Family Planning Among Married Adolescent Women in a Rural Area of Bangladesh

INTRODUCTION

A proverb runs thus – “Womanhood of a woman is expressed through her motherhood”. Despite the proverb being true, many married women at some time in their reproductive life do not desire to be pregnant. Nevertheless, they do not use any contraceptive method to avoid becoming pregnant. These women are considered to have an “unmet need” for family planning.¹ This gap between some women’s reproductive intention and their contraceptive behavior clearly poses a challenge to family planning program to reach and serve a huge number of women whose reproductive attitudes resemble those of contraceptive users, but who, for some reasons, arc not using contraceptives. Thus unmet need for family planning group includes all fecund women who arc married and living with her husband but who are not using any method of contraception and who either do not want to have any more children or who want to postpone their next birth for at least two more years. The unmet need group also includes all pregnant married women whose pregnancy are mistimed or unwanted. This study intends to find these women to identify the reasons for their unexpected contraceptive behavior so that the issue can be duly addressed.

During the last two decades, Bangladesh has achieved commendable success in its national family planning programme. The average annual increase in the CPR for the last 15 years is 2%, the current use of family planning methods has increased six-fold from about 8% in 1975 to about 45% in 1993 to 1994. Such a magnitude of increase in the CPR has resulted in considerable fertility decline in the country – TFR has been halved during the same period reaching 3.4 in 1993 – 94. The family size has now drastically changed – a high proportion of the couples now consider two-child family an ideal family norm.” About two-third of the married women of the country now use a family planning method at some time in their reproductive life. The success of FP programme has led a number of scholars to recognize that a fertility transition is underway.³ The programme is now on the verge of entering into the third stage, i.e., a transition between take-off and self-sustained growth.

Much has been attained but much more has yet to be attained. We, therefore, have to identify the problems, set program objectives and determine the course of actions to be undertaken for the stage of self-sustained growth. The main tasks for this stage seem to be 1) to sustain the level of program output already achieved, 2) to increase the output further, 3) to accelerate the impact of the program and 4) to increase the cost-effectiveness ^r the programs to be undertaken.^4,5 In order to achieve the national demographic goal, our FP program must focus not only on providing services to about 12 million current contraceptive users, but also on finding out the potential users who are presently not using a contraceptive but have an attitude resembling a user.⁶ In order to bring a long term sustainability in the family planning program, we have to put concerted efforts to transform these intenders (potential users) into users. The challenges are undoubtedly formidable, but certainly not insurmountable given our past accomplishment. It is possibly the recognition of the above challenges which had led the Government of Bangladesh to formulate a new strategy for the national family planning program with the vision to achieve a set of defined goals in the next 10 years. The goals are to increase access to family planning services for all potential users, improve quality of family planning services to enhance users’ confidence upon the services, enhance male participation, and revitalize the use of long-term methods and to reach the replacement level of fertility. Of all the above goals, priority option is to increase access to family planning services for all those who have an unmet need for contraception.

Since the identification of “discrepant behavior” among women desiring to control their child-bearing but not using contraception, unmet need has become a much-talked about issue, both among academics and policy makers. It has emerged as a plausible rationale for action programs and as a measure for the probable ‘market’ for contraception. That the international community has unanimously agreed to the usefulness of this concept is also reflected in the following statement of the International Conference on Population and Development – “Government goals of family planning should be defined in terms of unmet needs for family planning information and services.”⁸ In recent years much attention has been devoted to the replacement of demographic targets by a focus upon unmet needs, because this strategy is expected to raise the contraceptive prevalence above the level inherent in the demographic target.⁹ However, in order to shift the programmatic target approach to unmet need, strategies and program components should be redesigned, which in turn, requires analysis of contraceptive prevalence, unmet need subgroups by age, sociocultural perspective, ethnicity and son thus justifying the need of the present. The program should be redesigned in such a way that each subgroup can effectively be dealt with yielding maximum output in terms of input given.  

RESEARCH QUESTIONS & OBJECTIVES  RSEARCH QUESTIONS & OBJECTIVES

Keeping consistency with the above background information and rationale state for the study the following research questions and objectives were addressed.

Research questions:

• What proportion of married adolescent women are using contraceptives?

Objectives:

 General:

To find out the acceptance of family planning method and also to determine the magnitude of unmet need for family planning among adolescent married women in the rural area Bangladesh.

 Specific objectives:

• To find out the contraceptive prevalence among married adolescent
  women in rural area.
• To estimate the proportion of adolescent married women with unmet
  need for family planning.

• To study the sociodemographic characteristics of those women.
• To find the gap in information about access to family planning services.
• To find the barriers in access to information about FP services

LITERATURE REVIEW

An Overview:

Amongst the densely populated countries in the world, Bangladesh ranks number one. Around 130 million people live in Bangladesh with majority below the level of poverty. Based on calorie intake, 50 percent of the rural population and 46.8 percent of urban population are considered to lie below the poverty line. The literacy rate of the population aged five years and older is 45 percent (males 48 and females 40 percent); and life expectancy is 59 years for both males and females.¹⁰ Although infant and child mortality levels have declined they are still high owing to relatively poor MCH services, less than optimum birth spacing and widespread malnutrition. among children.¹¹ Resources scarcity and subsistence-level economic are inherent features of our economy.⁵ Although total fertility rate has much declined during the last two decades, Bangladesh has yet to reach the replacement of level of fertility.¹² In order to accomplish the objective,, Bangladesh FP program has already redefined its goals emphasizing unmet need for family planning as the highest priority to address.

 Regional distribution of contraceptive use and unmet need:

Contemporary literatures about contraceptive use rate and unmet need reveal that countries such as Burundi, Liberia, Uganda, Sudan, Ghana and Mali are still in the second stage of fertility transition.¹³ They have low use rate and high unmet contraceptive need (UCN). Sharply contrasting to these data, countries such as Sri Lanka and Thailand in Asia and Brazil and Colombia in Latin America are in the fourth stage of transition. These countries have satisfied most of the unmet need to raise the CPR to an appreciably high level. Bangladesh and a number of other countries like Mexico, Tunisia, Indonesia, Ecuador, Peru, El Salvador, Trinidad, and Tobago are presently in the third stage and have moderately high unmet need and use rate.

