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14. factors influencing nsv, minilap, norplant & iud acceptance in bangladesh.pdf

Abul Barkat
Avijit Poddar
Sayeedul Haque Khan

Ratha Loganathan
Sukanta Sarker

September 2003

The Government of Bangladesh (GOB) has been committed to family planning since its independence in
1971. In the mid-1970s the GOB adopted a broad-based, multi-sectoral family planning program.
Sterilization was the cornerstone of the public sector program for more than a decade. In the 1980s and
1990s the GOB focused on making a wider range of modern contraceptive methods available, adding
Norplant and Injectable to the method mix. The dramatic increase in contraceptive prevalence from 7.7%
in 1975 to 53. 8% in 1999, and the drop in total fertility rate by almost half from 6.3 in the early 1970s to
3.3 twenty years later, constitute a remarkable demographic transition and a programmatic success.
Since its peak in 1984/85, sterilization service performance has fluctuated and fallen off dramatically in
1990s. In 1984/85, nearly 500,000 sterilization procedures were performed as a result of intense
promotion of this method. However, since mid 1980s annual performance has steadily declined, as the
number of modern FP methods available in Bangladesh has increased thus expanding options for
Bangladeshi women and men. Increased access to modern FP in an informed choice context is a very
good outcome that should not be seen as a constraint to strengthen provision of permanent FP methods.
The challenge for policy makers and program managers is to make sense of the many lessons learned in
order to identify the most useful, strategic and innovative ways to improve provision of quality permanent
FP services, especially by understanding key supply and demand factors that contribute to increased
utilization of these services as it has happened in some areas of Bangladesh in recent times. This is the
purpose of the study presented here.

Strengthening Sterilization and other Clinical Methods Project (July 2001-September 2003)
In order to improve upon the situation of family planning method mix, the Sterilization and Other Clinical
FP Methods Service Delivery Project was launched in July 2001 in 16 districts of Bangladesh, selected by
the government. The project is funded by USAID and implemented by EngenderHealth in close
collaboration with MOHFW and a few NGOs. The objectives of the project are to increase demand and
improve upon supply of quality sterilization services and other clinical methods (IUD and Norplant) in
the selected districts.

The major activities implemented under the project include: improving and expanding access to
information about these methods at the community level by family welfare visitors (FWA) and health
assistants (HA); improving inter-personal communication of the field workers and clinical service
providers; increasing involvement of community leaders, especially women of the Union Parishad,
journalists, local leaders, and NGO representatives; conducting planning and mapping workshops at the
district and upazilla levels to orientate key stakeholders about the project ; improving access to services
by strengthening the skills of service providers through on-site training and supportive supervision by
Roving Technical Persons from EngenderHealth.
Objectives of the Study and Research Questions

The research questions for this qualitative study are
1. What are the supply and demand factors that have contributed to the acceptance of NSV and Minilap? How are these factors different and similar between high and low acceptance level upazillas? 2. What are the supply and demand factors that may have been barriers to the acceptance of NSV and Minilap? How are these factors different and similar between high and low acceptance level upazillas? Methodology
The study utilized a family planning demand-supply framework to focus on the factors affecting
sterilization, Norplant, and IUD acceptance. This framework was a key element of the sterilization
assessment that was conducted by MOHFW and EngenderHealth in 2000.1
Of the 16 districts included in the Sterilization and Other Clinical FP Methods Service Delivery Project,
the full set of intervention activities have been completed in 8 districts. The levels of NSV, Minilap,
Norplant, and IUD acceptance vary in each of these districts. Based on performance of sterilization in
these eight districts, the districts were divided into 2 groups--high performing and low performing areas
(HPA, LPA). Two high performing upazillas (Jaldhaka and Kaliganj) and two low performing upazillas
(Alfadanga and Begumganj) were purposively selected from these districts, in collaboration with
EngenderHealth and USAID for inclusion in the study.
In-depth interview and focus groups discussions were used to answer the research questions. A total of
221 users of four clinical FP methods (NSV, Minilap, IUD, and Norplant) were interviewed. In addition,
fifteen potential limiters from each upazilla were interviewed; a total of 60 (40 women and 20 men)
potential limiters were interviewed. Provider perspectives were also examined through in-depth
interviews with selected managers and clinical providers, and focus group discussions with field level
providers and local opinion leaders.
Key Findings
The average age of both NSV and Minilap clients who had undergone sterilization in the last six months
was lower among users in HPAs (36 years for NSV and 27 years for Minilap) compared to the LPAs ( 40
years NSV, 32 years Minilap). On average, all NSV clients in HPAs had fewer children compared to NSV
users in the LPAs (3.3 vs 4.0, respectively). Differences were also noted among Minilap users in both
types of districts: women in HPA had 2.6 children and women in LPA had 4.1 children. With regard to
occupational background, most of the NSV respondents were farmers, and the Minilap users were
homemakers/housewives (no difference noted between HPA and LPA).
IUD users were on average 30 years of age (no difference in area); Norplant users 28 years. IUD and
Norplant clients had on average 3 children. Half of all Norplant users and one third of IUD users were
illiterate. Female potential limiters had on average 3 children and male potential limiters had 4 children.
Although users knew about the advantages of Minilap and NSV, the data showed that there was still a
degree of misinformation regarding its disadvantages, and this issue will need to be addressed in future.
Most of the NSV/Minilap users, IUD and Norplant clients and potential limiters knew NSV/Minilap as a
permanent method for averting pregnancy that does not require invasive surgery. However, respondents
also reported that they had some concerns about the procedure prior to their interaction with health-FP
workers such as ‘it is a sin’, and ‘people will hate’.

