Despite impressive strides in Bangladesh's record, contraceptives and family planning options are still inaccessible to women across classes—and the problem starts at the doctor's mindset.
A few weeks ago, I advised a close friend, who recently got married, to pay a visit to a well-known international organisation that specialises in providing contraception and family planning services across Bangladesh and other countries they operate in. Let's call this organization by the name Women's SRHR Aid. My friend—let's call her Majeda—is in her mid-twenties and doesn't want to have kids just yet. This is a taboo itself, right? It sounds familiar to all the women as well as men reading this.
Now imagine you are young, inexperienced and seeking a safe, medical space to get access to safe birth control options, and you return home feeling humiliated, embarrassed, and shocked. The doctor at the branch she went to, a female one, had made fun of her, insinuated she was an unmarried girl who was there with her young boyfriend to have free sex, and asserted that birth control options were illegal for Bangladeshi women who are unmarried. In fact, she mentioned that the IUD was only available to married women after they have had their first-born child.
My natural question was why is it even relevant what marital status is in a country that is cracking under the weight of overpopulation? The Women's SRHR Aid webpage indicates that "Women's SRHR Aid International is obligated by WHO to provide contraception to everyone irrespective of age, marital status, economic status, parity or any other factor." Then, is there any rule specifically in Bangladesh that denies contraceptive methods to unmarried women?
I looked it up—turns out that despite birth control being widely subsidised by the Ministry of Health and Family Welfare (MoHFW) of Bangladesh, and services are available in all divisions of Bangladesh. The MoHFW also works with national and international partners to help bring contraceptive services to as many Bangladeshis as possible. This makes contraception cheap and easy to access in Bangladesh—an encouraging realisation. There are also options for women who have been exposed to unprotected sex.
Oral contraception pills i.e., "birth control pills" and "emergency contraceptive pills" are available over the counter to avoid unplanned pregnancies, but for options like IUD and Implants, the services must be availed from medical practitioners. And they ask for your marital status and can decline from providing consultation and service for contraception and family planning based on the above-mentioned. It's a circular problem once more—and it increases the chances of higher aggregate abortion rates in a country where abortion is illegal.
I posted the story on a Bangladeshi women self-empowerment's Facebook group I am a member of—called Thrive Women—and the public outcry was unbelievable. Swarms of women commented and privately messaged me sharing their stories, some positive and many negative. And negative experiences with a sexual and reproductive health (SRHR) practitioner was not limited to just Women's SRHR Aid, but at most places, across various levels of class-privilege, socio-economic and educational backgrounds. It is thus not an issue of availability of medical services, but rather of a doctor's whim and attitude towards client-provider ethics.
Some of these women on the Facebook group published alternative recommendations, name-dropping other doctors, only to have other women contest that with negative experiences they have had. One woman wrote to me, "I have become so discouraged after a couple of visits to gynaecologists that I went to Thailand for a good doctor when I could. I was sexually active before marriage and the doctors here shamed me for reasons that didn't seem medically relevant. Now I don't know what I would do because I can't fly out," she said, adding, "I'm married, and have a child!"
This indicates the underlying conservative mindset issue that is intrinsic to the South Asian cultural fabric. It is no secret that any talk of sex, sexual, and reproductive health and contraception is largely still a taboo topic in Bangladesh. But when this obstructs a medical practitioner from providing a medical consultation assuring ethics, sensitivity, and confidentiality, then it indicates a larger problem—that the behaviour of doctors discourages and discomforts patients from seeking out sexual and reproductive health services that could potentially affect their lives, fertility and social security.
Bangladesh boasts an inspiring sevenfold increase in its contraceptive prevalence rate (CPR) in less than forty years. Yet, the rate of unintended pregnancy declined only gradually during the period of 1993-2007 alone, and there is still a significant unmet need for family planning (FP).
A key concern in Family Planning programmes in Bangladesh, according to a study conducted by UKAID, is the high rates of discontinuation and switching to less-safe or less-effective contraceptive methods. Risks of abortion-related morbidity and mortality increase as a result of unintended pregnancies, particularly in countries like Bangladesh where abortion is against the law. For social security alone, women—married or unmarried—across economic classes may seek contraceptive options and be declined from it because of archaic cultural norms filtering the doctor's behaviour.
In an interview with the broadcaster Deutschlandfunk in November 2019, German Development Minister Gerd Müller praised Bangladesh's record on this front, saying that the Muslim-majority country — home to over 160 million people — made remarkable strides in reducing its fertility rate over the past five decades.
"Bangladesh has brought down the fertility rate from about seven births per woman to 2.1 births per woman, which is almost the European average, over the past 50 years," Müller said, underscoring the importance of female empowerment in achieving this decline. "Self-determination and equal rights for women, as well as ensuring full access to education and healthcare can make a huge difference."
I'd like to conclude by sharing a story a senior medical advisor from a reputed international SRHR organisation relayed to me; "I used to work in Iran at an SRHR centre and I refused an abortion to a young girl once. She said she was married, and in an abusive household. I told her to rethink her abortion, and she had agreed. An hour later, she committed suicide."
This shows that a doctor's insensitive handling can cost a patient's life—especially when social security is at stake. The doctor should not have spoken to Majeda like that—what if she got pregnant and felt unable to get an abortion and ended up in a suicidal state. You never know.
Post-Script: By the way, I called Women's SRHR Aid Bangladesh's media number listed on their website after all this to double-check whether they only work with married women for contraception—and the customer care agent said yes.