Women s Autonomy and Uptake of Contraception in Bangladesh. Nashid Kamal

Transcription

1 Women s Autonomy and Uptake of Contraception in Bangladesh Nashid Kamal 1

2 Acknowledging the need for gender equity as a major input towards fertility control and hence fertility decline, the Bangladeshi policy makers have taken major steps towards providing free female education over the last two decades. Using the most recent BDHS, this study finds that the woman s working status is a more powerful predictor of her contraceptive use over and above her educational levels or even her husbands. The model also finds that a woman s mobility and decision making power which were found to be important positive predictors of fertility control in earlier BDHS data are no longer so significant. It seems that for women in this society the concept of autonomy is best represented by the proxy variable `working status. This indicates that to achieve further fertility decline in Bangladesh creating further employment opportunities for women should be considered a priority. 2

3 Introduction Studies have suggested that greater gender equality may encourage women s autonomy and may facilitate the uptake of contraception because of increased female participation in decision making (Hakim et al.2003). However, it has not been set as a prerequisite for widespread adoption of contraceptives (Amin, 1998). Much of the relevant demographic literature that has addressed the links between gender inequality and fertility regulation has focused on women s autonomy (Furuta and Salway, 2006; Cleland et al.1996). The concept of autonomy is multidimensional, hence the factors included within the concept has also varied between authors. For most of the work in South Asia, women s participation in household decision making, her mobility, and control over her financial resources have been taken as indicators of autonomy. For Bangladesh, using the 1989 DHS data, the links between her mobility and decision making has been found to be positive (Cleland et al.1996). Women who had higher decision making ability and higher mobility were more likely to use modern contraception. Since 1989, Bangladesh has achieved greater gender equity in terms of high school enrollment. It has also witnessed an increase in the job market participation of women, and the success of various microcredit programmes has played a major role in alleviation of rural poverty and women s empowerment. The Government of Bangladesh has also strengthened its efforts in providing contraceptive services and comprehensive health services in static clinics all over the country. There has been immense mass media awareness programmes about subjects such as women s free education, late marriage, negative effects of domestic violence and positive effects of adoption of contraception and seeking health care. Men s roles have also been accentuated in mass media communication. In view of these changed circumstances it is imperative to understand the association of women s autonomy with her contraceptive use in Bangladesh. In this study, using data from the 2004 DHS the authors investigate the effect of women s autonomy on her contraceptive use, net of the effects of socioeconomic, demographic and other potential confounders. 3

4 Background Since Bangladesh came into being in 1971, all successive governments demonstrated two things in common with respect to population policy and planning. They exhibited serious concern about the rapid proliferation of human numbers and offered strong political commitment to solve the problems rising out of that (Mabud and Akhter,1996). In 1976, the government declared the rapid growth of the population as the country s topmost problem and adopted a broad-based, multi-sectoral family planning program along with an official population policy. Population planning was seen as an integral part of the total development process of the country and was incorporated into successive five-year plans (Menken and Rahman, 2001). From 1978 to 1997 Bangladesh government trained and appointed Family Welfare Assistants (FWA) to give doorstep services and by early 1990s evidence showed that this had helped to increase family planning awareness, as well as the rate of the use, contraceptive prevalence rate (CPR) increased by over six times during this period rising from 7.7% to 49% (Khuda, 2000). Subsequently, financial sustainability of the program was a major concern for international donors and this consideration led the government to introduce Health and Population Sector Program (HPSP). During the period the HPSP was designed to provide services through community clinics. Complete withdrawal of the FWA s from the field was identified as one of the reasons for the plateauing of fertility at the turn of the century, as operation research studies had found that 82% women reported to have preferences for home visits, mainly for the direct access to information (Mercer et al, 2005). However, selective visitation by FWAs was reintroduced and mass media campaigns to create awareness about the availability of services in the static clinics was strengthened. The 2004 BDHS found that contraceptive use had increased to 58.1 % for all methods (including traditional methods), which indicates that the measures are going in the right direction. Initial reports from the most current DHS (2007,not yet released) finds that the Total Fertility Rate has actually fallen to 2.8 births per woman in 2007, from 3 births per woman in 2004 (). Educational attainments for girls in Bangladesh were among the lowest in the world up until the early 1990s. In the last decade, there have been major changes and the country is 4

