Academic journal article Journal of Health Population and Nutrition

Measurement of and Trends in Unintended Birth in Bangladesh, 1983-2000

Academic journal article Journal of Health Population and Nutrition

Measurement of and Trends in Unintended Birth in Bangladesh, 1983-2000

Article excerpt

INTRODUCTION

Bangladesh is touted as a success story of demographic transition. In the 1970s, the total fertility rate (TFR) was just under seven births per woman, with 8% of women using contraception (1). By the 1999 Bangladesh Demographic and Health Survey (BDHS), the total fertility rate had dropped to 3.3, and 54% of currently-married women reported using contraception, with further progress documented by the 2007 BDHS (2,3). There are several factors integral to this fertility decline--the proactive policies of the national government with respect to the promotion of family planning and the legal provision of menstrual regulation (4,5). Menstrual regulation is the use of manual vacuum aspiration to restore menstruation, even without the confirmation of pregnancy status. The fertility decline in Bangladesh cannot only be attributed to family-planning programmes and policies but also to the broader social and psychological shift in family-size norms as indicated by in-depth work conducted in Bangladesh during this time (6,7).

Bongaarts has described the changes in the proximate determinants of fertility as nations undergo a demographic transition and the subsequent impact on the levels of unintended pregnancies (8). Individuals and couples first perceive a greater benefit of having smaller families. However, as a smaller family-size becomes the ideal, it is likely that there will be a gap between fertility preferences and the enactment of these preferences through fertility control. This gap equates to, at least initially, a higher level in unintended pregnancies. However, as couples and societies embrace a smaller familysize norm and policies and programmes support these revised preferences through the provision of quality services, the use of contraceptives will, ideally, begin to match fertility preferences, and unintended pregnancies will decline.

To assess these broader societal changes, it is important to measure fertility preferences and their impact on actual fertility. Most work examining fertility preferences is derived from demographic and health survey data, which assess fertility preferences through retrospective assessments of fertility preferences for births occurring within the past 3-5 years. Retrospective assessments are subject to rationalization bias as women are much less likely to characterize a pregnancy as 'unwanted' after the birth of the child (9,10). Prospective fertility preferences have been shown to be predictive of subsequent fertility; however, these assessments also have their limitations. For example, preferences may change over time and in response to intervening circumstances, e.g. death of a child and change in economic situation of family (11-13).

In addition to concerns regarding the timing of measurements, existing studies also note difficulties in ascertaining valid measurements of fertility preferences due to differences in the way that fertility is conceptualized by individuals and is believed to be under one's control. Studies across cultural settings document the existence of fatalistic or 'up to God' responses when asked about the desired number of children. Non-numeric responses may be more likely in populations in which fertility is not considered to be within 'calculus of conscious choice' of individuals (14), in populations where family-size is not conceptualized in terms of a numeric value (15), or in contexts in which there is high uncertainty concerning child survival (16,17). Educational attainment and exposure to a more 'modern' worldview have also been hypothesized to negatively influence the occurrence of non-numeric responses (18,19).

To assess fertility preferences and subsequent fertility, we used a unique, longitudinal dataset from the Maternal and Child Health-Family Planning (MCH-FP) Extension project sites in Bangladesh from 1982 to 2000. Using this powerful dataset, we were able to match prospective fertility preferences of women with nearly 20,000 subsequent birth outcomes and to assess the levels of and trends in unintended births over nearly two decades across six different areas of Bangladesh. …

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