Abstract

This cross-sectional study was conducted on married women residing in urban slums of Kamrangirchar in Dhaka to determine the magnitude of unmet need for family planning. A total of 265 married women of reproductive age who were fecund and living with husband were the sample of the study. The mean age of the respondents was 26.8±6.7 years. A little above 14% of the women were in the age group of 15–19 years. Almost equal proportion of respondents and their husbands were found to be illiterate. Nearly one-tenth of the respondents have not had ever experienced pregnancy, while 23% experienced pregnancy once, 18.1% twice and 33.6% three-four times, 17% more than four times. Among the respondents, 51.3% were currently using a contraceptive method. Around 5% were pregnant, which was intended. Another 3% wanted to conceive. The rest 41.1% wanted to use a contraceptive but certain barriers did not allow them to use the same suggesting that their family planning need was unmet. This need included limiting (21.5%) and spacing (19.6%). Lactational amenorrhea, no specific reasons, side effect of past contraceptive use, lack of support from husband or other family members, lack of proper knowledge of contraceptive and difficulties in obtaining contraceptive supplies were the cited reasons. Unmet need of contraceptive is high despite an extensive family planning programme in Bangladesh. Mean age at marriage is still below the legal age and gender discrimination plays a vital role in this unmet need.

Ibrahim Med. Coll. J. 2009; 3(1): 24-28

Key words: Unmet need, contraceptive, reasons of unmet need

Address for Correspondence: Dr. Shamsun Nahar, Associate Professor, National Institute of Preventive and Social Medicine, Mohakhali, Dhaka, 1212. e-mail: [email protected]

Introduction

The term unmet contraceptive need is defined as the percentage of currently married women in their reproductive ages who do not want additional children or wanting to postpone child bearing by at least two years and yet are not practicing any contraceptive method.1 This gap between some women’s reproductive intention and their contraceptive behaviour clearly poses a challenge to the ongoing family planning program.Unmet need has generated much interest, both among academics and policy makers over the years. At the international level, the policy makers are unanimous about the usefulness of this concept which has been amply reflected in the following statement of the International Conference on Population and Development “governmental goals for family planning should be defined in terms of unmet needs for information and services.”2, 3

Over the past three decades, Bangladesh has made impressive gains in indicators related to population and family planning.Ever use of any contraceptive method increased five-fold during the past two decades, from 13.6% in 1975 to 69.2% in 1997. The contraceptive prevalence rate (CPR) has increased six-fold, from 8% in the mid-1970s to 58% in 2004.4 Total fertility rate (TFR) dropped by half, from about 6 children per women to about 3 children per woman. However, there is a discrepancy between rural and urban areas, as well as between rich and poor population.5 Around 148 million people live in Bangladesh with majority below the level of poverty.6 Increasing landlessness, underemployment in the rural areas are the main factors to cause constant migration of the rural poor to the urban sector and the percentage of urban population has increased from 8.8 percent in 1974 to 18 percent in 1991.7, 8 With the expansion of the urban centers and increase in the urban population, the number of slums and slum dwellers are rapidly increasing. The slum dwellers are largely the distressed migrants from the rural areas and, more importantly, most of them live below the poverty line. The slum dwellers do not have sufficient access to education, employment and health facilities of the formal sector: The health and nutritional status and contraceptive use of the urban poor are even worse than that of the rural poor. In recent years much attention has been devoted to the replacement of demographic targets by a focus upon unmet needs to raise the contraceptive prevalence above the level inherent in the demographic target.9 Thus, this group of deprived urban slum dwellers become an area of research to find out the unmet contraceptive needs among the eligible couples.

Materials and Methods

This cross-sectional study was conducted on married women residing in urban slums of Kamrangirchar in Dhaka. Kamrangirchar is adjacent to Dhaka city and has 42 areas (paras/mohollas). Of those four paras: Matborbazar, Munshihati, Parshim Rasulpur, Nobinogor, were purposively selected for the study. Sample size was calculated by using formula n = Z2pq/d2,taking the prevalence rate of unmet need (p=11%),4 the calculated sample size coming to 150. Cluster sampling technique was used to select the sample. Data were collected by face-to-face interview with a pre-tested structured questionnaire, visiting every house in the selected slum areas. As per inclusion criteria a total of 265 eligible couples were found in the cluster. As all were included in the study, the number of sample was more than the calculated sample size.

Results

Socioeconomic and past obstetric history of the respondents:

A total of 265 married women of reproductive age (MWRA) were selected from the urban slums to investigate the unmet need for family planning and determine the reasons for the same. Out of 265 married women, 38 (14.3%) were adolescents and the remaining 227 (85.7%) were adults. More than 55% of the respondents got married when they were between 15-19 years. All but 1 were Muslims. Mean age was (26.8±6.7) years. Nearly one-third (31.7%) was illiterate and another one-third (30.6%) could only sign their names. Primary level educated was 23.8%, secondary 11.3% and S.S.C or above 2.6%. Around 26% of the respondents were involved with any type of earning. Only 2% of the husband was unemployed. More than two-thirds (67.9%) of the respondents had a monthly income between Taka 5000–10000; Median income 6000 and the range was Taka 1000–12000. Regarding past obstetric history, 8.3% respondents were never pregnant, while 23% experienced pregnancy once, 18.1% twice and 50.6% experienced more than two pregnancies. Majority (84.2%) of the outcomes of last pregnancy was live-births and the rest ended with still-birth (1.1%), neonatal death (3.8%), MR/abortion (2.6%). Sex distribution of the last child showed that 51.3% were males and 48.7% females (Table-1).

