What can be done to expand effective options in Bangladesh
Women in Bangladesh now have about 2.3 births on average over their lifetimes. Although more than 60% of married women of reproductive age use contraception, very few of them (9% in 2017) use long-acting reversible contraceptives (LARC), like IUDs and implants, or a permanent method (PM), such as tubectomies and no-scalpel vasectomies.
With such low fertility levels, couples often achieve their desired family size while still in their late 20s or early 30s and need to use contraception consistently for many years to avoid further pregnancies. LARCs and PMs offer several advantages for long-term use; they are highly effective and require little action on the part of users to continue using them effectively for many years.
Yet most couples (53%) who do not want any more children rely on short-term methods like pills, injectables, condoms, and traditional methods, and they frequently switch methods over time. These methods have higher risks of failure than LARCs and PMs, resulting in higher risk of unintended pregnancies and associated risks such as maternal morbidity and mortality.
Many countries with low fertility rates have high use of LARC and PM (eg, 38% in India and Vietnam, 40% in the UK and the US, and 53% in China). So why aren’t Bangladeshi couples choosing these methods more often?
Why is LARC and PM use low?
Unfortunately, both supply and demand-side barriers are responsible for the low use of LARC and PM. The supply side barriers exist as the public sector, the Directorate General of Family Planning (DGFP), is the primary agency that delivers LARCs and PMs but frequently experiences a high level of provider vacancy, poor facility readiness, and poor quality of care.
Shortage in supplies of equipment and medications is common in the delivery system. The demand-side barriers include stigma and cultural norms. Abundant myths and misconceptions exist against these methods, resulting in low demand.
The use of LARC and PM is also low among educated or high-wealth couples. One way to overcome this is providing proper counselling. However, appropriate counselling and follow-up with LARC and PM clients by providers is infrequent in the DGFP service delivery system.
Why are pills and injectables so popular?
Convenience and privacy are the main factors for the popularity of these short-term methods in Bangladesh. The widespread availability of pills in pharmacies and convenience shops make these methods the most readily available options. Injectables are also now available at selected pharmacies in addition to health centres.
On the other hand, inserting and discontinuing IUDs and implants -- a rather invasive procedure -- is dependent on providers, requires appointments, and often has long waiting times. Concerns about client confidentiality in receiving and discontinuing LARCs and PMs is another reason these methods are less popular among couples.
What happens when the pill fails?
Although pills are 99.8% clinically effective, the World Health Organization reports that about 7% of users are likely to conceive during 12 months of continued typical use. A series of Bangladesh national surveys shows a pill failure rate of 4-5%, so a rough estimate is that 436,000 women in Bangladesh who were using pills became unintentionally pregnant in 2017.
Estimates from another study indicate that 58% of unintended pregnancies ended in abortion or menstrual regulation in Bangladesh in 2014. These numbers suggest that about a quarter of a million menstrual regulations and abortions took place due to pill failures alone in 2017.
Read these numbers again and try to fathom the magnitude of the issue.
Making the right choice at the right time
Unfortunately, although there has been much improvement in overall health status in Bangladesh, health system strengthening interventions are still overdue. These interventions include minimizing vacancies of key providers and improving facility readiness to provide LARCs and PMs.
Postpartum IUDs and implants can be used immediately after delivery by those wishing to space or prevent future pregnancies. Women who do not want any more children can choose to have the most effective method -- tubectomy -- provided on the day of delivery of their last desired child, which will virtually eliminate the risk of future unintended pregnancies.
Harnessing the private sector
The recent remarkable increase in facility delivery in Bangladesh, currently at 50%, provides new opportunities to offer IUD, implants, and tubectomy immediately following delivery.
However, two-thirds of facility deliveries take place in private hospitals/clinics, so it will be important to include private sector delivery facilities in providing post-partum implants, IUDs, and tubectomies. Currently, there are no organized interventions to counsel pregnant women on planning a subsequent pregnancy.
During their antenatal care visits to providers (obstetrician-gynecologists, physicians, nurses, midwives, or paramedics), pregnant women should be informed that highly effective implants, IUD, and tubectomies are available at the time of delivery at facilities. Recently, icddr,b and Data for Impact developed an approach -- segmented client counselling based on couples’ birth spacing and limiting needs -- found to empower women to make an informed choice from the full range of contraceptive options available.
Couples who received this type of individual need-based counselling were more likely to choose LARCs and PMs. In addition, it is important to ensure that pill, injectable, and condom users are fully informed about the risks of unintended pregnancies associated with method failure, early method discontinuation, and method unavailability for these options.
For example, injectables have low failure rates but are provider dependent. Even with a long window in which women can obtain their next injection, some women become pregnant unintentionally because they are unable to obtain their subsequent dose.
High-quality counselling on the advantages and disadvantages of different methods is likely to help potential users choose the method best suited to their needs from all their options.
Shusmita Khan is Research Associate with the Data for Impact (D4I) of University of North Carolina at Chapel Hill, USA. Dr Mizanur Rahman is Senior Research Advisor with the Data for Impact (D4I) of University of North Carolina at Chapel Hill, USA. This article is produced by Data for Impact (D4I). D4I is funded by the United States Agency for International Development (USAID) under the terms of the D4I associate award 7200AA18LA00008. The views expressed do not necessarily reflect the views of USAID or the United States Government. To learn more, please email Shusmita Khan at [email protected]