The influence of husbands on contraceptive use by Bangladeshi women

HEALTH POLICY AND PLANNING; 15(1): 43 51 Oxford University Press 2000 The influence of husbands on contraceptive use by Bangladeshi women NASHID KAMAL School of Environmental Science and Management, Independent University, Dhaka, Bangladesh This study uses the 1993 94 Bangladesh DHS to evaluate the effect of the woman s perception of her husband s approval of family planning on her current and future use of modern contraception, after controlling for selected socioeconomic and demographic factors. While most husbands support family planning, contraceptive use among those whose husbands do not approve of family planning is much lower. In some areas of Bangladesh, however, husband s disapproval of family planning is still a major deterrent factor for woman s fertility control. As husband s approval does appear to be a major determinant of contraceptive uptake in similar developing countries in the region, more effective male targeting may be necessary for maintaining the success of the family planning programme in future. Introduction Bangladesh has come a long way in achieving a contraceptive prevalence rate (CPR) of almost 50% in 1993 94, from a mere 8% in 1975. Although it is a predominantly Muslim country (88.3%), Bangladeshi couples have cooperated well in the government drive to limit family size, although initial resistance was reported from certain religious quarters (Aziz and Maloney 1985). The high rates of acceptance of modern contraceptives may be credited to the strong national family planning programme (FPP) with wide-ranging mass media coverage and doorstep services by female fieldworkers. The programme utilizes female workers at the grassroots level to target eligible women only. Since the introduction of the FPP in Bangladesh (restructured in 1976) no provisions have been made to include men in the motivation campaign or to involve them in the programme in any way. In Mardan, Pakistan, outreach workers with the Urban Community Development Council, an all-male organization established 20 years ago, found that there was much higher demand for family planning information and contraception among men than assumed (Population Reference Bureau 1993). Although similar organizations do not exist in Bangladesh, recent research has found that involving husbands does produce the expected positive results (Amatya et al. 1994). In spite of the absence of direct targeting of men by the national FPP, the 1993 94 Bangladesh Demographic and Health Survey (BDHS) showed that 92% of husbands approve of family planning (FP). In Bangladesh 85% of the perceived husbands approval (i.e. approval perceived by women) was accurate, compared with 59% in the Dominican Republic and 45% in Uganda (using DHS data from these countries). However, in Bangladesh, if husbands do disapprove, use of contraception is rare. The survey data suggest that among women who are not using contraception and who do not intend to use it in the future, disapproval of FP (by husbands 1 ) does play a role (though there are other important factors). This indicates that there are some sub-groups of women in Bangladesh to whom the husband s support of FP is still a significant barrier to fertility control. This paper seeks to investigate the role of husband s approval of family planning (as perceived by the woman) on a woman s contraceptive use in Bangladesh, net of other socioeconomic and demographic factors. Methods and materials The study uses data from the 1993 94 Bangladesh Demographic and Health Survey (BDHS). This is a two-stage nationally representative survey. In the first stage, a total of 304 primary sampling units (PSU) were chosen, with probability proportional to size, from the Integrated Multi-Purpose Master Sample (IMPS) newly