In Pakistan, fertility rates and intended family size have fallen, but contraceptive use remains low. This has led to a high prevalence of unintended pregnancies, a large proportion of which result from disagreement between spouses about how to confront them. This study aims to understand how Pakistani couples view family planning, and how they communicate and make decisions surrounding fertility regulation. In-depth interviews were conducted with five couples and an additional five women and two men. Two focus groups--one for males and one for females--were also conducted. Family planning methods were more favoured by women than their husbands. Women reported the largest barrier to contraceptive use to be men's opposition to family planning or reproductive choices more generally, as well as fear of side effects of contraception. Abortion was viewed unfavourably except in situations of economic difficulty, having several young children or women's health problems. Couples reported rarely communicating about fertility intentions until later in childbearing after an unintended pregnancy. Discussions about family planning were largely initiated by women, although some felt unable to approach their husbands regarding this topic. Concordant intentions and communication between spouses led to desired pregnancy outcomes. In cases of discordance, women's intentions tended to determine actions and outcomes. Spousal communication, or the lack thereof, is an obstacle to effective contraceptive use, and strategies to improve couples' communication would undoubtedly enable them to achieve their reproductive intentions.