Gain in FP planning during the last two decades:

Bangladesh has already crossed the first two stages of transition and is passing through the third stage. If the existing unmet needs are effectively addressed many intenders are expected to turn into users.¹⁴ despite the low socio-economic indicators, Bangladesh has responded well to many family planning indicators. Ever use of any contraceptive method increased five­fold during the past two decades, from 13.6% in 1975 to 69.2% in 1997. Total fertility rate (TFR) dropped by half during the same period, the use contraceptive method increased five-fold during the past two decades, from 13.6% in 1975 to 69.2% in 1997. CPR increased six fold, rising from 7.7% »49.2%. Total fertility rate (TFR) dropped by half, from about 6 children per women to about 3 children per woman. However, Bangladesh still has a long way to go to achieve the replacement level of fertility, about 2.1 children per women. The CPR would have to be raised to over 70 percent for this target to be realized.¹⁵ Therefore, the challenge for Bangladesh is not only to sustain the present level of contraceptive users from about 12 million to over 22 million, but also to raise the CPR by at least an additional 20 percent. The later goal though difficult to attain, is not altogether impossible. The CPR could be raised by 20 percent if the program is able to bring within its fold that segment of the population described as having an unmet contraceptive need.

Concept of unmet needs:

The term unmet contraceptive need is conventionally defined as the percentage of currently married women in their reproductive ages who do not want additional children and yet are not practicing contraception.¹⁶ The family planning needs of these women are implicit; they do not want any more children, and therefore, can be considered as having a potential demand for family planning. Further program can devote sufficient efforts to motivate them to practice contraception.

Westoff (1978) originally proposed eight measures of unmet contraceptive need. These measures range from including all currently married women of reproductive age regardless of their current pregnancy of breastfeeding status, who say that they do not want any more children and are not practicing contraception, to only currently married non practicing limiters who are not pregnant and not breast feeding but are fecund.¹⁷

According to the standard definition, the unmet need group does not include pregnant or amenorrhea women whose current pregnancy or recent birth was intended even if they do not want to become pregnant again right way. Also, women who become pregnant unintentionally because of contraceptive failure are not considered to have an unmet contraceptive need in general, although they may be in need of more reliable contraceptive.¹⁶‘^Is

As per operational definition of the concept, the UCN includes: women who are fecund, not pregnant and non-amenorrhea, but who currently do not use any methods and want either to limit of delay child-birth or unsure about whether or when they want to have birth; pregnant women whose pregnancy was mistimed or unintended;   and amenorrhea women whose latest pregnancy was mistimed or unintended.

According to BDHS, 2005-2006 the estimated unmet need is 22.9% which include 12.9% of women who wanted to limit (unmet need for limiting births) and 10% of women who wanted to delay child-births (unmet need for spacing births). Among the three subgroups of non user women, the subgroups non amenorrhea nonpregnant is most important accounting for 15.5% unmet need. The pregnant women constitute 2.8% and the amenorrhea women 3.4% unmet need.

According to the 2006/2007 BDHS, half of the currently married women in the reproductive age groups do not want any more children; 9% of those women were sterilized. More than one-third (36%) of those women wanted to have child at some time in future; however, most of those women (22%of all married women) would like to wait 2 or more years before having their next child birth. Only 13% wanted to have child soon; 3% were undecided about whether they wanted another child. Thus great majority of women wanted either to space their next birth or to limit their child bearing altogether.

These   women   can   be   considered   as   having   a   potential   need   for contraception.¹⁸

Sociodemographic condition and CPR among adolescent women:

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 teen age women and women in their forties. Unmet need was higher among the younger women in the 2006/2007 BDHS; however, data from the 2006/2007 BDHS showed that, except among the oldest age groups, unmet did not differ much by age. Studies in developed 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). This difference may be attributed to the maturity, greater knowledge and experience of adults compared to adolescents.

Unmet need was higher among rural women (19 and 17%) than among urban women (15 and 11%) in 2004/2005 and 2006/2007 respectively. In the 1998/2000 survey it was highest among women in Chittagong and Barisal divisions (28 and 20% respectively); in the 2006/2007 survey, it was highest in Chittagong and in the newly formed Shylhet divisions (21 and 23% respectively). Unmet need for contraception was lowest among Rajshahi and Khulna divisions (14 – 16 and 12% respectively) in both surveys. Unmet need was slightly lower among women with some secondary schooling than among those with little or no education. No significant difference was found in unmet need among educated women and their uneducated counterparts in the 2006/2007 survey; however, there were significant differences in education in 2002/2004 survey. In the 2000 BFS, women with highest level of education (secondary and higher level) were 3 times as likely to practice contraception as those who had no education. As expected, education increases receptivity to new technologies including awareness and use of contraception. Educated women also may desire fewer children than their less educated counterparts because of the incompatibility between formal sector employment and child care.²⁰

The number of living children was emerged as the best predictor of unmet need for family planning in the 2006/2007 BDHS. Unmet contraceptive need increased with the increase in the number of living children. Desire for additional children declined among women who had achieved their desired number of children and who might need contraception for any on births. Unmet need was more than 2 times higher among women who had five or more children than among those who had no children In both surveys, unmet need was significantly lower (p < 0.001) among the ever users of any family planning methods. Discussion about family planning methods between husband wife was also a significantly important factor for unmet need in the 2006/2007 BDHS,¹⁸ but it was not statistically significant in the 2002/2003 BDHS.¹⁹ In the 2006/2007 BDHS, Muslim women were found to have significantly higher unmet need than non Muslim women, although not statistically significant, unmet need was higher among Muslim women than non Muslim women in the 2003/2004 BDHS also.