created by the Bangladesh Bureau of Statistics (BBS). It was not possible to obtain data from three PSUs, resulting in 301 PSUs. From each PSU, 25 households in the urban clusters and 37 in the rural clusters were selected in the second stage. This resulted in a total of 9640 questionnaires completed by female respondents; further details are available in Mitra et al. (1994). Users of male methods requiring husband s obvious consent (condoms and male sterilization) were excluded from this study, resulting in 8587 women. In this analysis, two models are presented. In the first model, the dependent variable is the responses of women to the use of modern methods. Depending on the means of access to the contraceptive method, they were differentiated into three categories: pills (oral contraception), IUD (intra-uterine device) and injections, and sterilization. Since 1978, pills have been supplied free at the doorstep by

44 Nashid Kamal female FP workers. Injections and IUD are considered as a single category because users have to visit the clinics (mobile or static), and greater spousal support may be necessary. For female sterilization, users are heavily dependent on spousal support. In the 1993 94 BDHS, 8.7% of women were found to be currently pregnant and 8% reported pregnancy due to contraceptive failure. Following techniques used in other models in the literature, pregnant women were classified as non-users (Kamal and Sloggett 1993). Users of traditional methods (safe period, abstinence, withdrawal and herbal medicine) were also considered to be non-users in this study. In the first model, the current use of contraception was regressed on several independent variables using a multinomial logistic regression model. This model is used when the dependent variable is polytomous, and the outcomes have no natural ordering. If the dependent variable has only two outcomes, the model is the usual logistic regression model. Table 1 presents the results of multinomial logistic regression. Instead of underlying coefficients, the odds ratios are presented, along with their levels of significance. For example, in Table 1 the odds of being a pill user versus being a non-user increase 5.21 times if the variable husband s approval increases by one unit (in this case, changes from Table 1. Variables Multinomial logistic regression of modern contraceptive methods used by females on selected variables, 1993 94 DHS, Bangladesh Methods of modern contraception used by females Pills IUD and injections Female sterilization Odds ratio Significance Odds ratio Significance Odds ratio Significance Husband approves of family planning Yes 5.21 <0.001 5.42 <0.001 4.34 <0.001 Husband s education Secondary or higher 1.32 <0.001 0.94 <0.60 0.68 <0.001 Primary/ None a 1.00 1.00 1.00 Woman s education Some 1.13 <0.10 0.88 <0.22 0.54 <0.001 None a 1.00 1.00 1.00 Woman earns cash Yes 1.13 <0.10 1.13 <0.30 1.94 <0.001 Woman allowed to travel Alone 1.29 <0.001 1.87 <0.001 2.27 <0.001 With child 1.19 <0.05 1.67 <0.001 1.77 <0.001 Not allowed a 1.00 1.00 1.00 Visited health centre in previous 3 months Yes 0.96 <0.60 3.36 <0.001 1.18 <0.10 Visited satellite clinic in previous 3 months Yes 1.27 <0.001 1.73 <0.001 0.74 <0.01 Religion Islam 0.96 <0.42 0.97 <0.84 0.55 <0.001 Others a 1.00 1.00 1.00 Member of any NGO Yes 1.13 <0.10 1.15 <0.17 1.31 <0.001 Division of residence Chittagong 0.08 <0.001 0.63 <0.001 0.36 <0.001 Rajshahi 1.42 <0.001 1.05 <0.60 1.19 <0.10 Barisal 0.98 <0.42 0.96 <0.48 0.89 <0.25 Khulna 1.24 <0.64 1.24 <0.57 1.12 <0.32 Dhaka a 1.00 1.00 1.00 Woman s age 30 years 0.97 <0.68 0.75 <0.01 0.19 <0.001 <30 years a 1.00 1.00 1.00 Interactions Husband approves in Chittagong division 5.74 <0.001 1.51 <0.36 1.59 <0.23 Husband approves in Dhaka Division a 1.00 1.00 1.00 a Reference category.

