Bangladesh must shift focus from population control to population management
Bangladesh once grappled with an exceedingly high fertility rate, which coincided with poor maternal and child health outcomes, including higher rates of maternal and child mortality. In response to these challenges, with the dual aim of curbing fertility rates and managing population growth, the nation prioritised family planning services and minimum healthcare for the entire population, beginning with the first five-year plan in 1973-78.
These initiatives involved a distinct framework for healthcare and family planning services, representing a transformation from the previous uniform framework, with a particular emphasis on ensuring the accessibility of family planning services at the community level. These programmes strengthened in subsequent years, with the recruitment of female field workers to provide household-level family planning services (initiated in 1976 with the First Population Policy) which later evolved to ensure services provided at the household level every 14 days (as part of the second Population and Family Health Project in 1980), and the establishment of family planning services through upazila health and family welfare centres (during the third five-year plan from 1985-90).
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The unification of health and family planning wings at the thana level or below was implemented in 1997 (as part of the fifth five-year plan) to ensure that family planning services were available both at the household level and at the nearest healthcare facilities. These initiatives made Bangladesh become an unlikely success story, with contraceptive prevalence increasing from eight percent in 1975 to 62 percent in 2014—a 55 percent increase over 39 years. Moreover, the total fertility rate plummeted from 6.7 to 2.2 during the same period, indicative of fertility levels approaching the replacement level of fertility. Other maternal and child health indicators, including maternal and child mortality, have also exhibited noteworthy improvement. However, one notable point is that the improvement of these indicators, which was quite significant before the turn of the millennia, has slowed down since then, while some indicators including contraception use rate have stagnated.
With notable strides in family planning, maternal and child health, and an increase in life expectancy by approximately 22 years between 1972 and 2021, credited to advancements in healthcare services, Bangladesh now finds itself in the third stage of demographic transition—a phase marked by rapid population growth. This growth is accompanied by two effects: firstly, the "black hole" phenomenon of population momentum, stemming from a youthful age structure rather than achieving replacement-level fertility; and secondly, an increase in life expectancy. The black hole effect of population momentum has also provided an opportunity for the country's rapid economic growth, driven by a larger proportion of the population being in the active working age group—a phenomenon commonly referred to as the demographic dividend.
However, despite these advantages, concerns are rising as projections indicate that Bangladesh may lose these advantages related to the population within the next three decades. The demographic dividend is expected to expire by 2035-36, and population growth is projected to cease by 2057 with the current level of family planning programmes, and this may occur earlier if family planning programmes and coverage are further strengthened. Both scenarios indicate a transition towards an older demography and a higher dependency ratio—a trajectory similar to that experienced by China, a country that implemented the One Child Policy (1980-2015) and subsequently revised it to allow for more children. Importantly, with such impending changes related to declining fertility rates, Bangladesh still grapples with a high rate of unintended pregnancies (22 percent among total live births) and short interval pregnancies (24 percent), and related poor maternal and child health outcomes.
These factors create challenges for Bangladesh in achieving the maternal and child health-related targets set in the Sustainable Development Goals by 2030. Effective family planning methods and counselling are still crucial to address these challenges.
However, with these challenges, Bangladesh now approaches population management through a focus on family planning and reproductive health, rather than strict population control measures as implemented before. This change in focus may be responsible for declining home visits by family planning workers and exposure to family planning messages that the country has been observing since the early 2000s, possibly leading to the stagnation of contraception use. It is important to mention that although the stagnation of contraception use rate has been reported, the current framework of family planning services provides help to an additional 30 million women who enter married life each year in Bangladesh, and this number is significantly higher than the number of women who exit from their reproductive life. This indicates that stagnation is occurring in the overall rate.
Such changes and stagnation may negatively influence rural, uneducated, and underprivileged people among whom the prevalence of unintended pregnancy, short interval pregnancy, as well as early marriage, adolescent pregnancy, pregnancy complications, maternal and child mortality are highly concentrated. Poor access to and use of maternal healthcare services and nutritional burdens including undernutrition and anaemia are also concentrated among these groups.
Importantly, the total fertility rate is also still high among these groups, at around 2.80 to 3.10, compared to 2.0 among the advanced group. There are several possible pathways to such a rising burden, including a lack of adequate knowledge and awareness that hinders their capacity to access family planning and contraception in the absence of home visits and availability at the community level. Moreover, structural challenges at the healthcare facility level may also hinder their access. Therefore, focusing on management without ignoring the needs of disadvantaged groups may increase this rate further, posing a significant burden for the country. Bangladesh is therefore still in need of focusing on family planning services and contraception as before, although different strategies may be implemented to address issues covered by population management.
Dr Md Nuruzzaman Khan is an assistant professor at the Department of Population Science in Jatiya Kabi Kazi Nazrul Islam University and associate fellow of Bangladesh Academy of Sciences.
Views expressed in this article are the author's own.
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