5 now a global leader in girl s education. Female adolescent literacy rate was 18% in 1981 that had reached 41.4% in 2001 (Census). Following the SVRS 2004 the literacy rate of adult women is reported to be 46.2%. Since 1991,the Government of Bangladesh (GOB) has encouraged the girl child s education by providing stipends for female students. Additionally, the government has been actively promoting exclusive girls hostels, quota for female teachers, teacher s training, and availability of books on time. The World Bank has been a keen supporter of this initiative from the inception, funding a large share of the program through interest-free credit. Coupled with the efforts of the Government, the non governmental organizations (NGOs) have contributed in improving the rates of female education. A notable NGO Bangladesh Rural Advancement Committee (BRAC) has had 10,000 schools for girls who had dropped out from government schools earlier. Given intensive training, good materials and a solid support network, these schools are able to channel 95 per cent of the children they teach into the public schools after three years. According to a survey, the gender disparity in the school participation rate has almost disappeared for primary level, and has turned in favour of girls at the secondary level (NIPORT 2005). In Bangladesh, the media is also playing a pioneering role in motivating public opinion, as well as persuading the government to pay more attention to rural development. Most newspapers highlight successful NGO activities, as they are playing very important roles in Bangladesh's rural development, and are focused mainly on women. More than 1,500 local and foreign NGOs are involved with rural development activities and they all have a family planning component. One of the most successful programmes in Bangladesh is the loan without collateral which is aimed at poverty alleviation of the poor and landless people. The Grameen Bank or Rural Bank is the pioneer in this field and has received international acclaim for empowering the women of Bangladesh. BRAC, the largest NGO in Bangladesh, pursues an integrated approach and provides training, credit, human development through basic education, nutrition and health related programmes and offers logistic support to its clientele. Another project of the Grameen Trust is the Grameen phone, a mobile company 5

6 that provides cheap telecommunications throughout the country. Through this networking, the women of Bangladesh are able to participate in various areas of trading and entrepreneurship which were solely in the male domain earlier. For educated women, the Grameen phone provides a different dimension of knowledge (market prices of various products), and barriers offered by lack of mobility, distance, gender equity have been permeated. Through the work of these NGOs, many women in rural Bangladesh, who were once forced to work in lowly paid agricultural jobs, now have land, commercial assets and bank savings. They are no longer dependent on government relief, private donations or doles, they are self-employed. The change in women s labour force participation is reflected in the Census. In the 1981 census only 4.3% women were involved in economic activities which had increased to 10.11% in the 2001 census and reached 19% in the BDHS The high participation of women in the labour market is expected to pave way for more autonomy and mobility for women as women s job participation strengthens her with more financial control as well as she has more mobility to travel outside for economic purposes. In summary, since 1989, the Bangladesh society has experienced immense success in attaining gender equity both at the educational levels and employment levels. No specific research has been conducted to assess or evaluate the association between women s autonomy and uptake of contraception, under this new setting. More specifically, no research has investigated whether household decision making and a woman s mobility continue to be important predictors of use of modern contraceptive methods in Bangladesh. This study looks at the association of women s household decision making and her mobility on the use of modern contraceptive methods net of other potential confounders. Data and method This study uses data from the Bangladesh Demographic and Health Survey (BDHS) 2004 (NIPORT, 2005).This is a two staged nationally representative survey. The BDHS 2004 sample is a stratified, multistaged cluster sample consisting of 361 primary sampling units (PSU),122 in urban area and 239 in the rural area. The PSUs were borrowed from 6

7 sampling frame created for the 2001 census of Bangladesh and which was termed Enumeration Area (EA). Mitra and Associates conducted a household listing operation in all the sample points from 3 October 2003 to 15 December A systematic sample of 10,811 households was selected from a complete list of households. All women aged were eligible respondents for this survey. In these households 11,601 women were identified as eligible for individual interview, and interviews were completed for 11,440 women. From them 10,554 currently married women were selected for this study. Binary logistic regression models were used to predict the probabilities, where the outcome variables in each case was coded 1 for presence of the attribute and 0 otherwise. All analyses were performed using the set of Stata Survey ( svy ) command in the statistical package, StataSE 8, which adjusts appropriately for the fact that the sample was both weighted and based on a cluster sampling design (Stata Corporation, 1999). Mobility In Bangladesh, the practice of purdah or seclusion is prevalent in various degrees depending on the socio-economic and educational levels of the men and women in the family. While some families do practice absolute seclusion, barring women from travelling alone for all kinds of activities; other families have redefined their sense of purdah, allowing women to travel outside when accompanied by an adult or child. The establishment of garment industries in Bangladesh has seen another generation of women who have joined the labour market and the norms of traditional village life has undergone major changes. For women in garment work or any other form of formal labour the mobility has been found to be higher than their peers (Naved et al.2001). Additionally, with high male labour migration to various parts of Asia, Europe and the Middle East, another group of women have emerged as household heads. The left behind women have the added pressure of performing various roles which were previously completely under the male domain, these women may no longer be required to be accompanied by a male adult and their mobility may be higher. Studies have found that women conditions have increased decision making compared to their peers, but the effect of mobility has not been investigated (Hadi, 2001). The measurement of mobility is not straightforward 7

