Central Journal of Family Medicine & Community Health

Cite this article: Mostafa Kamal SM, Rahman MPhil MA, Towhiduzzaman (2017) The Influence of Family Planning Workers on Postpartum Contraceptive use among Women in Bangladesh. J Family Med Community Health 4(6): 1127.

Abstract

Objective: This study examined the influence of family planning workers on postpartum modern contraceptive use among Bangladeshi women.

Materials and methods: The study used the latest 2014 Bangladesh Demographic and Health Survey data. A total of 1710 women were extracted from the nationally representative data set as eligible women for this study. Both bivariate and multivariate statistical analyses were employed to analyze the data. The association between the selected independent variables along with home visitation by family planning workers and postpartum family planning method use was assessed by chi-square tests. Multivariate logistic regression models were constructed to examine to what extent the home visitation of family planning worker influence the postpartum contraceptive use. The results of the analysis are presented by odds ratios (OR) with 95% confidence interval (CI).

Findings: Of the study women, only 27% women were visited by family planning workers. The use rate of postpartum modern family planning method was 49%. The multivariate analysis employed in the study yielded quantitative important and reliable estimates of postpartum modern contraceptive use. Compared to the women who were not visited, the women who were visited by family planning workers were significantly (p<0.01) more tended (OR=1.36; 95% CI=1.09-1.69) to be the postpartum modern family planning method users. The other factors identified to have influence on the use of modern contraceptive method during postpartum period are women’s education, place of residence, religion and wealth index.

Conclusion: Family planning workers should increase their visitations and should focus more on providing the necessary information to pregnant women and their partners to increase the usage of PPFP methods for long run benefits of maternal and child health.

*Corresponding authorSM Mostafa Kamal, Department of Mathematics, Islamic University, Kushtia-7003, Bangladesh, Tel: 88-01716-506096, Email:

Submitted: 17 March 2017

Accepted: 08 August 2017

Published: 30 August 2017

ISSN: 2379-0547

Copyright© 2017 Mostafa Kamal et al.

OPEN ACCESS

Keywords•Bangladesh•Family planning workers•Postpartum contraception•Logistic regression•Health care

Research Article

The Influence of Family Planning Workers on Postpartum Contraceptive use among Women in BangladeshSM Mostafa Kamal1*, M. Anisur Rahman MPhil1, and Towhiduzzaman2

1Department of Mathematics, Islamic University, Bangladesh2Department of Electrical & Electronic Engineering (EEE), Uttara University, Bangladesh

INTRODUCTIONGlobally, the family planning (FP) program of Bangladesh

is viewed as a success story in the world. This is because, the total fertility rate (TFR) of Bangladesh has declined drastically from 6.3 births per woman in the mid-1970s to 2.3 births per woman in 2014 [1]. The sensational decline in fertility is mainly attributed to the increased usage of contraceptive methods. The contraception prevalence rate (CPR) has increased from a low level of 7.7% to 62.4% during 1975 to 2014 [1]. A lion share of this great achievement may be attributed to the political commitment of the subsequent Governments and particularly, communication with eligible women by the Government FP Workers (FPW) and Family Welfare Assistants (FWA) and other actions undertaken by the national level FP program of the Government of Bangladesh [2,3]. Despite these, the country is yet to achieve the replacement level of fertility.

The Government of Bangladesh committed at the London Summit on FP (FP2020) which was held in July 2012, to the overall goal of ‘Ensuring quality and equitable FP services for all eligible couples by improving access to and utilization of FP services, particularly by the poor’. Specific targets were set out for reducing TFR, increasing CPR and method-specific coverage, reducing discontinuation rate and reducing overall unmet need for FP. To achieve the targets determined at the FP 2020 summit, Bangladesh has initiated a ‘Costed Implementation Plan’ (CIP 2016-2020) to reduce TFR at 2.0 by 2020 through enhancing its national FP program (NFPP). The overall objective is to develop a five-year CIP (2016–2020) to strengthen the NFPP to achieve its set goals and objectives by 2021 [4].