In 1989 BFS,²⁰ contraceptive use was low (31.1%) among the group of ever married women under 50 years of age who were studied. The current use rate was found to be directly associated with the respondent’s age, number of living children and duration of marriage. The level of education of both the respondents and their husbands seemed to have a positive effect on the current use of contraception. Urban residents surpass rural residents in the current use of contraception. The experience of child loss has a negative effect on contraceptive use. Those who do not desire addition more likely to be current users that those who desires additional children, Husband wife communication also has a positive effect, showing the highest use rates among those women who took a decision about family size jointly with their husbands. With an increase in the frequency of the visits by family planning workers, contraceptive use increases rather rapidly. Non Muslim women had higher current use rates than Muslim women. Administrative division also had a substantial effect on contraceptive use; a lower rate observed in Chittagong division.

Logistic regression analysis showed that the significant variables are the respondent’s level of education, participation in family planning decision making, the administrative division where they live, their desire for additional children, frequency of visits by family planning workings, occupation of husbands, experience of child loss, sex composition of living children, place of residence, duration of effective marriage, age of respondents and availability of electricity in the households. The remaining explanatory variables, namely the number of living children, religion of respondents and education of husbands do not seem to have significant independent effects on the current use of contraception.

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

Although the contraception use rate is gradually increasing Bangladesh, it is still very low compared with any developed country and many developing countries. Since the average age at marriage (14.8 years) in Bangladesh remains one of the lowest in the world, a large portion of the potential acceptors of contraception are married adolescents. ^21,22

Married adolescents and unmet need:

The adolescent phase of human life is often termed as a very ‘demographically dense’ phase because more demographic actions occur during these years that at any other stage of life. The level of unmet need among married adolescents was higher in South Asia than the Southeast Asia; the Philippines were an exception. Substantial differences in unmet need among adolescents existed in each region. In South Asia, for example, 19% of married adolescents in Bangladesh had an unmet need for Contraception, compared with 41% in Nepal. Similarly the level of unmet need in Southeast Asia ranged from 9-10% In Indonesia and Vietnam to 32% in the Philippines. Most of the unmet need was for means of spacing births rather than means of limiting childbearing. The proportion of married adolescents who had an unmet need for means of limiting births was lower than 2% in all countries, except in Philippines, where it was 5%. During the last decade, The level of unmet need among married adolescents has declined in all countries for which comparative data was available, but the magnitude of decline varies across countries. Unmet need declined by more than 30% in Pakistan and Indonesia, compared with 15% in Bangladesh and 11% in India.^22,23

Marriage is universal in Bangladesh. By age 25, almost 100 percent 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.²⁴ This gives rise to a very low average at first marriage. Several studies conducted in the 1960s and 1970s also reported very low age at marriage.¹³ During the period 1975-1976, the mean age at marriage among all ever married women in Bangladesh was reported to be 12.3 years. The Proportion of females ever married among the 10-14 year of age group has fluctuated, declining from 9% in 1975 to 5% in I996-1997.^{39, (40(18)} However the proportion of females ever married among the 15-19 year age group, decreased from 70 percent in 1975 to 50 percent in 1997. The proportion of women ever married declined from 95 percent in 1975 to 83 percent among the 20-24 years age group in 1997. Thus, the average age at marriage has been rising although this still remains very low. The mean age at first marriage is now over 17 years (1996-1997). Very little change has occurred in the actual proportion of married teenage women since 1989, indicating that very little progress has been made in this area during the past decade

Like early marriage, early childbearing is the norm in south Asia. The practice is pervasive in Bangladesh, where 63% of currently Married women have had a child.²⁵ In India and Nepal, those proportions are 48% and 43% respectively. Although early marriage is less common in Southeast Asia, early childbearing within marriage is as frequent. 60% of currently married adolescents in Indonesia and 45% of those in Vietnam have had a child. Thus the gender roles, sexual behaviors and marriage pattern that determine fertility intentions and contraceptive behaviors vary in Asian countries.

The proportion of contribution of teenage fertility to total fertility Bangladesh has gone up steadily from 9 percent in 1971-1975 period to 18 percent in 1989, to 21 percent in 1993-1994, and to 22 percent in 1996-199 Thus in 1996-1997, almost one fourth of all fertility was attributable to teenage women. Part of this trend is due to the more dramatic decline in fertility among older women of reproductive age because of the successful delivery of FP services to this group. 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.^23,26 This variations 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.

Age specific fertility among women aged 15-19 years fluctuated from a low of 109 births per 1000 women for the 1971-1975 period of the liberation war and the famine that followed, reaching a peak of 182 per 1000 in 1989, dropping to 140 per 1000 in 2004/2005, and increasing again by about 5 percent to 147 in 2006/2007.¹⁸

Contraceptive use among adolescents:

Current use of contraceptives nationally as well as in the Operation Projects’ study sites is substantially lower among the teen age married women than the older married women of reproductive age (MWRA). Not surprisingly, the teen age married women rely mostly on relatively temporary methods such as pill, condom, abstinence and withdrawal. Between 2004/2005 and 2006/2007, current use of method declined from 22 percent to 16 percent among married women aged 10-14 years, and had increased from 25% to 33% among the married women aged 15-19 years. For all MWRA, the CRP increased from 45 to 49 percent over the same period.^18,19

Overall contraceptive use was lower in South Asia except for Bangladesh and Sri Lanka than in Southeast Asia. Fewer than 1 in 10 married adolescent women reported using 2 traditional or modern contraceptive method in Pakistan (6%), Nepal (7%) and India (8%). In comparison, between 2 in 10 and 5 in 10 reported using a contraceptive method in the Philippines (22%), Thailand (43%) and Indonesia (45%).⁴

Although contraceptive prevalence differs among countries, there has been an overall increase in contraceptive use among currently married adolescents in these countries. In Pakistan, for example, proportion of married adolescents practicing contraception rose from 3.4% in 2002/2003 to 6.2% in 2005-‘ 825 increase. This proportion rose by 32% in Bangladesh between 1993 and 1994 and 2006/2007, by 20% in Philippines between 1993 and 1998, and 225 in Indonesia between 1994 and 1997. However, use of contraceptives among married adolescents in India rose only slightly from 7% to 8% between 1992-93 and 1998-99.²⁷