8 and various attempts have been made to condense information on multiple dimensions of mobility so that they form a cohesive score which can be used as an explanatory factor in regression models (Cleland et al. 1996). Hakim et al. (2003) maintain Observed mobility cannot be uncritically equated with some notion of freedom of movement. Thus, instead of using a computed score, mobility is investigated by using the responses to the question can women go outside the Village/Town/City alone? (ibid). Domestic decision making Many studies have looked at domestic decision making as the central indicator for women s autonomy and relationship with fertility control in South East Asia (Kamal, 2007; Furuta and Salway, 2006;Hakim et al, 2003). It is hypothesized that women who have more decision making power within the household, would have better control over her fertility and thus have positive effect on use of modern contraception. For Bangladesh, two studies have found that household level decision making positively influences use of modern contraception (Kamal, 2007; Cleland et al, 1996). Decision making in the household embodies a battery of questions regarding various household decisions. Singling out one or more as more efficient compared to others is a matter of judgement. In the studies mentioned above Principal Component Analysis was used to condense information and reduce the number of decision making variables to form an overall score. In another study using Pakistani data, Hakim et. al (2003) used two different questions on decision making and found mixed results. Following suit, the decision making analyses in this study considers two questions asked in the BDHS One regarding decision making on large household purchases and the other on the treatment of a sick child. Bivariate relationships between the mobility and decision making variables and various background characteristics of the women were first examined using the cross tabulations and design-based F tests of significant association. The Stata command, svylogit (logistic regression for survey data) was then used to estimate pseudo maximum likelihood logistic regression models in order to examine the combined effect of independent variables on the indicators of autonomy. The independent variables examined in this 8

9 study included life cycle and family structure indicators (age, number of living children and number of household members); indicators of socio-economic status (education, occupation, husband s education, husband s occupation, household asset score); and location factors (urban/rural, administrative regions of residence). First the predictors of mobility and decision making were investigated using logistic regression models. Following that, the influence of women s autonomy on her use of modern contraception was investigated using logistic regression models. The binary outcome variable was coded as: respondent (or husband) is currently using some method to delay or avoid pregnancy (including sterilization, modern and traditional methods of contraception) versus respondent is not currently using any method to delay/avoid pregnancy. The variables were first tested for two way associations using chi square tests and then logistic regression. The models were developed sequentially so that the effect of different combinations of factors on the current use of contraception could be examined in detail. Findings Predictors of women s mobility and decision making In the BDHS (2004) data used in this study, overall 28 percent women reported that they could go outside the village/city all alone. In this analysis the mobility was considered positive when she is allowed to travel to the village /city alone or with a child, as opposed to being accompanied by an adult. Similarly, the decision making variables which were considered were based on the reported final decision, whether it was taken alone or jointly with husband. Bivariate analyses revealed wide variations in both reported mobility and decision making between subgroups. Socio-economic factors. In bivariate analyses, all three indicators (mobility and two decision making variables) were positively associated with women s education, women s employment in a professional job, husband s education and increasing household economic status (as measured by ownership of assets). Life cycle factors. In Bangladesh, age and gender hierarchies are interrelated in complex ways. Women s roles and associated behaviours change with age and life cycle events. 9

10 As expected, age and number of living sons showed positive associations with mobility and decision-making in the bivariate analysis. Family household factors. Those who live within a nuclear family are expected to have more freedom and more modern outlook on mobility and decision making, compared to those living in an extended household. The association was not so straightforward for the mobility measure. Number of members living in household was grouped as follows: below four (indicating husband/ wife and two children), five or six (inclusion of some other relative),seven-nine and ten and above. These categories were made based on the twenty-fifth percentiles. The model finds that women in households with 5/6 members had higher mobility (41%) compared to the other groups which had similar levels of mobility (around 35%). For both the decision making variables, there was negative association with increase in number of household members and the association was found to be linear. Location factors. Currently, there are six administrative divisions in Bangladesh. There were significant differences in mobility and decision making between the regions. Sylhet region showed low figures in all three variables, next being Barisal. Khulna region showed higher levels of mobility and decision making. Similarly, compared to rural women, urban women exhibited higher levels of mobility and decision making. Multivariate findings One can very well see that the variables considered here are closely related.therefore, multivariate regression was employed to examine the combined effect of different background variables on the three selected indicators of women s autonomy. (Table 1 about here) Among all the predictors showed in Table 1, reported mobility had strong association with age, number of living sons and respondent s occupation. Compared to their counterparts, older women, having more sons and currently working were more likely to have greater mobility. Women belonging to the age group of were 2.03 times more mobile than those belonging the age Women from all ages groups had significant association with mobility and the trend of association was linear. As her age increased so did her mobility. Women aged above 45 had the highest mobility, which was 8.67 times higher, compared to the women aged below

