What Are the Barriers to Prescribing and Receiving the Most-Effective Family Planning Methods?

Modern contraceptives – such as condoms and monthly pills – are used by 52% of people in Bangladesh, which is a relatively high percentage for a developing country.

A doctor counsels and screens a family planning client at a private medical college hospital in Bangladesh supported by the Abt-led, USAID-funded Strengthening Health Care Through the Private Sector (SHOPS) project.
Photo credit: Stephen Rahaim

However, just 13 percent of these modern contraceptive users in Bangladesh use long-acting or permanent family planning (LA/PM) methods, such as intrauterine devices (IUDs), hormonal implants, and female and male sterilization. In other countries the LA/PM rate ranges from 6 per cent to more than 60 percent.

Why does LA/PM use in Bangladesh lag compared with other contraceptive methods?

Significantly, the public health sector provides 89 percent of all LA/PM methods in Bangladesh while private health providers dispense just 4 percent, although they play a larger role in distributing other contraceptives. Non-government organizations provide the remaining seven percent of LA/PMs.

To explore this discrepancy in contraceptive use, the Abt Global-led, USAID-funded Strengthening Health Outcomes through the Private Sector (SHOPS) project surveyed 385 ob/gyns, general practitioners, and nurses who provide reproductive health services in 194 private, for-profit facilities. The providers, all of whom were women, were asked about their knowledge, attitudes, and practices regarding contraception.

“SHOPS does not advocate for one particular method of contraception over another. Instead, our goal –which is shared by the government of Bangladesh – is to increase the contraceptive options available to everyone so that individuals and families can use the best option for them,” said Dr. A.S.A. Masud, SHOPS country representative in Bangladesh. Dr. Masud has more than 30 years of experience in family planning program management, clinic and hospital service delivery, and reproductive health provider training.

The SHOPS survey, released in February, found that LA/PM use in Bangladesh is hampered by a lack of provider knowledge of LA/PM methods, comfort dispensing LA/PMs, and availability of these methods. For example, 65 percent of ob/gyns surveyed named at least one incorrect side effect for male sterilization; 78 percent did so for female sterilization.

Also, between 55 percent and 72 percent of ob/gyns had no training on implants, IUDs and female sterilization, but felt competent to dispense them. This raises concerns about quality of care and patient outcomes, which could affect the popularity and use of LA/PMs.

Patient preference and provider deference also are potential barriers to LA/PM use, according to the study. More than 80% of private, for-profit providers agreed women and their husbands prefer “women to use oral contraceptives or condoms over LA/PM methods.” More than two-thirds of providers said women should not use contraceptive methods not approved by their husbands.

Of the doctors who do not provide implants, 29% said limited availability was a reason. That increased to 40% for IUDs. Availability was not an issue for male or female sterilization.

In response, the SHOPS project is implementing behavior change programs to give private providers the latest information on key clinical and policy related issues through a forum that meets their needs. The project is also working directly with private medical colleges to integrate LA/PM into the medical curriculum and train professors to offer graduating doctors practicums to learn these methods.

“I am confident that the private sector can play an even bigger role in the delivery of quality family planning services and further contribute to saving lives in Bangladesh,” said Richard Greene, USAID Bangladesh mission director.

“We believe these findings will be useful and informing approaches to helping private providers make a significant contribution to expanding the family planning method mix in Bangladesh – which is essential to reaching national development goals,” said Dr. Masud.