Contraceptive prevalence for married 15 – 19 years olds was 10-20 percentage points lower than that for their 20-24 year old counterparts in most of these countries. This difference was smallest in Pakistan (four points) and largest in Vietnam (37 points). This pattern reflects not only a lower level of sexual activity among adolescents, but also the-fact that many are just beginning the childbearing and are, therefore, less like to want to delay or avoid pregnancy than are older women. The CPR for the married women aged less than 20 years is only 24% in Bangladesh compared to the CPR of 44% for the women aged 20 – 29 years. This indicates that much of the increased contraceptive prevalence is attributable to the higher rates of contraceptive and FP acceptance among the relatively older and higher parity couples. Married women aged less than 25 years represent over one-third of the country’s reproductive aged women and this group will have tremendous influence on contraceptive prevalence and fertility during the next 10 years.²⁹

Married adolescent women use modem contraceptive methods more frequently than traditional methods in all these countries except Pakistan. The use modem methods were as high as 44% in Indonesia and as low as 2% in Pakistan. The use of traditional methods was less than 5% in both South Asia and Southeast Asia. However, In Sri Lanka and the Philippines, where traditional methods have always accounted for a relatively high proportion of overall contraceptive use, 1 in 10 married adolescents were currently using traditional methods.³⁰

The method most commonly used by married adolescents varied across countries. The pill was the most frequently used method in the Philippines (6%), Sri Lanka (7%), Bangladesh (18%) and Thailand (25%). The condom was the most frequently used method in Nepal (2%) and Pakistan (1%), the injectable dominated the method mix in Indonesia (24%) and the IUD did so in Vietnam (10%). Tubal ligation was the most commonly used method report among married adolescents in India, although this method was used by a negligible minority (2%). Within countries the method mix among adolescent women was similar to that among married women in their 20s. Periodic abstinence was the most widely used traditional method in Bangladesh, Sri Lanka and Thailand (2-5%), withdrawal was popular in Nepal, the Philippines and Vietnam (2-5%). In India and Pakistan, an equal proportion of married adolescents reported using periodic abstinence and withdrawal, 2% for each method in each country.

A large proportion of births to adolescents in all the countries studied were unplanned. The proportion of unplanned births ranged from less than 10% in Indonesia to 30% or more in Sri Lanka, Thailand and the Philippines. The vast majority of unplanned births were mistimed rather than unwanted. It is evident that , at the time these data were collected, current family planning programs were addressing only a small part of the contraceptive demand of adolescents in South Asia, with the exception of Bangladesh, where 65% of the contraceptive demand of married adolescents was satisfied.¹³ only 14% was met in Nepal, 21% in Pakistan and 23% in India. In comparison, the proportion of adolescent’s contraceptive demand being addressed by existing family planning programs in Southeast Asia ranged from 41% in the Philippines to 83% in Indonesia.³⁰

According to the BDHS 2006/2007, the unmet need for FP services highest among the 10-14 year age groups of married women, at 22 and 19 percent respectively. The vast majority of this unmet need for FP services was for spacing purposes. For the other age groups, beginning from 25-29 year old the total unmet need for FP (for spacing and for limiting) ranged from 5 to 18 percent¹⁸

 Knowledge about family planning among adolescents:

In calculating the percentage of adolescent and adult women who were aware   of any contraceptive method, it showed that knowledge of contraceptives is almost universal among both adolescents and adults in Bangladesh.³¹ While knowledge was almost universal among both adolescents and adults, only 26.3% percents of the adolescents and 48.4% of the adults reported that they had ever used any contraceptive method. Among the modem methods ever used by the adolescents, oral pills accounted for the highest percentage (15.3 percent), and condoms the lowest (6.2 percent). Thus experience with oral pills was found to far exceed experience with any method.¹¹

A small proportion of other modern methods were also used by adolescents. However the most surprising aspect of ever use of contraceptive methods is that traditional methods comprised a significant proportion of ever used of contraception. Among the traditional methods, the rhythm or save period method (6.3 percent) was the most popular; it is held second position in terms of ever use. Adult females also showed the same pattern of method specific ever use of contraceptive methods. Female sterilization was the second most used modem method by adults. Among the adults, about 10 percent of the females were ever sterilized. Use of this method was negligible among the adolescents (0.2 percent). The pill was also the most frequently tried modern method (23.2 percent) by adults, followed by female sterilization (10.2 percent), condom (6.5 percent), IUD (4.2) percent) and inject able (2.0 percent). Among the traditional methods, the safe period was also the most popular method (13.7 percent) ever used by adults?

Contraceptive prevalence rate (CPR) was only 15% among adolescents, out of the 1,820 currently married adolescents; only 279 of them were currently using any method of contraception, including traditional methods. The 15.3% CPR can be broken down further as 10.7% for modern methods and 4.6% for traditional methods. The corresponding CPR for adults and for the country as a whole is 34.4% respectively. Thus the observed CPR for adolescents is less than half of that observed in adults.

To gain knowledge about perceived attitude towards contraception, respondents were asked whether their husbands, older family members and female friends and neighbors approved or disapproved of family planning. Of the three types of family members, older family members were perceived by the respondents to be the most hostile to family planning. Among the adolescents, it was found that over one-quarter (28.6%) of the currently married respondents reported that their older family members were not in favor of family planning, compared with only 17% in the case of husband 10%) for female friends and neighbors. Nearly two-thirds (73.5%) of these respondents reported that their husbands were in favor of contraceptive use, compared with 60.2% in the case of older family members and 58.9% of friends and neighbors. Of them 11 % of older family members were undecided compared to 9.5% of husbands and 8.2% of female friends and neighbors.