11 The study finds that compared to women with no living sons, those with one son have 1.57 times higher odds of being mobile, while those with two living sons had almost 2 times higher odds of being mobile. Table 1 shows that compared to non-working women, working women had 1.44 times higher odds of being mobile. Urban/rural residence was found to be an insignificant predictor of mobility, but among the six regions, women from Sylhet had almost 30% lower mobility compared to those from Dhaka division. Woman s educational levels were insignificant predictors of her mobility, but her husband s education had some effect. Compared to women with uneducated husbands, those whose husbands had primary education showed almost 18 % lower odds of being mobile. The women with husband s educated beyond secondary levels, did not have significant differences in mobility with those whose husbands had no education. Women who lived in an extended household with 5/6 members had significantly higher odds of mobility, compared to those living in nuclear households. However, for other categories (higher number of members) the effect was insignificant. One possible explanation could be that families with 5/6 members may have a carer for the children (respondent s or husband s sister), thus enabling the woman to have more mobility. When the number of members is even higher (where in-laws or parents are also residing) the mobility may be hampered. Decision making Table 1 also presents the results from the final models estimated for decisions regarding large household purchases (column 2) and those regarding treatment of a sick child (column 3).Age had a strong positive relationship with both the decision making variables, although the relationship was not linear. The peak ages for decision making was found to be around for both the variables, after which the odds declined. Number of living sons was a significant predictor for the decision on purchase of large household items, it was insignificant for the decisions on treatment of a sick child. For both variables, woman s education had a strong positive relationship, it had more influence regarding the decision of treatment of a sick child. Similarly, women whose husbands were educated beyond primary level showed higher odds of being a decision 11

12 maker. Compared to unemployed women, working women had higher odds of taking decisions, although the effect was more pronounced for the decision on treatment of the sick child. Husband s occupational status had no influence on either models.husband s education was significant in both the cases. Compared to women whose husband s had no education, women whose husband s were educated beyond primary levels had significantly higher likelihoods of decision making. In both cases, primary education of the husbands did not have significant effect on decision making. Women from urban areas had higher odds of making decisions (both) and for both variables women in Chittagong division had higher odds compared to those in Dhaka division. For the decision on child treatment, women from Khulna also had 1.24 times higher odds than women from Dhaka division. Women from higher socio-economic group had higher odds of being decision makers in both models. For both models, compared to women with no assets those with asset score 2 and 3 had higher odds of being a decision maker, while those with asset score 1 had no significant effect. Another similarity between these two models was that household structure appeared to be an important factor. Women in extended households were less likely than those in nuclear ones to report final decision making about both child treatment and large household purchases. MULTIDIMENSIONALITY OF AUTONOMY The regression results presented above indicate the importance of different predictors of the mobility and decision making variables among the study s sample of Bangladeshi women. The differentials were similar in all three variables only with respect to the occupational status of the respondent. Compared to non-working women, working women had higher odds of being mobile, making decisions in both cases. Age had positive influence on all three variables, but the relationship with the decision making variables was non linear, while that for mobility was linear. Number of living sons was positively associated with mobility and decision making on large household purchases, but not on decision regarding treatment of the sick child. Women s education was not associated with mobility but was positively associated with both the decision making variables. Husband s education had interesting role in the two measures of 12

13 mobility. Women who had husbands with primary education, were less likely to be mobile. For decision making, with more educated husbands (educated beyond primary) there was significant increase in decision making. Women Living in a nuclear household was positively associated with decision making for both variables and negatively associated with mobility. Interesting to note, that decision regarding a sick child was found to be positively related to being from either Chittagong or Khulna division, compared to Dhaka division which is the capital and where more opportunities exist for women to seek health care on their own. Decision making on large household purchases was significantly higher in Chittagong division compared to Dhaka division, while mobility was not found to differ between Dhaka, Chittagong or Khulna region. Mobility was found to be the lowest in Sylhet division. These findings suggest that the three variables considered here are capturing three different dimensions of women s autonomy. Moreover, woman s occupational status is common in all three models and is also an important indicator of her autonomy and appears to be significant. Earlier studies have also found women s autonomy to have different predictors and little correlation in Pakistan (Kazi and Sathar,1996; Sathar and Kazi,1997).Thus, these variables do not indicate which are the most important ones in their control over fertility. In the next step we examine the uptake of contraception and the effect of these variables on women s autonomy. 13