Providers need additional support to ensure informed choice more effectively—most clients reported that
providers did not offer them alternative methods of FP or only offered a limited range of methods. For
example, some NSV clients, mostly from HPAs, reported that the providers offered Minilap for their
wives as an alternative option to NSV.
Overall, the majority of all clients reported they were satisfied with the decision to use their method, and
with the services provided. There were a few sterilization clients who said they were not happy with the
1 This project was developed as a result of the 2000 assessment. decision because of potential stigma associated with use of the method ("People in society do not like it").
Very high proportions of NSV/ Minilap users were in favor of recommending the methods to friends and
relatives. Program managers need to identify ways to utilize these ‘happy ‘ users to dispel myths,
misconceptions and reduce stigma associated with sterilization.
Although most clients were satisfied with services they received, NSV and minilap clients had long waits
at the clinics before they received services and were finally discharged. Minilap clients spent on average
12 hours in the clinic from the end of the procedure until they were discharged in addition to an additional
2 hours waiting for services. Furthermore women in the LPA spent twice as long as women from the
HPA. NSV users in LPA areas had shorter waiting times for the procedure compared to men in the HPA
(71 minutes vs. 93 minutes) and were discharged quicker (21 minutes, 41 minutes, respectively).
Most NSV/Minilap clients reported that they had no complication or had any major change as a result of
the procedure. The most common problem reported by the Minilap clients was suffering from severe pain,
and some complained of feeling weak. Very few NSV clients reported either swelling or infection in the
place of operation.
Most of the NSV, Minilap, Norplant and IUD were satisfied with the services they received and were
treated well by providers. With regard to things they disliked most, the most cited response concerned the
lack of medicines. The respondents didn’t like bad behaviour of SP, dirty SDP, and no sitting
Very high proportions of both NSV and Minilap users recommended the methods to friends and relatives
– and the main reason they recommend the method was that it as an easy operation and free of side
Focus Group Discussions (FGD) with field service providers revealed that the BCC materials developed
by the project were more beneficial to providers than to clients. Most providers recommend that wider
dissemination of information about NSV/Minilap and interaction with satisfied clients would help create a
stronger enabling environment for these methods.
Field service providers felt that insufficient attention was paid by clinical service providers to clients who
presented with complications. Field service providers suggested basic counseling training as a possible
solution. Some providers also reported that sometimes clients received no services because of lack of
funds to perform the procedure (NSV/Minilap) or supply of method (Norplant). Some providers reported
that such a situation was not uncommon, and that it was very frustrating for both providers and clients
especially in consideration of the efforts made by the former group to inform and motivate and by the
latter group to make the decision about the method.

Based on the findings from this qualitative study, the study team recommends the EngenderHealth
project, working in close collaboration with the MOHFW, address the following issues in the next phase
of program planning and implementation:
1. Develop a system to ensure the continuation of clinical training—basic and refresher—in order to both improve upon and maintain the competence of providers. 2. Counseling training, especially for field level providers is critical for dispelling myths and 3. Because many minilap clients complained of pain, the MOHFW needs to ensure proper supply of essential and appropriate analgesics to service sites providing these services. 4. BCC efforts need to focus on reducing social stigma related to use of FP methods. 5. Development of BCC materials designed for illiterates is essential. 6. Develop better distribution mechanisms for BCC materials to ensure that all providers have an 7. Develop job-aids to assist providers in counseling. 8. MOHFW needs to review the current logistics systems and identify ways to improve supply of essential medical materials and other funds for the FP program. In conclusion, this qualitative study shows some results, from client and provider perspectives about the achievements of the EngenderHealth technical assistance program to increase access to clinical methods. While not all supply side factors could be addressed in this study, they will be addressed in an in-depth review of the program inputs, scheduled for completion in October 2003.


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