Contraception among Adolescents in Bangladesh

Introduction:

Contraception has been practiced within the family unit for thousands of years throughout history, various civilizations and cultures have used a variety of plant extracts, herbs and mechanical devices to control fertility. However most of these were ineffective by today’s standards. Even the spermicidal agents, mechanical barriers and the rhythm method used in modern society are not very reliable. As the world experienced a ‘Population explosion’ during the second half of the present century the need for fertility control extended beyond the family to society levels as a means of limiting the population growth to a level within their socio-economic capabilities. With the willingness of various governments to support birth control programs and the advocacy of feminist leaders and increased financial support for biological research, the development of oral contraceptives began in 1950. However it was not until the early 1960’s that contraception became reliable and accepted effectively. The oral contraceptives remain among things the most effective reversible methods of birth control available today, providing almost 100 percent effectiveness with an impressively high margin of safety and  other important health benefits.

A lack of knowledge of contraceptive methods or a source of supple, cost and poor accessibility are the barriers that exist in these countries. The health concerns of these individuals also stop a lot of women and men from using modern contraceptive methods. Side effects perceived or real are a major factor for the abandoning of the modern methods, unintended pregnancies leading to induced abortions are the major drawback in the vaginal methods, periodic abstinence and withdrawal. These methods have the least health concerns but have frequent contraceptive failures. Bongaart and Bruce (1995) estimate that the health concerns reduce prevalence on an average of 71 percent for the oral pills, 86 percent for IUCDs and 52 percent for sterilization. The users for contraceptive methods in the subcontinent come from different socio-economic groups and demographic subgroups within a country are highly segmented.

In reproductive health there is an awareness of women’s and men’s views on contraception. Bruce emphasized no product can be fully acceptable if its intrinsic properties or service delivery procedures are ominous t the user’s personal and cultural needs (Bruce 1987). These research articles are very informative about the views of the people on contraceptive methods and this knowledge can help us in “developing and modifying technology and family planning programs to fit people rather than modifying the people to fit the programs” (Marshall 1977). Women’s perspectives on technologies and services are much appreciated now, “since women bear the brunt of the responsibility for fertility regulation, it is vital to include their perspectives in research on fertility regulation (Van Look P and Perez-Placois 1994). Who also aims to “expand its technical support for family planning services with broader reproductive health perspectives, placing particular emphasis on the needs young people (WHO EB 95/98). The objective of this chapter is to compare contraceptive prevalence among the adolescent and adult women married women in Bangladesh. A regression analysis is performed to assess the factors that affect the use of contraceptive among the married women.

Contraceptive Behavior among the Women of Bangladesh:

Women’s lives are in transition. There is a definitive fertility decline in Bangladesh that begun in 1980. Women’s statements reveal their awareness of socio economic transition and their interest in family size limitation which was bolstered by a strong family planning program. Although shifts in the social and economic circumstances are not large, in conjunction with strong family planning programs they constitute a powerful force for a change in attitudes, ideas and behavior in these women (Simmons R. 1996).

Some studies have been carried out in Bangladesh have been carried out in Bangladesh many of them in the Matlab area were family planning workers have offering various methods of contraception for at least 20 years. In a study conducted here in 1987-1988 a women remembered the arrival of ac community based family planning worker in her village 10 years early before she was married. The discussions showed that many young unmarried women learn about family at an early age from these community based family planning worker, female relative, and the media (Mitra R 1995).

Although contraceptive prevalence among currently married women of reproductive age is increasing rapidly in many developing countries, the rates have not yet reached those of developed countries. The level of contraceptive use in most developing countries is higher among women in their thirties and, typically, lowest among teenage women and women in their forties (United Nations, 1987). Studies in developed and developing countries demonstrate that behavioral patterns of contraceptive and developing countries demonstrate that the behavioral patterns of contraceptive acceptance and use differ significantly between adolescents (females) approximately 10-19 years of age) and adults (women 20-49 years) (United Nations 1980). This difference may attribute to the maturity, greater knowledge and experience of adults compared with adolescents.