After analyzing the relationship between contraceptive use and self reported desire to limit family size or postpone the next birth, it was seen that among the adolescents who said that they wanted no more children, only 29.4% were practicing contraception. This compares to a figure of 15.6% for adolescents who said they wanted another child at some time in the future. Thus limiters were found to be nearly twice as likely to use contraceptives as were the spacers. The pattern was also true for the adults surveyed, but the rate was higher for them than for the adolescents. The sharp distinction between the limiters and the spacers becomes more complex if the length of time that women wish to postpone the next birth is taken into account. Among the adolescents who were willing to have another child, the contraceptive use rate rose sharply from 6.5% of those who wanted the next birth to 28.2% for those who would prefer a delay of five or more years. Thus this latter group of long term spacers had a level of contraceptive use nearly as high as the limiters.

The factors affecting current use of contraception were identified as place of residence, administrative division, husband’s education, occupation, respondent’s participation in family planning decision making, visits by family planning workers, availability of electricity in the household, and respondent’s religion.

Factors Influencing contraceptive use:

It appeared that education is the most important factor affecting the current use of contraception among adolescents. Adolescent women with an education level of secondary and higher were found to be 2.5 times as likely practice contraception as those who do not had education.³²

Participating in family planning decision making in the second most important factor influencing the current use of contraceptive methods. Woman who discuss matters relating to family size with their husband are like to be current contraceptive users. Couples who make joint decisions regarding family planning were found to be 1.8 times more likely to be current users of any contraceptive method than those couples for which the husband alone makes such decisions.³²

Frequency of visits by family planning workers is significantly and positively related to current use of contraceptive methods among adolescent mothers. Adolescent mothers are more likely to use family planning methods when family planning worker visit them several times, than who are not visited at all by family planning workers. In view of the likelihood that visit by family planning workers can motivate adolescents by providing them with counseling on family planning methods and by providing Jam planning services and disseminating supplies to achieve their widespread availability, frequent visits by family planning workers to an adolescent target group would be a valuable approach.

In case of place of residence, the level of current contraceptive use is higher in urban areas (40.83 percent) than in the rural areas (30.09 percent). So the place of residence seems to be an important factor for motivating the adolescents towards the use of contraception. Region of residence also had a significant effect of current contraceptive use among adolescents. Chance of an adolescent ‘in Rajshahi division being a contraceptive user was 2.2 times higher than that of her peer in Chittagong division. Similarly, chances were 2 1 .3 and 2.03 times higher for adolescents in Dhaka and Khulna divisions respectively to be a user of contraception than those in Chittagong division. The factors that distinguish Chittagong from other divisions most clearly are cultural in nature. Women’s mobility had a positive impact on current use of contraceptive method. It was thought that the adolescent women who had permission to go out would adopt family planning methods more than the women who had no permission to go out.

The contraceptive use rate in influenced by the number of visits to the satellite clinic (SC). The rate was 1.5 times higher among those women who had visited the SC (51%) compared to 37 percent of the women who never visited the SC. Slightly less than one fifth of the respondents age less than 20 years had visited the SC. This may be the case either because the mobility of young women is restricted or because they are not aware of the SC or because they do not think that they need the services offered at the SC. In all age groups, except the 15 year and under category, the contraceptive use rate was remarkably high among the women who had visited the SC than those who did not.³²

Husband’s occupation also had an effect on the behavior of adolescent current users of contraceptives. The wives of husbands employed in sales, services or production sectors were 1.5 times more likely to practice contraception than are young wives of agricultural laborers or farmers. It is also showed that the relative chance of a young wife being a contraceptive user if her husband is a land owner is almost 0.97 times lower than an adolescent whose husband is working in an agricultural sector. Because land owners are usually characterized by low age at marriage, it is very likely that their contraceptive prevalence rate is also low, whereas opposite is likely to be true among professionals who are characterized by high age at marriage and high contraceptive use.

The availability of electricity in the household adolescents is an important /.able; it contributes positively to the current use of contraception. The relative odds were found to be almost 1.61, indicating higher prevalence of contraceptive use among adolescents who had electrical power in their household, as compared to those having no such facility. The fact that having electricity in the household dose improve the use of contraception among young women suggests that , with electricity, ratio and television may be useful media for reaching such people with motivational messages for young wives and their husbands with the use of contraceptives.³²

A study was undertaken by a group of demographers in the department of statistics at the University of Dhaka during 2000-2001 to investigate the important factors associated with contraceptive use behavior among married adolescent women in Bangladesh. The study was based on BDHS data 1996-1997 in which about 1418 adolescent married women aged between 10-19 years were interviewed.¹⁸

Independent predictors of unmet need:

Binary Logistic Regression analysis showed that married adolescents who had been visited by FPW during the last six months were 2 times more likely to use contraceptive methods compared to those who have not been visited by FPW. Involving husband into FP affairs has the highest significant effect on current use of contraceptive among adolescent. Among the adolescents who have discussed about FP with their husbands were 1.67 times more likely to use contraceptives than those who have not talked about the matter with their husbands. Education, regardless of level, has a positive effect on contraceptive use. Adolescent women who have secondary level education or above are 1.29 times more likely to use contraceptives than those who have no education. Having children has a significant positive association with current contraceptive use. Similarly, place of residence also had a net significant effect on current contraceptive use among the adolescents. Urban adolescents are 1.27 times more likely to use family planning method than their rural counterparts. Duration of marriage is also correlated with contraceptive use. Adolescents with marriage duration of three years or more are 1.42 times more likely to use contraceptives than those with marriage duration less than three years.³²

METHODS & MATERIALS

The following methods and materials were adopted to conduct the study.

Study design;

A cross-sectional study design was considered suitable for the present study. The contemplated design was implemented as follows:

• Study area
• All eligible couples
• Adult couples                                                               
• Adolescent couples
• Non-users, of FP methods

The study was conducted in a village, Hichmi of Mollapara, Bombu Union of Sadar Upazilla under Joypurhat District during six months period commencing from January 2010 to June 2010.

Study population:

All the adolescent married women residing in the above study area were the study population.

 Enrollment criteria:

Married adolescent women with following characteristics were enrolled in the study.

• Age ranging from 12-19 years
• Non-pregnant and non-amenorrhoeic
• Willing to participate in the study.