Table-1: Socioeconomic characteristics and past obstetric history of the respondents

Unmet need for family planning among the study group:

Out of the 265 respondents, 136 (51.3%) were using a contraceptive at the time of interview. Figure 1 presents a flow chart showing the varieties of subgroups of unmet need for family planning among the study group. The figure also shows the estimated proportion of women in each subgroup, either included in or excluded from unmet need, magnitude of unmet need and the magnitude of the two components- unmet need of limiting and spacing, which existed in urban slums at the time of study. The unmet need was 41.1%, which included 21.5% of women who wanted to limit and 19.6% of women who wanted to delay childbirths. Among the three subgroups of non-user women, the subgroup of the non-amenorrheic non-pregnant women is most important, accounting for 19.6% unmet need. The pregnant women accounted for 7.2%, and the amenorrheic women accounted for 14.3% of the unmet need.

Fig-1. Subgroups of Married Women Reproductive Age (MWRA) Constituting Unmet Need Reasons of unmet need for contraceptive

About 35% of the respondents with unmet contraceptive need mentioned not menstruating after last child birth as reason of non-use of any method though they are all beyond the post partum period, about 24% did not specify any reason of unmet need, side effect of past use were 19%, discouraged by husband or other family members were 11%, did not know about any method or did not know where to get contraceptives from were also 11% (Figure 2).

Fig-2. Reasons of unmet need for contraceptive (n=109)

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 eligible married woman living in urban slums of Bangladesh. According to the BDHS 2000 data, literacy rate among adolescents was found to be 51%. Illiteracy was found among 18.5% of the males and 25.1% of the females. Primary level education was completed among 9% males and 10.3% females and secondary level education was completed by 54.9% males and 47% females.4 In the present study we found that the proportion of women having primary level education was more than 2 times higher (23.8%) 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 the Bangladesh Government to encourage female education.

In the present study unmet need for family planning among married women was found to be 41.1%. Unmet need was found to be higher among rural women (19 and 17 percent) than among urban women (15 and 11 percent) in 1993/94 and 1996/97 respectively.10,11 In the 2004 BDHS, unmet need was calculated to be 11% among all currently married women.4 In current study the unmet need is 41.1%, which include 21.5% of women who wanted to limit (unmet need for limiting births) and 19.6% of women who wanted to delay child-births (unmet need for spacing births). Among the three subgroups of non-users women, the subgroup of the non-amenorrheic non-pregnant women is most important, accounting for 19.6% unmet need. The pregnant women constitute 7.2% and the amenorrhoeic women 14.3% of the unmet need. BDHS in 1993-94 found unmet need at 22.9%. Among them 12.9% were limiters and 10% spacers.8. The present study found a 41% unmet need for family planning, which is much higher than the national figures. Verities of subgroups of unmet need in women may raise this.

The study attempted to investigate the reason of unmet need for family planning among the 109 women who had an intention to use any method but in reality they were not using the same. On inquiry about this gap, about 24% could not specify any reason, some 11% mentioned that their husband or other family members, like father-in-law or mother-in-law did not allow them to use any contraceptives and the rest 19.2% were disappointed because of the side effects of past use. As the present study was conducted with a structured questionnaire, it did not have the scope to further probe into the reasons. However, it may be assumed that a good proportion of these adolescent women who did not specify a particular reason for their unmet need might have belonged to that category where decision about adopting family planning measures came from their husbands or their in-laws. Many studies including the present one have also revealed that apart from the external influences at the socio-cultural and policy levels that affect a women’s contraceptive behaviour, 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.12,13

Conclusion

The present study found a 41% unmet need for family planning, which is much higher than national statistics. The high percentage may be due to varities of subgroups of unmet need including non-pregnant non-amenorrhoeic, not wanting child soon, lactating amenorrhoeic beyond postpartum, and unintended pregnancy group. If the existing unmet needs of non-pregnant non-amenorrhoeic not wanting child soon group were effectively addressed, the CPR would have to be raised from 51.1% to over 70% in order to help achieve the replacement level of fertility, i.e. about 2.1 children per women for this group. Therefore, the challenge for Bangladesh is not only to sustain the present level of contraceptive users, but also needs to focus upon unmet needs, because this strategy is expected to raise the contraceptive prevalence above the level inherent in the demographic target. However, in order to shift the programmatic target approach to unmet need, strategies and programme components should be redesigned, which in turn, requires analysis of unmet need subgroups by age, sociocultural perspective, ethnicity and son preference thus justifying the need of the present. The programme should be redesigned in such a way that each subgroup can effectively be dealt with yielding maximum output in terms of input given.

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