Such considerations as desired family size and child-spacing influence contraceptive prevalence among married women at the individual level, while at macro level, laws and regulations and cultural mores are important factors that determine access to contraception. Some laws relate specifically to female teenagers. Both married and unmarried adolescents face the added obstacles of legal or cultural restrictions which limit their access to family planning services. However, unwanted pregnancies resulting from lack of contraceptive use have led to an increasing number of abortions among young women. In many parts of the world, despite the fact that young women are often denied access to legal abortion service, both the number and the proportion of abortions performed for young women have been increasing over time.

Aside from external influences at the socio cultural and policy levels that affect an adolescents’ contraceptive behavior, factors which vary at the individual level are also important, such as whether or not contraception occurs with a stable relationship, and whether or not either partner has previous experience with contraception.

Although contraceptive use rate is gradually increasing in Bangladesh, it is still very low compared with any developed country and many developing countries. Since the average age at marriage (15.02) years in Bangladesh remains one of the lowest in the world, a large proportion of the potential acceptors of contraception are married adolescents. The adolescent phase of human life is often termed as a very “demographically dense” phase because more demographic actins occur during these years than at any other stage of life.

Unfortunately, no exclusive and comprehensive study on the contraceptive behavior of married adolescents in Bangladesh has been undertaken; therefore, in view of the importance of this matter, an attempt has been made in this study to investigate their contraceptive behavior. For comparison, consider the contraceptive behavior of married adults along with that of adolescents.

There has long been strong social pressure for the preservation of virginity until marriage, which is cultural characteristic of the great majority of people in Bangladesh irrespective of their religion (Maloney   and others, 1981). Religion has a strong influence on early child marriage. The majority of Bangladeshis who are Muslim (about 85 percent of the total population) think that girls should be married immediately after menarche. In Bangladeshi society sex outside marriage occurs only seldom since premarital six is looked down upon harshly.

Marriage is almost universal in Bangladesh. By age 35, almost 100 per cent of females have been married. Bangladesh Fertility Survey (BFS, 1989) data suggest that 96 percent of ever married women were married when they were teenagers (Islam Nand Islam, 1993, Mahmud, 1994). This gives rise to a very low average age at first marriage in Bangladesh, i.e. only 14.8 years. Several studies conducted in the 1960s and 1970s also reported very low age at marriage (Obaidullah, 1966, sadiq, 1965, Khuda, 1978). The mean age at marriage among all ever-married women in Bangladesh was reported to be 12.3 years (BFS, 1975).

Adolescent fertility contributes substantially to overall fertility in Bangladesh, accounting for about 18 per cent of the total number of births (Huq and Cleland, 1990). The adolescent fertility rate, measured as the number of births per thousand women aged 15-19 years, was observed to be 239 per thousand in Bangladesh, whereas it is only 7 per thousand in the Republic of Korea, 35 per thousand in Sweden, and 44 per thousand in the United Kingdom of Great Britain and Northern Ireland (UN, 1988). This variation in the levels of adolescent fertility may be attributed largely to differences in the age at which women marry and the extent to which young married couples use contraception.

The objective of this chapter is to find and assess the practicing behavior and knowledge among the eve married

Knowledge of Family Planning:

Usually knowledge of contraceptive method refers to whether the respondent had heard of or knows of a family planning method. In the 1989 BFS, data on knowledge of family planning methods were collected through a series of questions by following what is popularly known as the “recall and prompting” procedure (WHS, 1980). The main purpose of the questions on knowledge was to define for the respondent exactly what is meant by contraception or family planning.

Table 6.3 presents the percentage of adolescent and adult women who were aware of any modern contraceptive method. It shows that knowledge of contraceptive is almost universal among both adolescents and adults in Bangladesh. Almost all the adolescents and adults interviewed were aware of certain family planning methods. However, it is obvious that knowledge of various modern methods of contraception does not imply that the respondents actually knew how to use these methods effectively.

Table 6.3: percentage of adolescent and adult ever married women who are aware of contraceptive method:

Among the adolescents 12.26 percent reported that they had knowledge of modern method as opposed to 87.5 percent of the adults, whereas it is found that percentage of ignorance about contraception among ever married women (both adolescent and adult) is least. But knowledge about modern method is lower among the adolescents (12.5 percent) than their adult counterparts (87.5 per cent). This situation indicates that knowledge about contraceptive methods is slightly lower among adolescents than adults in Bangladesh.

