Ensuring Choices and Rights

 Monjun Nahar, Lead, Advocacy and Communication, Marie Stopes Bangladesh

This year, the World Population Day focuses on comprehensive rights and choices on sexual and reproductive health. The theme itself refers to the global consensus that reproductive health rights are integral and indivisible parts of human rights. Particularly for women reproductive rights are deeply connected with their life and livelihood. The ability to take decisions about their sexual and reproductive health is a key indicator that women are in control of their own lives.

However, we are talking about rights and choices in a context where women have very little independence to take decision by herself. A woman's education, marriage, profession are mostly dependent on her family members.

The government has taken a series of initiatives and programs to increase access of women and girls to reproductive health services. Significant achievements have been made by the government of Bangladesh in reducing the gender gap in primary education, maternal and child mortality and the total fertility rate. However, there is much work to be done on this front in order to achieve the related sustainable development goals, along with other national and international commitments.

Additionally, the pandemic has overburdened our healthcare system with COVID-19 patients, and as a result, other health issues such as sexual and reproductive health, have been put on the back burner. Gender-based violence, child marriage, unsafe abortion and unwanted pregnancies have been on the rise during the pandemic.

To mitigate the collective challenges, and ensure access to these services, the government should focus on task-sharing, increasing the participation of private organisations and hospitals, encouraging male participation, and framing policies and programs with a commitment to women's rights.

Dr Abu Sayed Mohammad Hasan,

Programme Specialist, Sexual and Reproductive Health, UNFPA Bangladesh

Sexual and reproductive health (SRH) are essential, lifesaving interventions. The lack of proper information and access to reproductive healthcare leads to unwanted pregnancies and unsafe abortions. In Bangladesh, every year, around 1.7 million abortions take place, which may further increase during the COVID-19 pandemic. Improved access to SRH services could prevent unintended pregnancies and unsafe abortions; thereby reducing the risk of maternal mortality.  

We must identify more systematically why our healthcare facilities are failing to provide these services to women; especially those who are underprivileged. Increasing the number of telemedicine services can possibly help increase the accessibility to these services. However, we should keep in mind that these services are hard to access for people in rural areas, so telemedicine services should be designed taking into consideration the rural context. Additionally, the number of family welfare assistants has not increased for years now, while the population in their working areas has significantly increased. We must increase the number of family welfare assistants.

There are over 4,000 Union Health and Family Welfare Centres in Bangladesh, and through these centres, we can increase the access to SRH services for rural women. But to ensure quality services, government must take initiative to deploy skilled midwives in these union level facilities.

Prof. Dr Ainoon Nahar, Jahangirnagar University

I want to highlight that the concept of reproductive rights does not apply only for women and men. So, we need to think of it from a broader perspective by including people from all genders and sexual orientations.

To ensure rights and choices, the term consent is key to understand and practice. However, there is a lack of understanding about consent in relationships or in the household decision-making process, particularly for women, as our social and cultural norms consider men to be the decision makers. Women should be able to choose when they want to be sexually active or get pregnant, and men should be taught to respect women's consent. A lot of work must be done to ensure this, but we can start by raising awareness at the school level.

Another point is that, even though it is about sexual and reproductive health rights (SRHR), we often ignore the sexual part from this concept. Social taboos are a barrier to work on this issue. We need to encourage these conversations to take place freely.

To me, family planning program is not only about contraception, rather it is about the wellbeing and rights of people. It must be addressed that mental health issues are also a part of this. Moreover, the existing program primarily targets women instead of couples. This traditional approach needs to change and must include male participation.

From a policy perspective, we must review all our existing policies and address any shortcomings. Simultaneously, we also need to ensure we follow international guidelines on family planning and SRHR to promote women rights.

PROF. Dr Iffat Ara, Specialist, Gynaecology and Obstetrics Department, Popular Medical College Hospital 

The global commitment is around achieving zero unmet need for family planning information and services, zero preventable maternal death, zero sexual and gender-based violence, and harmful practices against women and girls by 2030. Accordingly, our government has also set its program, but the programmatic approach must focus on women's right issues.  

I also emphasize on sexual violence that women face. Sexual violence towards women has increased recently, with workplace sexual violence also increasing, so we must work on workplace safety for women as well. This is particularly important for garment factories, which are very unsafe workplaces for women and girls. Female garment workers are afraid to speak up against harassment for fear of losing their jobs. I recommend starting a #MeToo movement in our country to demand safer workspaces for women and girls.

Dr Mohammad Mainul Islam, Professor and Former Chairman, Department of Population Sciences, University of Dhaka 

According to the Bangladesh Bureau of Statistics (BBS), the total fertility rate (TFR) in Bangladesh is 2.04 births per woman. However, according to data from Bangladesh Demographic and Health Survey (BDHS) spanning 2011 to 2018 and the Multiple Indicator Cluster Survey (MICS) 2019 conducted by BBS and UNICEF, the TFR is stagnant at 2.3 births per woman. There hasn't been any improvement in the contraceptive prevalence rate (CPR) either. 