Husband s approval of family planning in Bangladesh 45 disapproval to approval). However, the table cannot be read across. In the second model the dependent variable was the response of a woman on her intention to use modern contraception in future (coded 1 if yes, 0 otherwise), based on a question in the 1993 94 BDHS. The analysis of intention to use excludes not only non-fecund women but also all current users of modern methods of contraception, resulting in 2539 women. This model used the usual logistic regression model. The principal independent variable in this analysis was the wife s perception of her husband s approval of FP. The BDHS country report makes two important points in connection with this variable: firstly, the possibility that people overreport their approval of family planning, and secondly, the fact that among women (and men) who report that their partner disapproves of family planning, many are wrong, i.e. the partner himself/herself reports approval. Additionally, using only one variable to capture the entire attitude of the husband towards FP may not be accurate. Despite these drawbacks this variable was considered as the principal determinant of contraceptive use in this study. It was coded into two categories (1 for favourable and 0 otherwise). Other categories such as don t know (2%) were taken as nonfavourable because of ambiguity. Variables used Other additional demographic and socioeconomic variables were chosen on the basis of prior knowledge of determinants of contraceptive use and exploratory data analysis. These variables were the age of the woman, her education, her region of residence (administrative division), her type of residence (urban/rural), her mobility, whether she is earning cash, her religion and her husband s level of education. Number of living children, which is often included in analyses of determinants of contraceptive use, was omitted because of its collinearity with the age of the woman. The variable respondent s opposition to FP was extremely skewed. Only 0.6% of women who were non-users expressed this reason for non-use. It was therefore omitted from the analysis. In the context of Bangladesh, a woman s mobility (to travel outside her homestead alone) is an important differential of her contraceptive use and has been discussed extensively in the literature (Kamal and Sloggett 1993; Cleland et al. 1994; Amin et al. 1995). The practice of purdah and other social restrictions prevent many women from freely utilizing the services provided by the government. However, the degrees of both purdah and hence mobility vary between families, and in general more mobile women are more likely to be users (Kamal and Sloggett 1993). This variable was therefore included in this study as a control. In the exploratory analysis of the data using principal component analysis (PCA), several socioeconomic variables were investigated (not presented here). It was found that among other variables available in this study, husband s level of education was the most significant contributor in the PCA. This was therefore considered as a socioeconomic control in this study. High educational levels of the husband were thought to represent higher socioeconomic status. Research has shown that involvement with an NGO results in higher contraceptive use and this variable was therefore included (Kamal et al. 1992; Schuler and Hashemi 1994; Kabir and Amin 1995). In this survey, information was available on membership status with four prominent NGOs, none of which are FP-based. Table 2 presents the variables in this study along with their distributions for all four categories of use. Regression analysis Table 1 finds that in spite of socioeconomic and demographic controls, husband s approval of family planning is the most significant predictor of current use of all methods of modern contraception used by females in Bangladesh. When the husband is favourable towards FP, odds of use of all methods considered here increase significantly. For pills, the increase is by 5.2, for IUD and injection, it is by 5.4, and for female sterilization the figure is 4.3. Each method is discussed separately in the sections below. Results Use of contraceptive pills Oral contraception is the most popular method in Bangladesh. In fact, since 1991, 76% of the increase in contraception has been due to the increase in use of contraceptive pills. It may be hypothesized here that women in rural Bangladesh are at liberty to use pills in spite of their husband s disapproval. The government FP worker supplies free pills at the doorstep. The argument is that, as opposed to other methods, women can be discrete about using pills because they do not need logistic or monetary support from their husband. This model reflects the contrary. When the husband approves of FP the odds of use of oral contraception increase by a factor of 5.2 in this model. This is true even when the model is controlled for socioeconomic status. Women from the highest socioeconomic group (indicated by husband completing secondary education or higher) have higher odds of being pill users. However, women from the middle socioeconomic group do not differ from those of the lowest group in their probability of using the pill. The relationship between husband s approval and his educational level was tested in the model and produced no significant result. This indicates that in Bangladesh, the educational level of the husband is not correlated with his opinion on FP. In fact, the interaction terms in the model found that husband s approval of FP varied according to division of residence, with residence in Chittagong division being the second-most influential predictor of use of pills in this model. Compared with women in Dhaka division whose husbands approved of FP, women whose husbands approved of FP in Chittagong division had almost 30 times higher odds of use. 2 Otherwise, the model

