Unmet need for family planning points to the gap between women’s reproductive desire to avoid pregnancy and contraceptive behaviour. An estimated 222 million women in low- and middle-income countries have unmet need for modern contraception. Despite its prevalence, there has been little rigorous research during the past fifteen years on reasons for this widespread failure to implement childbearing desires in contraceptive practice. There is demographic survey data on women’s self-reported reasons for non-use, but these data provide limited insight on the full set of possible obstacles to use, and one may doubt the meaningfulness of explanations provided by non-users alone. To rectify this evidence gap, this study will gather extensive information on women’s perceptions of contraception (generic and method-specific) and their past contraceptive experience, and it will allow for more complexity in fertility preferences than is standard in demographic surveys. A multi-site cohort study will be conducted in urban Kenya, rural Kenya, and rural Bangladesh. In each setting trained fieldworkers will recruit and interview 2600 women, with participants re-interviewed at 12 and 18 months. Data will be collected using a questionnaire whose development was informed by a review of existing literature and instruments from past studies in both developed and developing countries. Dozens of experts in the field were consulted as the instrument was developed. The questionnaire has three main components: a sub-set of Demographic and Health Survey items measuring socio-demographic characteristics, reproductive history, and sexual activity; additional questions on prospective and retrospective fertility preferences designed to capture ambivalence and uncertainty; and two large blocks of items on (i) generic concerns about contraception and (ii) method-specific attributes. The method-specific items encompass eight modern and traditional methods. Policy and programmes intended to reduce unmet need for contraception in developing countries should be informed by clear understanding of the causes of this phenomenon to better reflect the population needs and to more effectively target planning and investments. To this end, this study will field an innovative instrument in Kenya and Bangladesh. The information to be collected will support a rigorous assessment of reasons for unmet need for family planning.

Bangladesh has experienced a sevenfold increase in its contraceptive prevalence rate (CPR) in less than forty years from 8% in 1975 to 62% in 2014. However, despite this progress, almost one-third of pregnancies are still unintended which may be attributed to unmet need for family planning and discontinuation and switching of methods after initiation of their use. We conducted an extensive literature review on contraceptive use among married women of reproductive age (MWRA) in Bangladesh. A total of 263 articles were identified through database search and after final screening ten articles were included in this synthesis. Findings showed that method discontinuation and switching, method failure, and method mix may offset achievements in the CPR. Most of the women know of at least one contraceptive method. Oral pill is the most widely used (27%) method, followed by injectables (12.4%), condoms (6.4%), female sterilization (4.6%), male sterilization (1.2%), implants (1.7%), and IUDs (0.6%). There has been a decline in the use of long acting and permanent methods over the last two decades. Within 12 months of initiation, the rate of method discontinuation particularly the short-acting methods remain high at 36%. It is important to recognize the trends as married Bangladeshi women, on average, wanted 1.6 children, but the rate of actual children was 2.3. A renewed commitment from government bodies and independent organizations is needed to implement and monitor family planning strategies in order to ensure the adherence to and provision of the most appropriate contraceptive method for couples.

Missing from the huge literature on women’s attitudes and beliefs concerning specific contraceptive methods is any detailed quantitative documentation for all major methods in low- and middle-income countries. The objectives are to provide such a documentation for women living in Matlab (rural Bangladesh), Nairobi slums and Homa Bay (rural Kenya) and to compare the opinions and beliefs of current, past and never users towards the three most commonly used methods (oral contraceptives, injectables and implants). In each site, 2424 to 2812 married women aged 15–39 years were interviewed on reproduction, fertility preferences, contraceptive knowledge and use, attitudes and beliefs towards family planning in general and specific methods. We analysed the data from round one of the prospective cohort study. While current users typically expressed satisfaction and held more positive beliefs about their method than past or never users, nevertheless appreciable minorities of current users thought the method might pose serious damage to health, might impair fertility and was unsafe for prolonged use without taking a break. Larger proportions, typically between 25% and 50%, associated their method with unpleasant side effects. Past users of pills and injectables outnumbered current users and their beliefs were similar to those of never users. In all three sites, about half of past injectable users reported satisfaction with the method and the satisfaction of past implant users was lower. High levels of contraceptive use can clearly co-exist with widespread misgivings about methods, even those that are widely used. Serious concerns about damage to health, long term fertility impairment, and dangers of prolonged use without taking a break were particularly common in the Kenyan sites and these beliefs may explain the high levels of discontinuation observed in Kenya and elsewhere in Africa. This documentation of beliefs provides useful guidance for counselling and informational campaigns. The generally negative views of past users imply that programmes may need not only to improve individual counselling but also strengthen community information campaign to change the overall climate of opinion which may have been influenced by dissatisfaction among past users.