14 Predictors of Contraceptive Use Overall 56 percent respondents reported current use of contraception. Bivariate associations between background variables and contraceptive use were in the expected directions. Current use of contraception was positively associated with woman s and husband s educational level, woman/husband s employment status, age of the woman, number of living children, woman/husband s desire to have more children, asset score, roof material, number of household members, whether visited by FP worker, urban/rural residence and region of residence. Differentials in contraceptive use were also apparent by all two of the three indicators of female autonomy (Table 2). Among women who reported that they had gone outside the village/neighborhood without the company of an adult in the four weeks preceding the interview, 45 % reported current use of contraception, compared with 43 % who did not report this movement. The design based F test shows that this difference is not statistically significant. Women who reported having the final say (alone or jointly with husband) in decisions about large household purchases were significantly more likely to be currently using contraception (50 %) than those who did not report such decision making (43 %). A similar differential was apparent for the decision making on treatment of sick child. For both the decision making variables, the design based F test was highly significant. (Table 3 about here) A series of logistic regression models was run to explore the combined effect of various background variables, and in particular to examine the relationship between the indicators of women s autonomy and contraceptive use, having controlled for potential confounders. Table 3 shows the odds ratios of contraceptive use associated with each one of the autonomy variables, first unadjusted and then adjusted for various combinations of confounding factors. It can be seen that in each set of the models, the size of the odds ratio declines when controls for confounding factors are included, and the effects remain significant in the simpler models. Adjusting for age, achieved fertility and fertility desires reduced the odds substantially for mobility and for decisions on large household purchases, but completely made insignificant for decisions on treatment of sick child. Adding further combinations of confounding factors, specially visited by FP worker in 14

15 last 6 months makes both decision making variables insignificant, although the mobility still retains significance. In the final combination with all possible confounding factors only the variable decision making on large household purchases retains its significance. Interpretation of these combined effects is very complicated. Hakim et. al (2003) mention that Some of the background variables are confounding the relationship between autonomy and contraception use, and to act in part via an effect on autonomy. For example, region of residence is significant both in the autonomy variables and the contraceptive use. The single most important variable that emerges most significant in both models of autonomy and contraception is the current working status of the respondent. This is an important finding as it captures another dimension of women s autonomy. (Table 4 about here) Table 4 represents the detailed results for the final logistic regression model. It can be seen that, having controlled for a range of potential confounders women who report final decision making on large household purchases, have odds of contraceptive use 11% higher than those who do not report such decision making. Many of the other variables also retained a significant association with current use of contraception, among them number of living sons, asset score, region of residence, urban/rural residence and current occupational status and visits by FP worker, showed particularly strong effects. In Table 4 the data presented represents the dependent variable, users of modern methods with traditional method users coded as users. Here it is found that women with secondary education had higher odds of being a user. When the dependant variable excludes the traditional method users and recodes them as non-users the women secondary level of education loses its significance in the model (results not presented here). All other confounders remaining the same, this indicates that women with secondary education are more likely to use traditional methods. 15

16 Summary and discussion An analysis of the 1989 Bangladesh Fertility Survey (BFS) had revealed that both decision making index and mobility index were significant predictors of contraceptive use in Bangladesh. As decision making scores increased there was a gradient of increase in use of contraception. The links between contraceptive use and mobility score were also found to be very strong, in spite of potential confounders. As the woman became more mobile she was more likely to be a user of a modern method of contraception (Cleland et al.,1996). In view of the results presented above, using the data from BDHS 2004, the same cannot be said to prevail in Bangladesh. Mobility measures used in this study were no longer significant predictors of use, neither were her decisions to take a sick child for treatment. The only variable on autonomy (investigated in this study) that was significant in the presence of various potential confounders, was the decision on large household expenses. That too, had weak association with contraceptive use, when all other potential confounders were present. However, another variable which also represents women s autonomy emerges as a significant predictor of contraceptive use and has been found to be significant in all three models of mobility as well as decision making. This is the variable on current working status of the woman. In 1989, a very small percentage (4.3%) of women were in the work force and the variables decision making and mobility seemed to be appropriate proxies of women s autonomy. In the current data from BDHS 2004, 19% women report being in the work force and this variable emerges as a more powerful measure of women s autonomy. Being in the work force would then be a variable via which women would achieve more mobility and have more decision making power in the family. Even when potential confounders are introduced in the model, this variable retains strong significance, and women who are currently employed have 1.19 times higher odds of being a modern method user. However, an investigation into the profile of the respondents who are working finds that, among women who are working, 98% enjoy the freedom to go out alone or with a child. As for decision making, the study finds that among working women, almost one third of the time, decision on purchases of large household items and taking sick child to treatment are taken by the husband alone. This differs very little from the overall figures 16

