THE declining fertility rates witnessed up to a few years ago in Bangladesh have led some to ask whether the country will follow in the footsteps of Japan or other Western nations any time soon and transform from a country with an extremely young population to one populated by elderly people. A transformation of the age structure will take place in Bangladesh, marked by an increase in the elderly population. By 2061 the number of elderly will increase five times, from 11.2 million in 2011 to 55.7 million in 2061. But does that mean Bangladesh may end up with a huge number of elderly people and no young to support them? No, extreme ageing is a long way off and may never in fact occur. For Bangladesh population growth, including urbanization, is the most pressing challenge facing the nation today.
Taking a closer look at the actual figures even the lowest population projections in Bangladesh point to an additional 51 million people added to the current population by 2061. This, although being the lowest growth projection,already holds serious implications for population density and labour force absorption, and the measures necessary to deal with urban population growth as well as environmental concerns.
Choosing a small family
That said family planning programmes in Bangladesh did have remarkable success in the last three decades. The total fertility rate declined sharply from 6.3 births per woman in 1971-1975 to 5.1 births per woman in 1984-1988, followed by another rapid decline in the next decade of 1.8 births per woman to reach 3.3 births per woman in 1994-1996. Following a decade-long plateau in fertility during the 1990s at around 3.3 births per woman, the TFR declined further by one child and now remains stagnated at 2.3 births per woman since 2011. Bangladeshi women are thus having, on average, two or more children currently, but when asked in surveys (BDHS 2011) it becomes apparent that the vast majority of Bangladeshi women today actually want a small family of two children or less. This clearly shows that there is further need for family planning in Bangladesh in order to make sure that all women and their partners are able to choose the family they wish for.
Knowledge of ways to prevent a pregnancy is widespread in Bangladesh. The high contraceptive prevalence rate (CPR) is a major contributor to the reduction in the TFR. The CPR for all methods has increased from 7.7% in 1975 to 62.4% in 2014 and the prevalence of modern contraceptive rate accounts for 54.1% of the total CPR. The CPR for modern methods has increased due to the availability and accessibility of a choice of temporary, long acting and permanent, modern methods in the basket of contraceptives, a so called 'cafeteria approach'. Not withstanding this broad availability of modern methods a disconcerting phenomenon has become apparent. A significant reduction in the use of long acting and permanent methods (LAPM)can be observed, which in turn means a high dependence on temporary methods such as pills, injectables and condoms. Although modern contraception is reliable if correctly used, some methods are more reliable than others in the sense that they are less dependent on individual behavior. The most reliable forms of contraception are those that do not require a daily activity such as taking a pill or a visit to a health centre or clinic every three months to obtain an injection. Women, who use methods, which require daily or regular activities on average have higher discontinuation rate of up to 30%, meaning that one in three users discontinue a method within one year of use.
Currently 8% of the married couples use a long-acting and permanent method, namely IUD, Implants and male and female sterilizations. In the past few years the use of such methods has been stagnant while the dependency on the shorter acting temporary methods has increased. Reasons why women and men are hesitant to choose long-acting and permanent methods vary, including health concerns, but also opposition voiced by husbands. This stagnation of contraception has significantly affected the overall CPR and the TFR of Bangladesh, which is why we have not witnessed a further lowering of the fertility rate over the past years.
Reliable and long-acting contraception
Another concern in Bangladesh is the age of child bearing, coupled with the discontinuation of short-term contraceptive measures. As the practice of child marriage is still highly prevalent in Bangladesh the average age at first birth is very young. This actually means that for most women child-bearing is completed by the mid-to-late twenties, which in turn means that these women have to protect themselves from pregnancies for the next two to three decades of their reproductive life. The most efficient and hassle-free method for these women would be a long acting or permanent method protecting them from unwanted pregnancies and the life-threatening consequences of unsafe abortion. Women therefore need to be provided with further access to and information about sexual and reproductive health services. This will enable them to make informed choices, and will also have an impact beyond the individual level. The fall of mortality and fertility rates in Bangladesh have contributed to development in many ways. Overall better health leads to improved productivity; with a slower growing youth population educational efforts have been made to further raise enrollment ratios and lower fertility has enabled more women to enter the labour force. Besides demand creation for more long-term and permanent methods of contraception the supply side needs to ensure that supplies are available at health centres at all times and home visitations by community-based distributors continue regularly. Especially among the rural population of Bangladeshi family planning service delivery needs to be continuously improved.
The age structure in Bangladesh will not change overnight, as it still reflects an earlier, higher fertility resulting in continued population growth for decades even if fertility rates below replacement level are achieved. It is not until 2061 that the effect of population momentum on growth will have largely played itself out. For now having fewer children and first and foremost having children later opens up new possibilities, especially for women, and can enable the country to make use of its largely untapped female and youth potential.
Long Acting and Permanent Methods of Contraception
Supply: The provision of LAPMs requires skilled personnel trained to offer the methods, access to medical instruments and consumable supplies specific to each method, and attention to infection prevention procedures when providing services, processing instruments, and disposing of medical waste. Many countries have introduced task shifting/sharing with supportive supervision and referral systems as a means of expanding access to these methods, ensuring quality of care and managing side effects.
Enabling Environment: Policy makers and programme managers at national and district level need to ensure that service providers and supervisory staff are in place and retained—especially in hard-to-reach and remote areas. The supply chain and information systems should ensure that contraceptives, equipment, and consumable supply needs are included in procurement plans and that data are used to avoid stock outs. Infection prevention procedures must be implemented, including hand washing, processing of equipment and supplies, and medical waste disposal.
Demand: If Bangladesh is to achieve replacement level fertility (TFR =2), the family planning program has to significantly strengthen demand creation by addressing misconceptions and socio-cultural issues. Engaging media and civil society, including religious community leaders will be crucial. Under utilized methods, such as LAPMs, benefit from behavior change communication efforts to increase awareness about the methods and their attributes and to inform clients where they can find easy access to affordable, quality services. Counseling and interpersonal communication informs clients about the range of contraceptives available to them and enables them to make an informed and voluntary choice of the method they wish to use.