A growing body of literature evidently shows that doorstep delivery service of modern FP methods by the Government FPW and FWA helped immense to increase knowledge and awareness

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about FP, as well as to up taking and the continuation of the use of modern contraceptive methods in the Bangladeshi couples [2,5]. Since the demand for contraception fluctuates over the course of a woman’s reproductive life, the service delivery must be considered as part of any integration effort in FP program [6]. Unfortunately, the interruption of modern FP method supply and irregular visits of the FPW are two important causes of low use rate of modern contraceptive methods in the poor and disadvantaged regions of the country [4]. Despite being the major supplier of the modern contraceptive methods, the Government provides only 20% of the total demand of modern FP methods among the eligible women, which may be an important cause of failure to achieve the replacement level of fertility in Bangladesh [4].

The postpartum period is particularly important for a woman’s life; because, many routine interventions are provided to mothers for this time [7]. Not only this, many important issues like maternal and child health care, breastfeeding, menstrual resumption, and resumption of sexuality are associated with postpartum period. Previous studies conducted elsewhere reveal that, the demand for effective contraception may be high immediately after delivery [7,8], since adverse birth and health outcomes are associated with short birth interval [9]. Earlier studies conducted elsewhere show that home visitations paid by FPW and FPWA are positively associated with contraceptive use among women [8]. In this study, we attempt to examine whether interpersonal communication of FPW influences Bangladeshi women to use modern FP method during postpartum period; and if yes, to what extent.

DATA AND METHODSData

Data used in this study have been extracted from the most recent 2014 Bangladesh Demographic and Health Survey (BDHS). BDHS data are available in the public domain. The authorization to use the data set was obtained from MEASURE DHS through their website by providing a brief description of the study. The BDHS is a nationally representative survey and employed a two-stage stratified sampling procedure. The survey gathered information on socio-demographic, health indicators including contraception and maternal and child health care services utilization. The details of the survey are given elsewhere [10]. The 2014 BDHS gathered information from a total of 16,858 currently married women aged 15-49, of whom 1,710 women gave at least one birth in the last twelve months preceding the survey. These 1,710 are considered to be the eligible women and the subjects of this study.

Variables

The post-partum family planning (PPFP) method usage is defined as a woman’s use of modern FP method at sometime during the last twelve full months following her most recent childbirth. Therefore, the outcome variable of this study –PPFP, has been expressed as the binary outcome, whether a woman used postpartum FP method or otherwise. PPFP was coded “1” if a woman used any modern FP method following her childbirth in the last twelve month and was coded as “0” for otherwise. The main exposure variable of this study is the home visitations paid

by FPW. During the survey the women were asked whether they were visited by any FPW in the last six months. If the response was ‘yes’ then it was recorded as: (i) talked; (ii) gave FP method; (iii) talked and gave medicine; and (iv) no. The first three responses were merged and assumed that the eligible women were paid visit. The survey recorded the frequency of visits but not the timing of visits. The predictor variables considered for analyses of PPFP usage are the most commonly used variables in the study of FP method use, such as: current age of women (15-24, 25-34 and 35-49); number of living children (<3 and 3+); women’s level of education (no education, primary and secondary+); place of residence (urban and rural); religion (Islam and others); and wealth index (poorest, poorer, middle, richer and richest).

Data analysis

To analyze the association between the independent variables and the outcome measure “PPFP method usage”, bivariate analyses namely chi-square tests were performed. Besides, to examine the net effect of home visitations by FPW, multivariate logistic regression models were constructed. Let Pbe the probability of the outcome variable, i.e., the probability of being a PPFP method user. Then the logistic regression model can be expressed as follows:

11 XP

e b−=+ ;

where b is an unknown coefficient of the covariate X that affects the dependent variable. This logistic regression has been extended to model with multiple explanatory variables

(X). The model for ( )1i iP Yπ = = probability that 1iY =

and ( )1 0i iP Yπ− = = at values 1,2,3, ,X k= of k predictors and the subscript i denotes the ith individual and the model assumed is

01

01

exp

1 exp

k

j ijj

i k

j ijj

X

X

b bπ

b b

=

=

+

=

+ +

∑

∑

,where jX are explanatory variables and 1,2,3, ,j k=

. Then the log odds of having 1iY = is modeled as a linear function of the explanatory variables, i.e.,