17 where the husband alone makes final decisions in these two cases 35% of the time. This indicates that although the working status of the woman has obvious effects on her mobility, the decision making is not significantly affected by her working status. Studies also show that in spite of being in the work force, women have very little control over their finances and once they are married they become worse off (Kamal and Zunaid). This may explain why, after potential confounders are introduced in the model, the decision on treatment of a sick child and those on mobility completely lose their significance. How exactly the working status has a role on women s autonomy and hence on her fertility control cannot be understood from a quantitative study. From the author s qualitative work in the garment sector which currently provides jobs to twothirds of the total women in the labour force, it is observed that women who are working have greater exposure to mass media messages on family planning, as well as has greater scope for knowledge from peers. For example Shefali (not her real name), lives in the urban slums of Dhaka, works for a garment factory and every single day after her work she watches television. This indicates that neither decision making, nor mobility are significant predictors of contraceptive use in Bangladesh. Instead, women who are working have positive association with contraceptive use through other variables which were not measured in this study. The most likely factor is their exposure to mass media messages and networking through fellow workers and ideational change through examples of other successful users. Another factor mentioned by Amin et al (1998) is the perception of loss of earnings which encourages women workers to delay childbearing. Hence, the current work status of women and its positive association with contraceptive use maybe due to many other factors which are beyond the scope of this study. The study also finds that in spite of controlling for mobility, decision making and women s working status, the administrative divisions vary significantly in their contraceptive uptake. Women from Sylhet division have significantly low odds of use, and this has been discussed extensively in the literature. Both Barisal and Chittagong division have 13% and 38% lower odds of use, compared to Dhaka division. Previous studies have had similar results regarding regional differences in use of modern contraception in Bangladesh (Kabir et al., Amin et al.,2002). This study finds that 17

18 mobility, decision making and women s participation in the work force are consistently low in Sylhet division. The model finds that son preference is the most important predictor of contraceptive use in Bangladesh. This comes as no surprise as studies conducted in South Asia, have found highest levels of son preference in Bangladesh (Arnold 1997). All other covariates of contraceptive use considered in this study, have much lower predictive power, compared to the variable number of living sons. This is exemplified by the odds ratios for those having one living son as compared to none, is increased by a factor of 1.99 and for two living sons by a factor of 2.55.Whereas, for women s working status the increase in odds is only by a factor of This, and the desire to have more children (by both respondent and her husband) indicate the pro natalistic attitudes of couples in Bangladesh which may be driven by their strong son preference. As mentioned earlier, the decision making role is taken over solely by the husband in more than one third cases, this too indicates the existence of male dominance in the society. Similarly, husband s education plays a major role in the prediction of mobility and decision making, the three variables of autonomy. Women whose husbands have no education may be forced to allow their wives to work outside their homestead and thus have no significant effect on her mobility. Men with more than primary education also do not seem to influence their wives mobility. These men are expected to be more modern and progressive in their outlook. It is the group in between, ie men with primary education where traditional values and norms are upheld and men cause barriers to their wife s mobility. In this study, the visits by the family planning worker causes a drop in the odds of adoption of any method. This result is hard to interpret, as all previous analysis have found positive association between visits and contraceptive use (Kamal, 1994). In recent times, when the field workers have actually been withdrawn from the program, the government has made static clinics to provide all services under one umbrella (including child immunization and pre/ante natal care). Currently, the field workers make selective visitation, visiting only those couples who are known to be non users, which may explain the association of their visits with low odds of contraceptive use. 18

19 Policy implications This study finds that although mobility and decision making do not have any major influence on the contraceptive use of women in Bangladesh, her working status does have substantial effect. The government should therefore create more job opportunities for women which would enable them to have further their lives in different dimensions and have more control on their fertility. Sylhet, Barisal and Chittagong regions lag behind in contraceptive use. Creating more opportunities for women in these areas in the form of jobs, microcredit, more emphasis on girl s education may also be considered positive inputs for increasing fertility decline. Currently, all the garment industries and other opportunities for female workers are centred around Dhaka, the capital. More decentralization is needed to create job opportunities for women, specially in those regions of the country where fertility is currently high. It is obvious from this study, that women s participation in the job market will pave way for further fertility decline. The study also finds that educated men are more likely to afford more gender equity in the family. The Government should also introduce free secondary education for men and introduce stipends and incentives similar to the existing ones for women, since at this level currently there is higher enrollment for women and more drop outs of men (NIPORT 2005). Bangladesh still being a patriarchal society, men s educational levels have more influence on the decision making role within the family, and more educated men will positively contribute towards achieving the gender balance within the family. 19

