Alarming rise in contraception failure

Contraception use remains an important public health intervention and a cost-effective strategy to reduce maternal and child health. It helps to avert unintended pregnancy and related adverse consequences including maternal and child morbidity and mortality. Over the years, contraception use has been remarkably increased in Bangladesh. As per the recent Bangladesh Demographic and Health Survey (BDHS) conducted in 2017/18, around 62% of the reproductive-aged women in Bangladesh use contraception, increased from only 8% use in 1971.

This is around two times higher than the average percentage of contraception use in Low- and Lower-Middle Income Countries (LMICs). This progress is obviously for the continuous investment of the Government of Bangladesh to ensure reproductive and maternal healthcare services. Credits must also go to the Ministry of Health and Family Welfare of Bangladesh which is actively working to ensure family planning and contraception at the community level. Their achievements over family planning and contraception have been linked to Bangladesh's long-term plan to stabilize population growth.

The total fertility rate has fallen from 6.87 in 1971 to 2.3 in 2017, which is lower than the average in LMICs (3.8 in 2015). Such reduction of total fertility rate as well as the improvement of family planning and contraception were major among the Bangladesh's achievements in terms of reductions of maternal and under-five mortality rates that were targeted in the Millennium Development Goals (MDGs, 2000-2015).

However, instead of significant progress in ensuring family planning and contraception, higher unmet need for contraception and unmet need for modern contraception are always major concerns in Bangladesh. Consequently, unintended pregnancies are always reported as a significant public health threat in Bangladesh with around 25% prevalence in 2018. An equal prevalence of unintended pregnancies was reportedin the previous years.

However, in our recent study published in Scientific Reports last week, we found a 20% rise in pregnancy attributed to contraception failure between 2011 and 2017/18. Contraception failure was found highly prevalent among two dominant contraceptive methods users (pills and male condoms users, around two-thirds of the total contraception users in Bangladesh use one of these two methods) in Bangladesh. The likelihoods of the failure of contraception were found higher among women aged less than 19 years, who had more than 2 children at the time of the survey, who resided in the urban area, and the Rangpur division.

Though by these findings, we cannot tell that the actual occurrence of contraception failure has been increasing in Bangladesh, however, this is an obvious matter of concern and needs serious consideration. Otherwise, it mightbe threatening for the country's progress in achieving the Sustainable Development Goals (SDGs, 2015-2030)3 (Good Health and Wellbeing for all at all ages) and 5(achieve gender equality and empower all women and girls). Targets related to maternal mortality (reduce maternal mortality to less than 70 per 1000,000 live births by 2030), neonatal mortality (reduce at least as low as12 per 1000 live births), and under-five mortality (reduce at least as low as 25 per 1000 live-births) are at particular risks.

One positive direction is that such a rising prevalence of contraception failure in Bangladesh could be linked to its overall development. Perception over the number of children has been changed in the last decade and a growing number of families are now reluctant to take more than two children. Besides, rising levels of education and socio-economic development over the years are making couples more aware of their reproductive goals and enabling them about sharing their experiences of contraceptive use and failure.

This improved situation is congenial to implement programs to reduce unintended pregnancies that could be attributable to the rising prevalence of contraception failure. If this is true, then additional programs need to be taken in the existing programs to make further progress in reduction of contraception failure and unintended pregnancy as well as improvement in maternal and child health.

However, the weaker focus on family planning and contraception promotion in Bangladesh in the last few years could be the major reason for such a rising prevalence of contraception failure. The programs for family planning and contraception in Bangladesh are guided by the five-year plan that was developed twice during 2011- 2017 (the period that the referred study covered, the sixth five-year plan (2011-2015), and the seventh five-year plan (2016-2020).

Compared to the previous five-year plans, these two-five years plans had a weaker focus on family planning and contraception promotion, and a stronger focus on intrapartum, birthing, and postpartum care aimed at reducing maternal and child mortality. Such focuses were made to achieve, initially, the MDGs and later the SDGs. While the provision of family planning services at the household level remains functional, there appears to be less enthusiasm than it was during the 1990s and the first decade of the 2000s.

Also, a shortage of family planning workers is common along with inadequate skills, monitoring, and supervision, and these problems are becoming acute day by day. Consequently, there is a lower number of family planning visits at the household level than what is recommended and poor-quality services about the effective use of contraceptives. Together this leads to such a rising prevalence of contraception failure.

Family planning and contraception are now provided in an integrated fashion in Bangladesh, started in 2016 as a program recommended in the seventh five-year plan. Consequently, both health care centres and family planning workers are now working toward to ensure family planning and contraception in Bangladesh. Such integration reduces family planning workers accountability to ensure contraception in their coverage area that had before integration as they may wish people will receive family planning and contraception from healthcare centres.

However, in Bangladesh, contraception is considered culturally sensitive and warrants privacy for providers to discuss, albeit rarely facilities have such private corners. Moreover, healthcare centres in Bangladesh are usually overcrowded which further increased for such provision of joint services. Consequently, healthcare workers, for whom providing maternal healthcare is the priority, do not get enough time to discuss about contraception, and counselling services. This relatively low priority may result in women's preferences for traditional, less effective but handy contraceptives than long-acting methods.

Together, these indicate system-level challenges to contraceptive uptake and their consistent use, and thereby, an increased likelihood of contraception failure. Also, there exists little or no coordination between services being provided at household levels and healthcare centres. Such uncoordinated delivery results in unequal coverage, and some people may miss out on services. This disjoint approach may also increase the risk of the contraceptive method mix, which is an important predictor of contraceptive failure.

Whatever the reasons are, such finding of a rising prevalence of contraception failure in Bangladesh needs serious consideration in the national level policies and programs to ensure Bangladesh continuing its progress in terms of maternal and child health. Availability of family planning services at the household level and to improve the coordination between the services provided at the healthcare centres and household levels should be ensured.
Dr Md Nuruzzaman Khan a public health expert and assistant professor of Population Science at Jatiya Kabi Kazi Nazrul Islam University, Mymensingh