8m women’s contraception needs unmet

After enduring six pregnancies so far in her 13-year-long marriage, 36-year-old Rokeya Begum, a resident of Korail slum, is now a mother of three children, the youngest being two years old.

She had lost one of her sons, who was 12, to a genetic condition while another died just three days after birth.

The last time she discovered she was expecting again, she was already five months pregnant. She opted for an abortion through medication bought from a dispensary in the slum. She then experienced severe health complications that put her life at risk.

Despite Rokeya's resolve not to have any more children, having faced the difficulties of multiple pregnancies and loss of children, she is yet to use any contraception.

"My husband thinks it's an additional expense that he can't afford. He earns a living as a hawker, managing a family of five with expenses like rent, food, and essentials," she said.

Like in her case, there has been an increasing number of women in the reproductive age bracket of 15-49 who wish to stop or delay childbearing but do not use any form of contraception.

Despite the government's goal of achieving universal access to contraception by 2030, the latest data from the Bangladesh Sample Vital Statistics (BSVS) 2022, prepared by Bangladesh Bureau of Statistics (BBS) and published in January this year, revealed that the contraception needs over 8 million women in that age group, or 17 percent, are unmet.

This group includes women who are currently unintentionally pregnant, those who recently gave birth but are not using contraception despite not wanting their last pregnancy, and women who wish to delay or prevent future pregnancy but are not using birth control.

Another study, the Bangladesh Demographic and Health Survey (BDHS) 2022, published a year ago by National Institute of Population Research and Training, however, showed that the number was 12 percent of women in the reproductive age bracket.

Md Alamgir Hossen, project director of BBS, said the data in the BDHS survey was drawn from BBS data, and was based on a smaller sample size.

According to BBS, contraceptive needs going unmet cause significant negative impacts, including unintended pregnancies, unsafe or induced abortions, delayed or no antenatal care, and maternal and neonatal deaths.

Alamgir pointed to some worrying trends in the total fertility rate (TFR) and contraceptive prevalence rate (CPR).

"New data revealed that the TFR has increased to 2.20 from 2.05 as reported in Sample Vital Registration System-2021. Simultaneously, the contraceptive prevalence rate has dropped from 67 percent to 63.3 percent."

Under the fourth Health, Population, and Nutrition Sector Programme, the health ministry aimed to lower the TFR to 2.0 by 2023. Conversely, the programme aimed to boost the CPR to 75 percent by 2023.

Analysing regions, it was found that Khulna has the highest percentage of women (19.2) with unmet contraceptive needs.

"In line with this, the contraceptive prevalence rate in Khulna has also decreased from 63 percent in 2021 to 59.3 percent in 2022," added Md Alamgir.

Monjun Nahar, head of advocacy at Marie Stopes Bangladesh, highlighted the reasons behind the high unmet needs.

"Many women lack awareness of where to get contraceptives and don't know which method to use. They also face pressure from family and in-laws when making decisions about having children, and often can't access services.

"On the supply side, mass campaigns educating women about contraception have been running at an extremely slow pace, nearly unnoticed for over a decade, hindering information spread."

She added, "Moreover, there's a shortage of family welfare assistants visiting door-to-door to distribute contraceptives due to retirements without replacements.

"Additionally, generalised programmes that don't cater to the needs of diverse populations exacerbate the situation."

However, according to the World Health Organization, the unmet contraception needs serves as a critical indicator of women's ability to achieve their desired family size and birth spacing, reflecting the effectiveness of reproductive health programmes.

This rights-based indicator evaluates how well a country's health system and social conditions support women in deciding the timing and number of children they have, it mentioned.

According to BDHS 2022, the private medical sector, including pharmacies and drugstores, is the primary source for modern contraception for 60 percent of women in Bangladesh, showing a steady rise from 42 percent in 2011.

Government health facilities serve 37 percent of those who use modern methods, with experts emphasising that people below the poverty line are the primary users of these services.

If these government services do not operate effectively, many of them may struggle to afford contraceptives, worsening the situation, they said.

However, the 2022 vacancy data provided by the Directorate General of Family Planning (DGFP) indicated alarming rates of vacancies in positions critical for family planning services, which hampered the activities of the programmes.

According to it, the vacancy rate was 98 percent of a total of 464 assistant family welfare officers; 53 percent of 517 family planning officer; 75 percent of 495 assistant family planning officer; and 39 percent of 636 family welfare visitor.

Furthermore, despite issuing a circular in March 2020 to recruit 1,080 family welfare visitors, the DGFP cancelled the recruitment almost four years later in January, citing irregularities in the written exam.

As of January 31 this year, according to the health ministry's data, the national stock of condoms stood at 50.7 lakh, projected to last until February 2024. Additionally, the stock of injectables, currently at 4.14 lakh vials, was expected to be depleted by mid-February 2024.

Although it has been mentioned that procurement is underway, according to DGFP officials, it typically takes nearly a year to acquire the necessary stock.

The Daily Star contacted three top officials of the Ministry of Health and Family Welfare, but none agreed to talk on the increasing rate of unmet needs for contraception.

Monjun suggested that family planning programmes can address this barrier by offering comprehensive counselling on available methods, improving client-provider relationships, and involving men in discussions and service-seeking behaviours to create a supportive environment for both sexes.

Family planning specialist Pulak Raha, CEO of Team Associates, emphasised that the government should expand door-to-door distribution of contraceptives by deploying additional personnel to address this issue.