Confronting stagnation in Bangladesh's contraceptive uptake

World Contraception Day, observed on September 26, raises awareness about family planning and contraceptive access. This year's theme, "A choice for all. Freedom to plan, power to choose," emphasises individuals' fundamental right to make informed decisions about their reproductive health. "A choice for all" highlights the need for universal access to contraception, ensuring everyone can decide if, when, and how many children to have. "Freedom to plan" underscores the role of family planning in enabling individuals and couples to shape their futures and balance personal goals with available resources. Finally, "Power to choose" emphasises the autonomy that comes with control over reproductive choices, free from societal, economic, or cultural barriers.

This focus is particularly relevant as the world, through the Sustainable Development Goals (SDGs), has set ambitious targets to reduce maternal and child mortality, empower women, and ensure universal access to sexual and reproductive healthcare by 2030. While the world continues to grapple with population growth, effective family planning and contraception are crucial to achieving these goals. However, with only six years left to meet the SDGs, over 164 million women globally who wish to avoid pregnancy are still not using contraception. This accounts for approximately 8.6 percent of the 1.9 billion women of reproductive age worldwide, with the majority living in low and lower-middle-income countries (LMICs), where relevant indicators have shown little progress over the years. A similar situation is evident in Bangladesh, where the 2022 Bangladesh Demographic and Health Survey reported a 10 percent prevalence of unmet need for contraception, a rate comparable to that recorded a decade earlier in 2012. This stagnation has slowed progress on key maternal and child health indicators, including maternal and child mortality.

Earlier in the 2020s, Bangladesh was often cited as a model for LMICs aiming to build strong family planning programmes, and with good reason. The country has had one of the strongest and most successful national family planning initiatives in the world, increasing its contraceptive prevalence from only three percent in 1971 to 58 percent in 2004. This groundbreaking success contributed to reducing the total fertility rate from 6.3 to 3 children per woman and maternal mortality from 600 to 372 per 100,000 live births between 1975 and 2004. However, Bangladesh's progress stagnated following the 2000s, with contraception use increasing only by six percent, from 58 percent in 2004 to 64 percent in 2022. The unmet need for contraception has remained constant since the early 2000s. Long-acting and permanent methods (LAPMs) remain very low at eight percent over the decades. As a result of this stagnation, Bangladesh has failed to meet the commitments it made at the 2012 London Summit on Family Planning, including increasing contraceptive use to 75 percent by 2021 and improving the choice and availability of LAPMs.

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Is family planning solely women’s responsibility?

Several factors may explain the stagnation in contraceptive use and the unmet need for contraception. These include religious norms, social and community-level restrictions, the perception of contraception as solely a women's issue, and reproductive coercion—all of which have historically been prevalent among the Bangladeshi population. However, the most significant reasons appear to be the reduced efforts at the governmental level to increase contraception uptake, alongside a declining fertility rate and recent achievement of replacement-level fertility. This devaluation is concerning, given the country's high burden of unintended pregnancies (around 22 percent of total live births), short interval pregnancies (around 25 percent), and unsafe abortions.

The devaluation of governmental efforts has occurred through several pathways, affecting both exposure to family planning messages and the distribution of contraception. For instance, the exposure to family planning messages that Bangladesh ensured in the early 2000s through routine home visits by family welfare assistants (FWA) declined significantly. Moreover, the government has increasingly privatised the supply sources of modern contraception methods. In contrast, private sectors, including pharmacies and private hospitals, have become the dominant sources of modern contraception.

Several interconnected challenges have diminished the effectiveness of field level family planning services, contributing to the stagnation of related rates—governmental devaluation being among the most significant. Other challenges include field-level issues faced by FWA, such as the lack of monitoring of their activities and a serious level of dissatisfaction with their jobs, stemming from low salaries and limited acceptance within the community. These issues have largely gone unaddressed over the years, hindering their effectiveness, leading to a higher number of vacant FWA positions across the country. Besides, the population of Bangladesh since the establishment of the FWAs in 1980s have almost doubled, and FWAs are now serving couples at double the rate they did in the 1980s. Moreover, FWAs are increasingly engaged in other activities, such as vaccinations. Consequently, while the provision of family planning services at the household level remains operational, there appears to be less enthusiasm than in the past, resulting in lower quality of services and fewer visits.

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Despite progress, there are miles to go

Since the early 2000s, Bangladesh has shifted contraception distribution from field-level visits by FWA to healthcare facilities. This change signals to FWA that women should collect contraception from the nearest facility, which may lead them to focus less on field-level distribution and more on other duties. Contraception is culturally sensitive in Bangladesh and requires privacy for discussions, yet facilities often lack private spaces. Overcrowding at healthcare centres means that workers, prioritising maternal healthcare, have limited time for contraceptive counselling. Even when time is available, many healthcare providers feel uncomfortable discussing family planning despite having MBBS degrees. Additionally, coordination between household-level services and healthcare centres is minimal, leading to unequal coverage and some individuals missing out on services. The overcrowding also drives people to rely on private sources for contraception, though increasing purchasing power also contributes to this trend.

These factors represent systemic challenges to contraceptive uptake and contribute to stagnation in related indicators. Regardless of these challenges, ensuring universal access to contraception is crucial, not only to meet SDG targets but also to empower women to control their fertility and plan their families. Immediate governmental focus on this aspect should be a priority.

Dr Md Nuruzzaman Khan is associate professor in the Department of Population Science at Jatiya Kabi Kazi Nazrul Islam University in Mymensingh and also an associate fellow of the Bangladesh Academy of Sciences, Dhaka, Bangladesh, and a McKenzie Fellow at the University of Melbourne, Australia. He can be reached at Nuruzzaman.khan@unimelb.edu.au.

Views expressed in this article are the author's own. 

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