia’s highest fertility rate, at about four children per woman. Amid massive electricity shortfalls, failing schools, high unemployment and rising Islamist militancy, many here say the booming population is a ticking time bomb.

“Do we want to become the fifth-largest nation with large segments of the population falling below the poverty line who are uneducated and unhealthy?” Prime Minister Yousuf Raza Gilani said on World Population Day in July.

But Pakistan’s family-planning efforts have lagged far behind those of other large Muslim-
majority nations, including Iran and Bangladesh. In those countries, governments have stuck to population-control policies and backed them with money and political will, according to researchers. In Pakistan, where the powerful military consumes a large chunk of the budget and development spending has stagnated, family-planning efforts have consistently fallen victim to tumultuous and weak governance.

Today, just one in five Pakistani women ages 15 to 49 uses modern birth control. Contraception is shunned under traditional social mores that are fiercely defended as fundamentalist Islam gains strength.

Yet religion is hardly the main obstacle, public health workers say. Although some clerics scorn birth control, health workers have persuaded other imams. The bigger cultural hurdles, the workers say, are husbands and mothers-in-law, as well as the inability of many women to make decisions for themselves.

Young brides commonly live with their husbands’ families after marriage. In most such units, the mother-in-law runs the house. If a health educator stops by, the mother-in-law must first be approached, as Shahid experienced in Mirwah.

“So what? I will take care of the children,” the mother-in-law, her arms covered in bangles, said when Shahid expressed concern that the daughter-in-law, still a teenager, was not using birth control.

Leaving the house, Shahid — who works for Greenstar Social Marketing, a nongovernmental organization that trains health providers and markets subsidized contraceptives — vowed to woo the mother-in-law in successive visits.

“Slowly, I will convince the people,” she said.

Rates of contraceptive use are particularly low in rural Pakistan, which is home to two-thirds of the about 180 million people in the nation. In this area of Sindh province, literacy rates are dismal, teenage marriage rates are high, and 10-children families are not uncommon.

Over 50 years, Pakistan’s fertility rate has dropped from about six children per woman to an average of about four. But the decline has been far too slow for the country to reach its target of 2.2 children per woman by 2020.

Even in Sindhi deserts and the northwestern mountains, Pakistani women have heard of modern contraception, survey data show. That is in part because government and private health agencies, some funded by U.S. assistance, have churned out advertisements featuring jingles about condoms and vignettes about couples visiting health clinics.

These days, the campaigns emphasize “birth spacing,” or waiting three years between births — a message that family-planning programs emphasize is endorsed by the Koran, which encourages breast-feeding for 24 months.

But men are difficult to convince, health workers said. At a men’s meeting in Mirwah, a man with a cigarette dangling from his mouth and a baby in his arms stormed away, muttering that birth control amounted to “interfering in God’s ways.”

Others said they were unopposed but uninterested. “Our mothers, they are the deciding figures,” one man said. “Our wife? What does she know?”

The government says it is committed to slowing population growth, which it referred to in a report last year as a “major impediment to [Pakistan’s] socioeconomic development process.” But public health experts say they have seen little beyond lip service.

In rural areas, access to family-planning services is limited and hampered by deteriorating security, while government health workers are overburdened. International donors want bang for bucks, and working in the countryside is more expensive, said Mohsina Bilgrami of the Marie Stopes Society, another nongovernmental organization.

Greenstar is the country’s largest contraceptive provider, but “we’re a drop in the bucket in a country of 180 million,” said Shirine Mohagheghpour, the technical adviser for Greenstar, an affiliate of the Washington-based Population Services International. “You have to do this community by community.”

Shahid keeps her message basic. In one colorful illustration she shows on home visits, grimy children wail in a tattered house. In another, a mother shakes a rattle at a baby, a father frolics with a toddler and a child reads a book in a tidy dwelling.

Intrauterine devices can help make the second picture a reality, she says.

“You can live tension-free,” she said to a roomful of women in Mirwah. “Your husband will be happy. Your mother-in-law will be happy. You can pay attention to the children you already have. If you continue having children year after year, you will get sick.”

In urban, middle-class areas, the message is slowly resonating. Two hours away, in the city of Mirpurkhas, a similar talk with women and a few mothers-in-law sparked boisterous discussion. Several said children were simply too expensive.

“If it’s a sin, there shouldn’t be doctors who offer it,” one said of contraception, eliciting nods.

At a private clinic in Mirwah, a woman named Buri, 35, said firmly that a small family is best. But it was too late: Married at age 13, she was pregnant 12 times before she opted for tubal ligation, a sterilization procedure. Ten of her children lived. None attends school.

“They are uninterested in school,” she said. “Parents are too busy in the fields to pay attention.”

Next to Buri lay her sister-in-law, silently shivering under a floral sheet, in labor with her first child. Presiding over the scene was their mother-in-law, a woman in ornate silver jewelry, who matter-of-factly stated that the newborn should be the first of at least eight children.