Worldwide, for an estimated 358,000 women, pregnancy and childbirth end in death and mourning, and beyond these maternal deaths, 9-10% of pregnant women or about 14 million women per year suffer from acute maternal complications. This paper documents the types and severity of maternal and foetal complications among women who gave birth in hospitals in Matlab and Chandpur, Bangladesh, during 2007-2008. The Community Health Research Workers (CHRWs) of the icddr,b service area in Matlab prospectively collected data for the study from 4,817 women on their places of delivery and pregnancy outcomes. Of them, 3,010 (62.5%) gave birth in different hospitals in Matlab and/or Chandpur and beyond. Review of hospital-records was attempted for 2,102 women who gave birth only in the Matlab Hospital of icddr,b and in other public and private hospitals in the Matlab and Chandpur area. Among those, 1,927 (91.7%) records were found and reviewed by a physician. By reviewing the hospital-records, 7.3% of the women (n=1,927) who gave birth in the local hospitals were diagnosed with a severe maternal complication, and 16.1% with a less-severe maternal complication. Abortion cases—either spontaneous or induced—were excluded from the analysis. Over 12% of all births were delivered by caesarean section (CS). For a substantial proportion (12.5%) of CS, no clear medical indication was recorded in the hospitalregister. Twelve maternal deaths occurred during the study period; most (83%) of them had been in contact with a hospital before death. Recommendations include standardization of the hospital record-keeping system, proper monitoring of indications of CS, and introduction of maternal death audit for further improvement of the quality of care in public and private hospitals in rural Bangladesh DOI: http://dx.doi.org/10.3329/jhpn.v30i2.11295 J HEALTH POPUL NUTR 2012 Jun;30(2):131-142

Objective: The objective was to assess the provision of the combination of mifepristone misoprostol for menstrual regulation (MR) in randomly selected urban pharmacies in Bangladesh. Study design: We conducted a cross-sectional survey among 553 pharmacy workers followed by 548 mystery client visits to the same pharmacies in 3 municipal districts during July 2014 December 2015. Results: The survey found that 99% of pharmacy workers visited had knowledge of MR procedures but only two-thirds (67%) could state the legal time limit correctly; they mentioned misoprostol (86%) over mifepristone-misoprostol combination (78%) as a procedure of MR with medication (MRM); 36% reported knowing the recommended dosage of mifepristone misoprostol combination; 70% reported providing information on effectiveness of the medicines; 50% reported recommending at least one follow-up visit to them; 63% reported explaining possible complications of using the medications; and 47% reported offering any post-MR contraception to their clients. In contrast, mystery client visits found that the mifepristone misoprostol combination (69%) was suggested over misoprostol (51%) by the pharmacy workers; 54% provided the recommended dosage of mifepristone misoprostol combination; 42% provided information on its effectiveness; 12% recommended at least one follow-up visit; 11% counseled on possible complications; and only 5% offered post-MR contraceptives to the mystery clients. Conclusions: We found knowledge gaps regarding recommended dosage for MRM and inconsistent practice in informing women on effectiveness, follow-up visits, possible complications and provision of post-MR contraceptives among the pharmacy workers, particularly during the mystery client visits. (C) 2017 The Authors. Published by Elsevier Inc.