01

log1

ki

e j ijji

Xπ b bπ =

= + −

∑,

where 0 1, 1,2,3, ,j kπ≤ ≤ =

and1,2,3, , .i n=

Here we used a very effective and well-known Newton–Raphson iterative method to solve the equations, which is known as iteratively weighted least square algorithm. The regression analyses involved three stages of estimation. In the first step, we included only the variable namely “visitation of FPW” to estimate the crude odds ratios (OR). The second step included

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demographic variables with “visitation of FPW” and in the final model, we included all of the selected predictors with “visitation of FPW”. Data were analyzed by SPSS v21. The results of the logistic regression analyses have been presented by OR with 95% confidence intervals (CI). The level of significance was set at 0.10.

RESULTSTable 1 depicts the distribution of women who had their most

recent birth in the last twelve months of the date of interview by their selected background characteristics. The mean age and mean number of living children were 23.5±5.6 and 1.9±1.2 (not shown in Table). Only 27% of the women were paid visits by FPW. Only 16.5% of the women, who were paid visits by the FPW, were provided some contraceptive methods (not shown in Table). The average number of visits paid by the FPW was 3.4 times per woman (not shown in Table). Only 14.1% of the women had no formal education, and slightly over one-fourth was urban residents. The vast majorities were Muslims by religion. Over two-fifths were poor. More than half of the women were PPFP method users.

Table 1 further shows that home visitations by FPW, current age of women, number of living children, place of residence, religion and wealth index were found to be significantly (p<0.10) associated with PPFP method usage. Current age of women did not show to have significant association with PPFP method

usage. In particular, the women most likely to be a PPFP method users were had been visited by a FPW (visited by FPW 55% vs. non visited by FPW 47%), were older aged, with less than three or fewer children (≤2 children 51% vs. three or more children 44%), with some education (no education 39% vs. secondary or higher 55%), living in an urban areas (urban 55% vs. rural 47%), were of a religion other than Islam (Muslim 34% vs. Others 51%) and the wealthier (poorest 40% vs. richest 56%).

The results of logistic regression analyses are shown in Table 2. Model I shows that the crude odds of being a PPFP method user increased by 36% when the postpartum women were visited at least once than those who were not visited by the FPW. Model II depicts that, compared to the women who were not visited by FPW, the postpartum women who were visited by a FPW were significantly 38% more tended to be a PPFP method users after being adjusted for demographic factor. Model III suggests that when other socioeconomic and demographic factors are controlled for, the risk of being a PPFP method user increased by 36% when the women were paid visits by the FPW as compared to those who were not visited by FPW. Except for the demographic factors current age of women and number of living children, other factors appeared to have significant effect on the utilization of PPFP method. The variable identified to be significant predictors of being PPFP method users are women’s level of education, place of residence, religion and wealth index.

Table 1: Background characteristics and prevalence of PPFP method use among postpartum women in Bangladesh (N=1710).

CharacteristicsFrequency PPFP method userN % N % χ2

Visited by FPW 7.89a

No 1250 73.1 52.7 47.3Yes 460 26.9 45.1 54.9

Current age of woman 5.65b

15-24 1059 62.0 48.8 51.225-34 580 33.9 54.7 45.335-49 71 4.1 47.0 53.0

No. of living children 5.30a

≤2 1307 76.4 49.2 50.83+ 403 23.6 55.7 44.3

Level of education 34.72a

No education 242 14.1 61.4 38.6Primary 475 27.8 57.6 42.4Secondary+ 993 58.1 44.8 55.2

Place of residence 8.58a

Urban 438 25.6 44.7 55.3Rural 1272 74.4 52.8 47.2

Religion 13.04a

Islam 1575 92.1 65.7 34.3Others 135 7.9 49.4 50.6

Wealth index 23.25a

Poorest 357 20.9 60.5 39.5Poorer 336 19.7 53.6 46.4Middle 348 20.4 46.7 53.3Richer 330 19.3 47.6 52.4Richest 339 19.8 44.5 55.5

Total 1710 100.0 50.7 49.3Note: Level of significance a p<0.01; and b p<0.05.