20 Table 1: Final Logistic Regression Models of predictors of indicators of autonomy (mobility and decision-making) among currently married women (aged 15 to 49 yrs),bdhs 2004 Predictors Reported Mobility Decision Making on Large HH Purchase Decision Making on Child Treatment Age *** 1.27*** 1.36*** *** 1.72*** 1.82*** *** 1.79*** 2.13*** *** 2.07*** 2.32***] *** 1.88*** 2.17*** *** 1.53*** 1.78*** Living Sons None son 1.57*** 1.05*** 1.04 n.s 2 or more 1.99*** 1.05*** 1.03 n.s Women's education None Primary 1.12 n.s 1.32*** 1.38*** Secondary 1.13 n.s 1.20*** 1.63*** Husband's Education None Primary.82**.92 n.s 1.07 n.s Secondary.92 n.s.99 n.s.98 n.s Higher.82 n.s 1.31 ** 1.25 ** Region of Residence Dhaka Barisal.92 n.s 1.06 n.s 1.10 n.s Chittagong.98 n.s 1.24 ** 1.28 ** Khulna 1.16 n.s 1.09 n.s 1.26* Sylhet.71 *.91 n.s.93 n.s Rajshahi 1.01 n.s 1.02 n.s.93 n.s Asset Zero Asset1.94 n.s.97 n.s 1.01 n.s Asset2.91 n.s 1.16 ** 1.17 ** Asset n.s 1.23** 1.27** Household Members Below ,6 1.14*.82 ***.83** 7,8,9.94 n.s.71***.73*** 10 above.88 n.s.54***.57*** Respondent s Occupation Not Working Working 1.44*** 1.35*** 1.24*** Husband's Occupation Not Working Working.90 n.s 1.08 n.s.93 n.s Residence Rural Urban.96 n.s 1.42*** 1.37*** 20

21 Table 2:Bivariate relationships between indicators of women s autonomy and current use of contraception (all methods) among currently married women (15-49 years) Mobility Going outside village/neighbourhood without adult in the past four weeks preceding the interview Yes No Decision making Who has final say in decision about child treatment (women with living children) Respondent alone/jointly with husband Husband alone/other family members Percentage of women reporting current use of contraception Design based F test 1.42,p= ,p<.001 Who has final say in decisions about food purchase? Respondent alone/jointly with husband Husband alone/other family members ,p<

22 Table 3: Unadjusted and Adjusted logistic regression odds ratios of current contraceptive use by indicators of women s autonomy among currently married women. Indicators of Autonomy Reported going outside the Reported decision making on Reported decision making on village/town/city alone large household purchases child treatment Unadjusted Adjusted for Age, Desire for n.s Children, Living Children Adjusted for Asset and Household structure Adjusted for region and residence Adjusted for FP n.s.85 n.s Adjusted for all confounders 1.07 n.s n.s Notes: 1.All odds ratios retained significance at.01 level or lower unless non significance is indicated by ns 2.Models adjusting for achieved fertility and fertility desires included age, number of living children, respondent s desire for more children and respondent s report of husband s desire for more children. 3.Models adjusting for socio-economic factors included respondent s education, husband s education, household asset score, and respondent s occupational status. 4.Models adjusting for residence and region included urban/rural residence, and belonging to any of the 6 administrative divisions. 5.Models adjusting for access to health/family planning services included whether the woman had been visited by any kind of health or family planning fieldworker in the past 12 months. 6.Models adjusting for all potential confounders included age, number of living sons, respondent s desire for more children, respondent s report of husband s desire for more children, respondent s education, husband s education, region, household asset score and urban /rural residence 22

23 Table 4 Final Logistic Regression Model for predictors of contraceptive use among currently married women (15-49) (Traditional method users counted as users) Predictors Odds Ratio 95% p value Confidence Interval Mobility (Can go outside) No 1 Yes Decision Making Household purchase No 1 Yes Age Living Sons None/One 1 Two Three Four Women s Education None 1 Primary Secondary Husband s Education None 1 Primary Secondary Higher Desire of Husband Wants more 1 Wants no more Desire of Women Wants more 1 Wants no more Asset of HH Asset0 1 Asset Asset Asset Roof Material 23

24 Kutcha 1 Tin Cement Respondent s Occupation Not working 1 Working Husband s Occupation Not Working 1 Working No. of HH member <4 1 5, FP visited No 1 Yes Residence Rural 1 Urban Region of residence Dhaka 1 Barisal Chittagong Khulna Rajshahi Sylhet