 Sample size and sampling procedure:

A total of 73 married adolescent women meeting the above enrollment criteria were selected purposively from 197 households.

 Research instrument:

A structured questionnaire (research instrument) was developed which included all the variables of interest. The research instrument was modified taking feedback from the field testing.

 Data collection procedure:

Formal permission from Atish Dipankar University of Science & Technology,Dhanmondi,Dhaka, Bangladesh was obtained. One female field worker from the study were selected and trained for the purpose of data collection. All the households in the study area were visited. Obtaining verbal consent from the adolescent married women (respondents) face to face interview was conducted on variables of interest.

 Data processing and analysis:

Data were processed and analysed using SPSS (Statistical Package Social Sciences) version 11.5. The test statistics used to analyse the data were descriptive statistics, Chi-square (%~) and Student’s t-Test. The data presented on categorical scale were compared between unmet need group and FP method user group using Chi-square (% ) Test and those presented on continuous scale were compared between groups with the help of Student’s t-Test. For all analytical tests level of significance was set at 0.05.

Study limitation:

Only one study area was selected and the selection was done without using random allocation procedure. So the result obtained might be representative of that area only and cannot be generalized as national situation.

The questionnaire was structured one which did not have scope to go deeper into a problem.

Pregnant and amenorrhea women whose pregnancy was mistimed or resulted from contraceptive failure were not included in the unmet
group. So the present estimate of unmet need for family planning might be an underestimate of the true situation.  

RESULTS

Number and type of couples in the surveyed area:

To obtain the desired number of respondents, a total of 197 households were visited in the Bombu Union of Sadar  Upazilla. Of them 155(78.7%) households had 1 couple, 32(16.2%) households 2 couples and 10(5.1%) households 3 couples (Table I) thus giving a total of 249 couples in the visited households. Out of 249 couples, 248(99,6%) were eligible (Table II).

Table I. Distribution of households by number of couples

Table II. Distribution of couples by their eligibility criteria

Among the eligible couples 15(6%) informed that their husbands were living .

Number of couples by age:

Fig. 2 demonstrates that out of total 249 couples, 73(29%) were adolescents (age below 20 years) and the remaining 176(71 %) were adults (20 years and above).

Table III. General Characteristics of the respondents

* Respondents’ mean age = (18.0 ±1.1) years; ** Husbands’ mean age = (25.7 ± 2.8) years.  

# Mean age difference = (7.7 ± 2.5) years.

 General characteristics:

Table III shows 63% of the respondents was between 15-18 years of age 35.6% of the respondents’ husbands’ age was found in the range of 20 – 30 years, while 4.1% were 30 or above 30 years age. Majority (87.7%) of the respondents’ age was > 5 years lower than their husbands’ age while the rest 12.3% were 3-5 years lower than their husbands’ age. Over 86% was Muslim and the rest (13.7%) Hindus. More than half (53.5%) of the respondents was illiterate followed by 28.7% primary, 5.5% secondary, 11% SSC level educated. In terms of husbands’ education, 58.9% were illiterate, 26% primary, 9.6% secondary and 5.5% SSC or higher level educated.

Table III General characteristics of the respondents (contd.)

# dian (range) = 1800 (SOO – 20000) Tks. [ Mean age at marriage = (15.5 ± 1.2) yrs.

Husbands¹ mean age at marriage = (22.9 ± 2.7) yrs.

Over 98% of the respondents were house-wives. Fifty eight percent of the husbands were labours, 19.2% businessman, 13.2% farmers, 2.7% service-holders and the rest 6.8% were other occupants. Nearly half (46.6%) of the respondents had monthly income of 1500 Tks or below, 34.2% between 1500 – 3000 Tks. and 19.2% > 3000 Tks. Thatched house was 80% followed by Pacca and semipacca 6.8% and 12.4% respectively. Over 82% of the respondents’ age at marriage was – IS years, while 94.5% of husbands’ age at marriage was between 20 – 30 years. About 55% of the respondents’ duration of married life was 3 or < 3 years.

Table IV Distribution of respondents by their obstetric history

Obstetric history:

Table IV shows that nearly one-third (31.5%) of the respondents was never pregnant, while 46.6% experienced pregnancy once, 16.4% twice and only 4(5.5%) thrice. Asked about the outcome of last pregnancy, majority (94%) informed that they had delivered a live baby, 4% gave birth to a still baby and 2% aborted. More than 45% of the respondents had 1 child, 16.4% had 2 children, 2.7% 3 children and the rest did not have any children. About 55% of the respondents’ last child’s age was 12 months or below followed by 32.6% from 13 – 24 months, and 13% over 36 months. Of the 73 respondents, 13(18%) were currently pregnant.

Access to BCC media:

Fig. 3 demonstrates that 28.8% of the respondents had a radio and 17.8% had a TV at home. However, 16.4% of the respondents informed that they listened FP programme on radio, while 16.4% watched FP programme on TV.

Table V Decision making about adopting family planning measures

 Decision making about FP:

Table V displays that majority (71.2%) of the decision making process about family planning was influenced by their husbands. In 24.7% of the cases decision’ was influenced by father-in-laws and in 4.1% by mother-in-law’s. In 1.4% cases decision comes from respondent herself or and in another 1.4% by other in-laws.

Table VI. Users’ source of information about family planning (n = 13*)

* Multiple response.

 Source of information about FP:

Table VI demonstrates that all the respondents were informed of family planning from Family Planning Workers. The second most common source of information was NGO workers (46.2%). TV and radio were found as the least common source of information (each 7.7%).

Over 40% of the respondents with unmet FP need did not specify any reason of unmet need, 35.3%₀ mentioned that their husband were unwilling. Discouraged by other family members and side effects of past use were each 23.3% (Fig. 8).

Table VII. Sociodemographic determinants of unmet FP need (n = 73′

Table VII demonstrates that neither respondents’ age nor husbands’ age played any role on unmet need for family planning, (p = 0.394 and p = 0.670 respectively). Husband-wife age difference was also not found as the determinant of unmet need (p — 0.348). Distribution of religion was no different between met and unmet family planning need (p = 0.424). In terms education illiterate respondents were observed to be significantly associated with the unmet FP need (p – 0.05). Neither the respondents’ education and occupation nor their husband’s education and occupation were found to be associated with unmet need (p > 0.05).