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Table 2 Logistic regression models showing the odds ratios (ORs) of utilizing PPFP controlling for selected variables.Background characteristics Model I Model II Model III

Visited by FPW (ref: No)

1.36(1.10-1.68)a

1.38(1.11-1.71)a

1.36(1.09-1.69)a

Current age of woman (ref: 15-24)

25-34 0.88(0.69-1.11)

0.84 (0.66-1.07)

35+ 1.29(0.76-2.18)

1.26 (0.74-2.15)

No. of living children (ref: ≤2)

3+ 0.78(0.60-1.03)c

0.97(0.73-1.30)

Level of education (ref: No education)

Primary 1.03 (0.74-1.44)

Secondary+ 1.62 (1.17-2.25)a

Place of residence (ref: Urban)

Rural 0.73 (0.56-0.95)a

Religion (ref: Islam)

Others 1.94 (1.33-2.84)a

Wealth index (ref: Poorest)

Poorer 1.20 (0.88-1.64)

Middle 1.45 (1.06-1.99)a

Richer 1.12 (0.80-1.56)

Richest 1.31 (0.91-1.60)b

Note: Level of significance a p<0.01; and b p<0.05.

DISCUSSIONOur study findings reveal that only 27% of the women who

delivered their last child in the last twelve months preceding the survey were communicated by FPW and 49% of the women were PPFP method users. The home visitations by FPW significantly increase the likelihood of postpartum contraceptive use. A study conducted in 1998 reported that Bangladeshi women seldom begin PPFP method use [11]. However, our study findings are consistent with earlier studies conducted elsewhere [6,8]. It may be said that the situation has been changed over the recently past decades. At present the CPR is high in Bangladesh and it is expected that if the trend of the usage of FP method continues, Bangladesh would achieve the replacement level of fertility soon.

Bangladesh Government has set out some specific objectives for its NFPP which included: (i) improving access to quality FP

services by the target population; (ii) improving awareness of FP by strengthening information, education and communication (IEC) activities; (iii) improving the knowledge and skills of FP service providers, supervisors and managers; (iv) strengthening procurement and supply of FP commodities ; (v) strengthening planning and management systems, including resource allocation; and (vi) strengthening policy advocacy efforts [4]. Government should pay special attention particularly for the postpartum women to adopt effective FP method so that they can make substantial space for the next pregnancy or to stop childbearing.

There are several limitations in this study that urges to be discussed. First, the results are subject to information bias due to the reliance on the retrospective nature of the data. Second, there was no information regarding the timing of home visitation by the FPW. Third, the survey questionnaire and report did not provide any information whether the FPW recommend PPFP method use in the women. Finally, we have limited data on the pattern and discontinuation of FP method use during the last twelve months following the most recent childbirth of the women. Recognizing these limitations, findings from this study represents a significant step in understanding contraceptive method use of the Bangladeshi women during the last twelve months soon after their delivery. Future studies are needed to determine pattern and discontinuation of contraceptive method use during postpartum period of women in Bangladesh.

CONCLUSIONThe study findings encompass to emphasize the

communication between postpartum women and FPW for further increase of PPFM use among Bangladeshi women. It is likely that, the FPW are able to motivate the postpartum women to adopt modern contraceptive methods. To increase the use of contraceptive methods, activities should be designed to strengthen FP service delivery involving different stakeholders, which should be emphasized at the national level. Since interpersonal communication by FPW increase the usage of PPFP method, thus it is recommended that home visitations by the FPW should be increased by motivating them to be more dedicated to their jobs. Proper monitoring of the jobs of FPW and FPWA may be fruitful to increase their home visitations. Moreover, both FPW and FPWA should provide suitable modern FP methods and more focus should be given to providing the necessary information and consultation to the postpartum women and their partners to improve the usage of PPFP methods.

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Mostafa Kamal SM, Rahman MPhil MA, Towhiduzzaman (2017) The Influence of Family Planning Workers on Postpartum Contraceptive use among Women in Bangladesh. J Family Med Community Health 4(6): 1127.

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