We are have failed to achieve the goals set by the Bangladesh Population Policy 2012. We targeted a CPR of 72 percent and TFR of 2.1 by 2015, but our CPR is now close to only 62 percent. If we cannot increase the CPR soon, it will be difficult for healthcare services to accommodate the rising number of unwanted pregnancies during this pandemic. As a result, a lot of women might have to resort to unsafe abortions.

We need to train programme managers and service providers on how to run the program during the pandemic. Transport and communication allowances can be provided to incentivise fieldworkers to continue their work even during the lockdown.

There should be routine analysis of service data, which will help us better understand where family planning services are lacking in terms of accessibility, and thereby helping to revise our existing programs.

PROF. Dr Sehereen F Siddiqua, 
Professor and Head of Gynaecology and Obstetrics, Anwer Khan Modern Medical College Hospital 

During the pandemic, the number of child marriages increased significantly. We must ensure family planning services and information to these young women to reduce unwanted and early pregnancies. We have failed to increase the usage of both short-term and long-term contraceptives. There has been a 20 percent reduction in the use of oral contraceptives, even though telemedicine services are operational, and pharmacies are all open. The user rate has reduced significantly in Chattogram, Kishoreganj, Narail, Netrokona and Rangpur.

We also found that number of unsafe abortions have been increasing day by day, which is in turn increasing the number of maternal deaths. Therefore, we must prioritise on safe abortion services to protect women from infections and further health risk issues caused by unsafe abortions.

We still put all the responsibilities on women for contraception. Men and women should both be a part of the process, as contraceptives are available for both. Yet, procedures such as non-scalpel vasectomies are rarely performed. Going forward, men must also become a part of the process by ensuring they are taking contraceptive measures instead of leaving the full responsibility on their partners. Contraception must be made available through door-to-door services, especially in rural areas. Our monitoring system must be strengthened to ensure the quality service. There should also be a dedicated research cell to conduct needs assessment surveys, so we can work and plan accordingly.  

S M Shaikat, Executive Director, Socio-Economic Rural Advancement Committee Bangladesh

According to a Population Reference Bureau policy brief, the failure rate of contraceptives is the highest among Bangladeshi youth aged 15 to 19. This group often discontinues using contraceptives for various reasons, even though they are not planning to conceive. As a result, most of them opt for abortions.

A considerable percentage of Bangladeshi youth depend on emergency contraceptive pills. They believe that the morning-after pill is an easy method to avoid pregnancies. However, they are unaware of the adverse side effects of these pills because the pharmacy salesperson does not provide any information about the side effects and complications. Contraceptive counselling support should be made available to the youth and adolescents.

Moreover, adolescents do not have the access to the proper services in the case of short-term contraceptive failure. Moreover, there is no accountability from manufacturers in case of product failure. Those whose rights are violated do not have the choice to hold the company or industry accountable for contraceptive failure. 

 There is a significant gap in service provision due to services being provided based on marital status. SRHR cannot be conditional for only those who are married. It is a human right.

Dr Halida Hanum Akhter, 
Senior Associate, Department of International Health, John Hopkins Bloomberg School of Public Health

Recent research studies found that most deaths during pregnancy are caused due to a lack of information and proper services. We should provide information to pregnant women and their families about how to save their life in case of complications. 53 percent of deliveries are still done at home. Among them, only 3 percent is carried out by trained midwives. The rest are carried out by untrained midwives, which oftentimes results in death.

In addition, 60 percent of adolescent girls are getting married, and they are the ones that need counselling on SRH. They are at a high risk of death from pregnancy, but adequate and proper counselling, information and awareness are not provided to these young girls.

Many young women are denied contraceptives at clinics and pharmacies unless they can provide a marriage certificate. This is discriminatory, as contraceptives should be provided irrespective of marital status.

Marriage itself can be violent from time to time. Most women get pregnant three to four months after getting married because they are not educated on contraceptives. Sometimes, women are forced to continuously bear children, as otherwise they are considered "unproductive" or "infertile".

We must ensure that women are informed where they can avail the services by the trained midwives. A sufficient number of midwives must also be made available for women at the upazila level so that all women can seek their services if they want.

To mitigate the shortage of skilled human resources, we must focus on task sharing and, in this regard, nurses are potential resources to provide family planning services. We should consider that and must take a plan to build their skills on family planning service.

Masrurul Islam, Country Director, Marie Stopes Bangladesh

Violation of women's rights start with child marriage, and it is said that approximately 50 percent of marriages in Bangladesh are child marriages. At this age, young girls are unaware of their rights, and they are also unable to express their opinions. During this pandemic, child marriage has increased even more. If we want to reduce this, we need a comprehensive plan. The government can offer financial assistance to the families of adolescent girls, which will help prevent families from marrying their daughters off forcefully to mitigate their financial problems. We need to incentivise raising and educating girls till they are adults and allowing them to get married when they choose to.