Table VII Sociodemographic determinants of unmet FP need (contd.) (n = 73)

* Figures in the parentheses denote corresponding %; level of significance was 0.05.

# Fisher’s Exact Test was employed to analyse the data;

* Data were analysed using Student’s t-Test and were presented as mean ± SD.

About 95% of the unmet need group had monthly family income of 2000 or below 2000 Tks. compared to 76.8% of the met group, although the difference did not turn to significant (p = 0.103). Type of house was not found as the determinant of unmet need (p = 0.418). Respondents’ and husbands’ mean ages at marriage and mean duration of married life were also not observed to be any different between met and unmet need for family planning (p > 0.05). The mean age of the last child among the met group was, however, observed to be much higher (15.22 ± 10.10 months) than that found among the unmet group (9.73 ± 7.19 months) (p < 0.05).

Table VIII. Association between past obstetric history and unmet FP need

* Figures in the parentheses denote corresponding %;  level of significance was 0.05.

# Data were analysed using Chi-squarcd (^2) Test; Data were analysed using Fisher’s Exact Test.

Table VIII shows that unmet need for family planning was not associated with past obstetric events like number of past pregnancies or problem encountered during last pregnancy. Respondents’ number of children was, as well, not found to play any role in determining unmet need for family planning (p = 0.101).

Table IX Association between access to BCC media and unmet FP need

* Figures in the parentheses denote corresponding %

# Data were analyzed using Chi-squared (%2) Test; level of significance was 0.05.

Table IX depicts the role of Behavior Change Communication (BCC) media on acceptance of a family planning method. None of the BCC media like radio or TV at home was found to be associated with unmet need for family planning (p = 0.104 and p = 0.647). Listening FP programme on radio or watching the same on TV was not found to be associated with family planning need (p = 0.569).

Table X. Association between sharing about FP with husband and unmet FP

* Figures in the parentheses denote corresponding %

# Data were analyzed using Fisher’s Exact Test; t level of significance was 0.05.

Sharing about FP with husband:

Table X demonstrates that the unmet and met groups were not statistically different in terms of sharing with husband about adopting a family planning method (p = 0.519).

Discussion

The findings derived from data analysis leave some scope for discussion to arrive at a conclusion. The present study was conducted with the objective of assessing the acceptance of family planning method and to estimate the extent of unmet need for family planning among adolescent married woman living in rural areas of Bangladesh. The study also looked for the determinants of unmet need. In the study area a total of 249 couples were found in 197 house-holds visited. Of them 248 were eligible couples. Among them, 73(29%) were adolescent couples.

In the present study the mean age at marriage for the girls was 15.5 years and that for the males was around 23 years. Bangladesh fertility survey (BFS, 1989) data suggested that 96% of ever married women were married when they were teenagers.³³ During the period of 1975-1976, the mean age at marriage among all ever married women in Bangladesh was reported to be 12.3 years (BFS, 1975). In another study conducted in 1996-1997 it was found that mean age at marriage was over 17 years which nearly corresponds with the mean age at marriage for the girls found in the present study. There was a decrease in mean age at marriage from 15.0 years at the time of 2000-2001 BDHS to 14.8 years in 2005.²⁴

According to the BDHS 2006 data, literacy rate among adolescents was found to be 61%. Illiteracy was found among 18.5% of the males and 25.1% of the females. Primary level education was completed among 49% males and 29.3% females and secondary level education was completed by 54.9% males and 47% females. In the present study we found that the proportion of girls having primary level education was 3 times higher (28.7%) than the national statistics. This might be due to the increased awareness and motivation about the importance of female education among the rural families during the last 5 years due to the opportunities provided by Bangladesh Government to encourage female education.

The present study revealed that about one-third (31.5%) of the respondents had not ever experienced pregnancy, 46.6% had experienced it once, 16.4% twice and only 5.5% thrice, A study conducted by Islam et a/, 1998 found that contraceptive use was much lower among the women who had never been pregnant.” Also women who suffer from complications during .or after pregnancy are more likely to use FP methods either to space or limit future birth.³³ but in this study, no significant relationship was found between these variables.

Asked about whether they had faced any problem during last pregnancy majority (94%) of the respondents informed that they gave birth live babies without any adverse outcome, 4% had still birth and 2% ended in MR abortion? In the 2006/2007 BDHS, it was observed that among the ever married women aged 15-19 years, 31.0% were mothers and another 4.6% were pregnant with their first child. This indicates that more than one third (35.6%) of the adolescents started childbearing by the age of 19 years. Ever use of contraceptive methods was found to be 45% among the respondents whereas in the 1989 BFS it was only 26.3%. This indicates that awareness about family planning has increased among the adolescents.

