Análisis del micro ambiente

From 2009 to 2014, unmet need for contraception among adolescent girls in Bangladesh decreased by 2%, from 19% to 17% . During that same time, modern contraceptive prevalence increased by 9%, from 38% to 47% (Figure 8) [80, 118].

Figure 8: Contraception Utilization for Adolescent Girls 15 to 19 Years of Age in Bangladesh

Source: Bangladesh Demographic and Health Survey 2007, 2011 and 2014.

While unmet need among Bangladeshi adolescent girls is relatively low at 17.1% [80], this number must be approached with caution. As previously discussed, adolescent girls have limited reproductive autonomy and newly married couples are faced with strong societal expectations to have a child shortly after marriage [119]. Given that contraception use by young couples is perceived as inappropriate or disadvantageous [119, 120], unmet need for family planning may be underreported for adolescent girls and contraceptive prevalence may be a more dependable indicator.

Factors associated with adolescent use of modern contraception in Bangladesh are explored below in alignment with the levels of Social-Ecological Model.

Individual Determinants

Education, poverty, and living in an urban versus rural area are the key correlates of modern contraception use among adolescents in Bangladesh. Multivariate logistic regression analyses of Bangladesh Demographic and Health Survey (BDHS) data found that the rate of contraceptive use was the lowest for girls with less education and family wealth, and those living in rural areas [114, 121]. Face-to-face semi-structured interviews conducted among married females of reproductive age in seven villages concluded that contraception utilization was associated with greater exposure to family planning messaging and women’s empowerment, including involvement in social networks [122]. In-depth interviews with adolescent girls found constricted autonomy regarding contraception use and method choice and that interpersonal relationships, societal norms, and access to healthcare are highly influential with regard to contraceptive decision- making [123].

Interpersonal or Relationship Determinants

Relationships with mothers-in-laws and husbands are the primary determinants of contraception use at the interpersonal level. Qualitative interviews indicate that due to their own experiences with childbearing, mothers-in-law are often regarded as the authority on reproductive health and in this role directly advise their daughters-in-law or indirectly dispense advise through their sons [123, 124]. Husbands are also influential in the decision to use contraception. A study of 300 married women in the rural district of Meherpur found that 53% of women had used a contraceptive method selected by their

husbands, thereby demonstrating the importance of engaging men in reproductive health education [125]. Sisters-in-laws or other female relatives were also found to provide information about family planning methods, however their role was more limited [124].

Inter-spousal communication and joint decision-making are strong predictors of contraception use [114, 126], however cultural norms and traditional religious beliefs hinder spousal communication about family planning, particularly for young girls [119]. Qualitative studies have identified shyness, shame, fear of social disapproval, poor negotiation skills, and perception of husbands’ opposition to family planning as factors that hinder discussion of family planning [103, 119, 123, 124]. Wives who received visits from FWAs more frequently discussed family planning with their husbands [126], however one study found that FWAs make fewer visits to recently married couples [119]. Research about contraception use among nulliparous adolescent girls in Bangladesh is limited to two qualitative studies. One study of 30 girls found that married sisters, sisters-in-law, or older women frequently provided oral contraceptives on the girls’ wedding day, however little consideration was given to the girl’s reproductive intentions or whether she wanted to take the pill. Further, instructions on how to take the pill were limited and no attention was given to educating girls about sex or their bodies. In several cases, husbands were reported to have prevented their new wives from using contraception at first sex. Two-thirds of the young girls (n=23) in the study reported use of contraception before their first pregnancy, including three girls who had expressed the desired to get pregnant shortly after marriage and girls who had discordant fertility preferences with their husbands or in-laws. [124]. In both studies girls, their husbands,

and their in-laws sited concern about the potential side effects of contraceptives and misinformation that use of contraceptives before the first pregnancy may cause infertility [119, 124].

Community Determinants

The inability of young women to leave the home to obtain contraception is another factor that must be considered with regard to access to and use of contraception, especially in conservative and rural areas. Research conducted in 1992 found that 70% of women using oral contraceptives or condoms reported that their husbands obtained or assisted in obtaining the method [127]. Another study published around the same time found that husbands were not only instrumental in obtaining the method, but they also act as instructors on use of the method [128]. More recent evidence indicates that only 43.1% of adolescent girls are able to go to a health center alone or accompanied by children [80] and that husbands of adolescent girls have greater access to knowledge regarding contraception than girls themselves [119].

Societal Determinants

Societal determinants of family planning utilization by adolescent girls in Bangladesh are related to health care policy and programming. As described in detail earlier this Chapter, adolescent-friendly health services are a relatively new consideration in Bangladesh. Historically, efforts and resources were focused on children and women, who were considered the most disadvantaged groups based on health and mortality

indicators, whereas adolescents were considered healthy and therefore were not prioritized for health services [63]. More recently, policymakers and funders have begun to advocate for comprehensive sexuality education, however, Bangladesh has limited experience in this area. The few NGOs that provide reproductive health services to adolescents primarily focus on sexual and reproductive health awareness and counseling on puberty, rather than the full package of sexual and reproductive health services, including contraception information and services. Furthermore, government and NGO health facilities are generally viewed as “family planning clinics”, which limits adolescents use due to the stigma associated with young people accessing family planning [129].