Marie Stopes Bangladesh has been working with a mission that "Children by choice not Chance". Therefore, these rights are our key concern in providing SRH services. To design and implement our program, we always consider, women's participation in the decision-making process as these are the fundamental to the empowerment of women. 

During the pandemic, we are trying to open our clinics so that women have proper access to our services. All of us working in healthcare in the country need to re-evaluate our strategies to ensure that they are feasible given the current conditions posed by the pandemic.

Quazi A K M Mohiul Islam, Former Director General, Directorate General of Family Planning (DGFP)

The pandemic threatens our progress in health and family planning. To overcome this, we need transformational family planning programs. The organisations working on family planning need to replicate the proven innovations to monitor their clients digitally. We should enable our field workers to move faster by providing them with transport such as cycles or motorcycles. We need to identify the vulnerable families that are susceptible to child marriage and provide them with incentives and education to discourage this practice. Child marriage is the underlying cause of around 20 percent of deaths in maternal mortality. The parents should be made aware of the dire consequences of child marriage, as well as the importance of SRH. The ideas of youth, for better access to SRH services during pandemic, should be included in our planning.

Due to geographical diversity, different regions suffer differently. Due to uniqueness of region-specific challenges, we should develop region specific strategies to achieve national and global goals.

Dr Nurun Nahar Begum, 
Line Director, DGFP

Considering the Covid-19 situations, our family planning directorate established a telemedicine and information centre for 24-hour service, which can be reached through 16767.  Besides this, we have developed infection prevention guideline for family planning, maternal and adolescent health services. We are providing virtual orientation to the service providers, introducing digital supportive supervision, assigning Depo-holders at the community level to continue expanding access to SRH services. DGFP also formed taskforce at the Ministry of Heath and Family Welfare level, as well as the divisional, district, and sub-district level to continue the field level implementation. We have increased the distribution of pills and condoms to the users for an extended duration of two to four months.

We have been implementing a nationwide campaign to provide information on family planning, reproductive health, adolescent health, etc. However, there is no doubt that like other programs, family planning programs have also been disrupted.  Restricted physical mobility, fear of Covid-19, limited awareness about Covid-19, are key challenges to the implementation of our plan and programs. Simultaneously, we are also facing challenges due to shortage of human resources.

Dr Mohammed Sharif, Director (Maternal and Child Health-Services) and Line Director (Maternal, Child, Reproductive and Adolescent Health), Directorate General of Family Planning

During this pandemic, contraceptives and other commodities have been made available in each clinic. We have successfully facilitated the Electronic Management Information System (EMIS) in 36 districts. But we must implement the EMIS in all the districts of the country. I also recommend that the ministry provides an ambulance service dedicated to pregnant women in each upazila to increase the number of institutional deliveries.

We are providing medical menstrual regulation services, but women are opting to buy unprescribed contraceptive medication from local pharmacies, as it is easier to access. Without the consultation of a doctor, these unprescribed contraceptives sometimes fail to work, as most people are not told how often they need to consume these contraceptives, or about the possible adverse effects on their health.

At the same time, we need to help infertile women, as they are often the ones who face the most violence due to infertility which society views negatively. We will try our best to set up fertility clinics in every division to help women facing infertility.

We have a quality assurance team in each district, but we have lack of human resources, we have posted 1,450 doctors but only 736 doctors are employed. I am asking for support from the development partners to provide volunteers in ensuring the service to our people.

Mohammad Abdus Salam Khan, Joint Secretary, Ministry of Health and Family Welfare

The theme of the World Population Day this year is set as 'Rights and choices are the answer: Whether baby boom or bust, the solution lies in prioritizing the reproductive health and rights of all people' which is extremely relevant to our context. SRHR include a girl's choice to choose when she will get married, when she wants to get pregnant, and how many babies she wants to take. This right does not and should not depend on her financial status and education level. Unfortunately, neither the adolescents nor the people around them are aware of the rights, let alone implementing them.

Child marriage is one of contributing factors to unplanned pregnancies. Unplanned pregnancy leads to unsafe abortion and eventually to maternal death. Pregnancy is not a disease, but mothers die due to pregnancy related complications. We cannot let this continue to happens anymore. Our commitment is to make sure every pregnancy is expected and planned.

Although, the issue of child marriage is beyond our jurisdiction, we are working collectively for building awareness by implementing nation wide campaigns through print and electronic media on the consequence of child marriage and risks associated with early pregnancy, as well as awareness around SRHR.

The Ministry of Health and Family Welfare is implementing Fourth Health, Population and Nutrition Sector Program to ensure that all citizens of Bangladesh enjoy health and well-being by expanding access to quality and equitable healthcare in a healthy and safe living environment.

Ensuring SRH is a key commitment to ensure we meet the targets set by our SDGs and the International Conference on Population and Development (ICPD). However, it is not possible for the government to implement these rights by themselves. We need to approach this together as a society. In this regard, I am requesting all, especially the print and electronic media, development organisations, UN agencies, NGOs and INGOs to come forward to proactively participate in the campaign to ensure the SRHR of women and girls are realised.