Ever Use:

The term “ever use” refers to the use of a contraceptive method at any time before the date of interview without making any distinction between past use and current use. Any respondent reporting that she or her spouse had ever used some form of contraception was counted as an ever user regardless of the time of use. Also, and ever user might have used more than one method. The following table 6.4.1 represents the percentage use of contraceptive methods among the adolescent and adult ever married women. It is evident from the table that folkloric method is used by 4.17 percent of the adolescents and 95.83 percent of the adults. However the most surprising aspect of the ever use of contraceptive methods is that, modern method comprised a significant proportion of ever use of contraceptive among the adults (89.77%) but among the modern method users only 10.23 percent is adolescents. Traditional method is more popular among the adults than the adolescents. Among the users of folkloric method proportion of adolescent comprises only 4.17percent whereas proportion of adults is 95.83 percent.

Table 6.4.1: Percentage of adolescent and adult women who have ever used contraceptive methods:

 Table 6.4.2: Percentage of current use of contraceptive among adolescent and adult women:

 Again the following table 6.4.2 is given to assess the levels of different contraceptive methods that are currently used among the adolescents and adults women. The table shows that among the pill users only 13.19 percent are adolescents and 86.81 percent are adults. Among the IUD users 91.39 percent are adults and 8.6 percent are adolescents. Similarly in other methods it is clear that practice of contraception is dominated by the Adults. However and important aspect of the ever use of contraceptive methods is that, practice of male and female sterilization is absent among the adolescents.

Factors affecting Current Use of Contraception:

In this section, multiple regressions are used to identify the factors affecting contraceptive use among the married women. Current use of contraceptive is considered as the dependent variable and the explanatory variables are:

• Duration of marriage
• Respondent involved in income generation
•  Desire for additional children
• Number of living children
• Discussion of family planning with partner
• Respondent’s education
• Husband’s education

Here a hypothesis is made to assess that women’s autonomy influence their access to modern knowledge, modes of action and hence their propensity to engage in innovative behavior, including fertility limitation within marriage. Table 6.5 presents an estimate of the regression coefficients β corresponding to the selected explanatory variables, Odds ratio of these estimates.

Table 6.5: Regression analysis of current contraceptive use among women on some socio-demographic characteristics

Here, ‘*’ indicates reference category.

From the above tables it is clear that the current use of contraceptive is positively associated with respondent’s involvement in income generation, discussion of family planning with husband, economic independency whereas, it is inversely related with the desire for additional children . This indicates that desire for additional children preference is still a major constraint in the adoption of contraception. The higher the desire for more children the lower is the likelihood that a woman adopt contraception.

Similarly, women who are involved in income generation program can take financial decision independently are likely to be contraceptive users. Husband and wife’s interaction is important whether or not a couple should use contraception. Education of respondent and her husband is another important factor that influences the current contraception use. Maternal education is a strong predictor in the multiple regression of current use of contraception.

Marital duration has no impact on the usage of contraceptive method.

Working and educated respondents have the exposure to know about the current contraception methods and are aware of family planning issues. Their contraceptive usage plays an important role in the reduction of fertility.

Conclusion and policy Implication:

The study contains a number of implications for policy purposes that could be useful in devising ways to increase the contraceptive prevalence rate among adolescents and thus bring about a further reduction in fertility in Bangladesh.  These are as follows:

• Provide education to and create more employment opportunities for young women to increase their status in society.
• Create awareness among adolescents about the negative health, social and economic consequences of early marriage, early pregnancy and large family size. This could be done through special information, education and communication (IEC) campaigns, regular home visits by family welfare visitors (FWVs) and family welfare assistants (FWAs).
• Proved adolescents with information on the availability of family planning methods and their use-effectiveness.
• Improve the quality of care of reproductive health services and make them available at the door-step; and
• Devise programs designed to overcome the resistance of husbands and in-laws