25 References Amin, S., A. M. Basu, and R. Stephenson (2002) Spatial Variation in Contraceptive Use in Bangladesh: Looking beyond the borders, Demography 39(2): Amin, S., I. Diamond, R. T. Naved and M. Newby (1998) Transition to Adulthood of Female Garment factory Workers in Bangladesh Studies in Family Planning, 29 (2): Amin, S. (1998) Women s lives and rapid fertility decline: some lessons from Bangladesh and Egypt Policy Research Division Working Paper 117.New York: Population Council. Arnold, F. (1997) Gender Preferences in Children DHS Comparative Studies No.23 (Calverton,Maryland, Macro International,Inc.). Cleland, JG; N Kamal and A. Sloggett (1996) Links between fertility regulation and the schooling and autonomy of women in Bangladesh, in Jeffery R. and A.M. Basu (eds) Girls schooling, women s autonomy and fertility change in South Asia. New Delhi: Sage Publications. Dyson, T and M. Moore (1983). On kinship structure, female autonomy and demographic behaviour in India, Population and Development Review 9: Furuta, M. and S Salway (2006). Women s Position Within the Household as a Determinant of Maternal Health Care Use in Nepal, International Family Planning Perspectives,32(1):17-27 Hadi, A. (2001) International Migration and the Change of Women s Position among the Left Behind in rural Bangladesh, International Journal of Population Geography 7: Hakim, A., S. Salway and Z. Mumtaz (2003), Women s autonomy and uptake of contraception in Pakistan, Asia-Pacific Population Journal, 18(1): Jejeebhoy, S. (1995). Women s Education, Autonomy and Reproductive Behaviour: experience from Developing Countries, Oxford: Clarendon Press. Kabir, A.M., M.M.H. Khan, M Kabir, M.M. Rahman, and F.K. Patwary Impact of woman s Status on Fertility and Contraceptive use in Bangladesh: Evidence from Bangladesh Demographic and Health Survey, Kamal, N.(1994) Role of Government Family Planning Workers and Health Centres as Determinants of Contraceptive Use in Bangladesh (Demographer s Notebook),Asia Pacific Population Journal, 9(4):

26 Kamal, N. (2007) Determinants of contraceptive use among women workers in the urban slums of Bangladesh Paper presented in the Mixed Methods Conference in Cambridge, UK. Kamal, N., U.R. Saha, M. Khan (2007) Use of periodic abstinence in Bangladesh: do they really understand? Journal of Biosocial Science. 39 (1): Kamal, N., A. Sloggett (1993). The influence of religiosity, mobility and decision making on contraceptive use. Secondary analysis of BFS 1989 data. National Institute of Population Research and Training (NIPORT), Dhaka, Bangladesh. Kazi, S. and Z. Sathar (1996) Gender and development: searching for explanations for fertility changes in rural Pakistan, Paper presented at the International Union for the Scientific Study of Population Seminar on Comparative perspectives on fertility transition in South Asia, Islamabad. Khuda, B., N. Roy and M. Rahman (2000) Family planning and fertility in Bangladesh, Asia Pacific Population Journal, 15(1): Mabud, M.A. and R. Akhter (2003) Recent shift in Bangladesh s Population Policy and Programme Strategies: Prospects and Risks in Bangladesh, In Population Momentum, Consequences and Policy Implications.Centre for Policy Dialogue (CPD) Pathak Shamabesh Bangladesh. Mercer, A., A. Ashraf, N.L.Huq, F.Haseen, A.H. Nowsheruddin, M.Reza (2005), use of Family Planning Services in the Transition to a static Clinic System in Bangladesh,International Family Planning Perspectives,31(3): Menken, J. and Rahman, O.(2001) Reproductive health. In Michael H. Merson, Robert E. Black and Anne J. Mills (eds.), International Public Health: Diseases, Programs, Systems, and Policies: pp Gaithersburg MD: Aspen Publishers, Inc. Naved, R.,M. Newby and S. Amin The Effects of Migration and Work on Marriage of Female Garment Workers in Bangladesh, International Journal of Population Geography, 7(2): NIPORT, 2005 Bangladesh Demographic and Health Survey 2004 National Institute of Population Research and Training (NIPORT) Dhaka, Bangladesh; Mitra and Associates ; ORC Macro Calverton, Maryland, USA. Sathar, Z. and S. Kazi (1997) Women s autonomy, livelihood and fertility: a study of rural Punjab, Islamabad: Pakistan Institute of Development Studies. 26

27 Appendix 1 Principal Component Analysis (PCA) is a statistical technique which can be applied to a set of highly correlated variables in order to construct a smaller set of uncorrelated components. These components can be used in place of the original variables in the interests of efficiency and parsimony. The technique identifies groups of variables which are highly correlated with each other, and constructs components based on these groups. The method can extract as many components as there are variables. That does not serve the purpose of variable reduction, and only components which explain a good proportion of overall variance and have an intuitive interpretation, are usually extracted for subsequent use in regression analysis (Kamal and Sloggett, 1993). Variables that could be possible indicators of Socio Economic Status (Asset) were subjected to PCA and the results are presented in Table A.1 Table A. 1 Component scores following PCA with Component Matrix for Asset variable Variables Communality Has Electricity.544 Has Radio.641 Has Television.692 Has Bicycle.475 Has motorcycle/scooter.427 Household own land.362 Household has a sewing machine.378 Household has a cot or bed.338 Household has a watch or clock.648 Household has a chair/bench.638 A new variable asset was constructed using the communalities as weights. This was made into four categories and was entered into the logistic regression model as an independent variable. 27