In the present study unmet need for family planning among married adolescent women was found to be 23%. Unmet need was found to be higher among rural women (19 and 17 percent) than among urban women (15 and 11 percent) in 2004/2005 and 2006/2007 respectively. In the 2004 BDHS, unmet need was calculated to be 11% among all currently married women. The present study did not compare unmet need between rural and urban women and the high estimate of unmet need (23%) might be due to the fact that a different denominator was used as well as a small sample size. Although several studies have reported that unmet need is largely influenced by sociodemographic characteristics of the adolescent women, the present study did not find so. In the present study none of the sociodemograpiric characteristics  like     respondents’   age,  husbands’   age,  respondents’ husbands’ age at marriage, husband-wife age difference, income, religion, respondents’ education and occupation or their husbands’ education and occupation were observed to be significantly associated with the unmet FP need (p > 0.05). However, age of the last child was found to be associated with unmet need with higher prevalence being observed among the adolescents with a child of less than 12 months age (p = 0.041). Islam and Mahmud³² demonstrated that among the factors determining contraceptive use among adolescents, education played the most significant role. Large and statistically significant differences in contraceptive use by education level were observed despite having controlled for other variables. Adolescent women with an education level of secondary and higher were found to be 2.5 times as likely to practice contraception as those who had no education. Khuda also found a significantly higher unmet need for family planning among the illiterate married adolescents compared to their literate counterparts (p = 0.50).³⁶ Husband’s occupation also has an effect on the behavior of adolescent current users of contraceptives. Husband’s employed in sales and services or production sectors were 1.5 times more likely to practice contraception than were young wives of agricultural laborers or fanners. The study also showed that relative chance of a young wife being a contraceptive user if her husband was land-owner was almost 1.97 times lower than an adolescent whose husband was working in the agricultural sector.³² Khuda,³⁶ however, did not find any particular occupation of husband having influence on the contraceptive use of married adolescent women which is consistent with findings of the present study. It has also been shown that availability of electricity in the household is an important variable determining the use contraception. The relative Odds of are found to be almost 1.61 times, indicating higher prevalence of contraceptive use among adolescents who have electricity in their household as opposed to those having no such facilities. The fact that having electricity in the household does improve the use of contraception among young women might be that with the help of electricity they readily get access to radio and television which are considered to be useful media to familiarize family planning messages among young wives and their husbands.

The present study, although, did not investigate the availability of electricity in the households of the respondents it intended to assess the access of the respondents to such media and their association with unmet need for family planning. The study, however, did not find any association of such media with the contraceptive behavior of the young couples. Khuda³⁶ demonstrated that respondents having a radio or a TV at home had significantly less unmet need compared to those who did own these communication media (p < 0.005 and p < 0.05 respectively).

Participating in family planning decision-making is the second most important factor influencing the current use contraceptive methods. Nevertheless, the present study did not reveal any difference in use of contraceptive whether the women discussed the issue of family planning with their husband or not. Sharply contrasting to this study, another study demonstrated that women who discussed matters relating to family size with their husband were likely to be current contraceptive users. Couples who made joint decisions regarding family planning were found 1.8 times more likely to be current users of any contraceptive methods for those couples for which the husband alone makes such decisions.³²

The analysis further indicates that frequency of visits by family planning workers is significantly and positively related to current use of contraceptive methods among adolescent women. Adolescent mothers were more likely to use family planning methods when they were frequently visited by the family planning workers than those who were not visited at all by them.³²   In view of the likelihood that visits by family planning workers can motivate young wives by providing them with counseling on family planning methods and by providing family planning services and ensuring supplies to achieve their widespread availability, frequent visits by family planning workers to an adolescent target group would be a promising approach.

Respondents’ mean duration of married life in the present study was 2.53 years and 2.39 years for the unmet need group and contraceptive users respectively. According to 1989 BFS, an inverse relationship was found between duration of married life and contraceptive use indicating that women whose marriage was of shorter duration were more likely to use contraceptives than women whose marriage duration was longer.³² but no such association was found in this study.

In this study very limited attempt has been made to investigate some important aspects of contraceptive behavior among married adolescents in Bangladesh. The study attempted to investigate the reason of unmet need for family planning among the 17 adolescents who had an intention to use any methods but in reality they were not using the same. Asked about such discrepant behavior, 7(41.4%) did not specify any reason, some 35.3% mentioned that their husband did not allow them to use any contraceptives and the rest 23.3% were disappointed because of the side effects. In the analysis of decision waking role about adopting family measures by the adolescent women it was seen that in more than 70% of die cases decision came from their husband, in 24.7% of the cases from their father in-law. Only 1 respondent had the freedom to decide herself whether she would use a contraceptive. As the present study was conducted with a structured questionnaire, it did not have the scope to further probe into the reason who did not specify any reason behind their unmet need for family planning. However, it may be assumed that a good proportion of those adolescent women who did not specify a particular reason of the their unmet need might have belonged to those category where decision about adopting family planning measures came from their husbands or their father in-laws. Studies have shown that the low age at marriage in Bangladesh is directly related to poor socioeconomic conditions and many cultural factors. Most married adolescent women in Bangladesh are economically poor and uneducated. Moreover their status in the family and society is so low that they have little say in the decision-making in a family. In a recent study, Kamal and Stogett³⁹ observed that social conservatism is partly responsible for low performance with regard to contraceptive use among women in Chittagong division. The also pointed out that women’s mobility and their decision-making power in the family greatly determine their use of modern dependable contraceptive methods.  In another study Red pointed out that it is cultural factors which inhibit women from adopting family planning,   despite   the   fact   that   they   high   unmet  need contraception.

Although .contraceptive prevalence among currently married women in Bangladesh is increasing insidiously, the rates have not yet reached those of developed countries. The level of contraceptive use in most developing countries is highest among women in their thirties and, typically, lowest among teenage women and women in their forties (United Nations 1987).⁴¹ Studies in developed and developing countries demonstrate that the behavioral pattern of contraceptive acceptance and use differ significantly between adolescents and adults (United Nations, 1989). Studies including the present one have also revealed that apart from the external influences at the socio-cultural and policy levels that affect an adolescent’s contraceptive behavior, factors influencing unmet contraceptive need vary at the individual as well as the regional level and are of practical significance in the light of policy implications.

CONCLUSION

The findings of our study as compared with other similar studies indicate that aside from the external influences at the socio-cultural and policy levels that affect an adolescent’s contraceptive behavior, factors which vary at the individual level as well as the regional level are also important. Although contraceptive prevalence rate is gradually increasing in Bangladesh, it is still very low compared to any developing country and many developing countries. Since the average age at marriage (around 15 years) in Bangladesh remains one of the lowest in the world, a large proportion of potential acceptors of contraception are married adolescents. Policy-makers and programme managers should, therefore, provide due importance to this fact while formulating policy and designing programme strategy so that these potential acceptors could be turned into contraceptive users. If this could be done effectively not only CPR would be increased, but a substantial proportion of maternal and neonatal mortality would be decreased as a sizable proportion maternal and neonatal mortality result from teen-aged pregnancy.