46 Nashid Kamal Table 2. Distribution of users of modern female contraceptive methods according to selected socioeconomic and demographic variables, BDHS 1993 94 Bangladesh Variable (%) Non-user (%) Pills (%) IUD/injection (%) Female sterilization Husband s attitude towards family planning Disapproves 25 4 4 8 Approves 75 96 96 92 Woman s education Some 43 54 47 28 None 57 46 53 72 Husband s education Secondary or higher 29 39 31 20 Primary 25 24 9 22 None 46 37 43 58 Woman earns cash Yes 11 15 16 25 No 89 85 84 75 Woman allowed to travel Alone 36 43 47 52 With child 36 36 40 38 Not allowed 28 21 13 10 Visited health centre in previous 3 months Yes 20 23 50 23 No 80 77 50 77 Visited satellite clinic in previous 3 months Yes 26 32 41 20 No 74 67 59 80 Religion Islam 88 86 87 80 Others 12 14 13 20 Member of any NGO Yes 17 22 24 27 No 83 78 76 73 Type of residence Urban 13 17 18 12 Rural 87 83 82 88 Division of residence Chittagong 25 11 20 14 Rajshahi 23 35 26 33 Barisal 10 11 11 11 Khulna 12 14 16 14 Dhaka 30 29 27 29 Woman s age <30 years 38 36 42 23 30 years 62 64 58 77 n 5615 1629 604 739 found that women from Chittagong had much lower (0.92) odds of use compared with those from Dhaka. The model also finds that women who are mobile (both travelling alone or with child), and are from Rajshahi division, are more likely to use oral contraception. These findings are as expected and have been discussed in previous studies. A woman s visit to the satellite clinic was a significant predictor of her pill use in this model, although a visit to the health centre was not. In earlier surveys, visiting the health centre was found to be an insignificant predictor of use of any modern reversible contraceptive method, although information on visits to satellite clinics was not available in the earlier study (Kamal 1994). Women s education, cash earning status and membership of an NGO are not significant at the 5% level, but are significant predictors at the 10% level. The woman s age and religion are insignificant predictors of pill use. Use of IUD and injection In this model, when the husband approves of FP the woman s odds of using an IUD/injection increase by 5.42. This is the most significant predictor of use in this model. The next most significant predictor is her visit to the health centre. When the woman has visited a health centre at least once in the previous three months her odds of use are 3.3 times higher compared with no visit in the last 3 months. Similar results were observed for visits to satellite clinics. Injection users need to visit health centres regularly in order to continue their doses, and there is obviously a circular relationship between visits to the health centre/satellite clinic and use.

Husband s approval of family planning in Bangladesh 47 This model found that women who had higher mobility had higher odds of use. The odds ratios were higher than those observed for the model on pills, indicating that increased mobility has more influence on use of IUD and injection compared with use of pills. This may be expected as pills are supplied at home, but use of IUD and injections requires regular visits to a health centre/satellite clinic. Younger women (below 30 years) were more likely to be users of IUD/injection; older women had 0.25 times lower odds of use. It is possible that younger women are more motivated to use these modern methods, since IUD and injections are more recent additions to the FPP in Bangladesh (introduced in rural areas in the late 1980s). Other variables such as woman s education, cash earning status, religion, membership with any NGO and socioeconomic status (indicated by husband s educational level) were insignificant predictors of use in this model. Regional differences in husband s opinion on FP were not significant in this model. Female sterilization As in the two previous models, husband s approval of FP was the most influential predictor of acceptance of female sterilization in this model. Odds of acceptance increased by 4.33 when the husband approved of FP compared with when the husband disapproved. Sterilization is a permanent method and a husband s approval will naturally be of great importance. Additionally, every woman has to stay overnight in the thana health centre and needs both written spousal permission and logistic support to do so. Usually the thana health centres are more than 4 5 km from the clients villages. It is almost impossible for a woman to access such facilities on her own and stay overnight. The role of the husband s approval is clear from the model. The woman s mobility is the second most influential predictor. As mobility increases, there is a monotonic increase in the odds of acceptance of sterilization. This too is in the expected direction and has been observed in other studies, since poorer (indicated by lower levels of husband s education) women enjoy more freedom of movement and they are more likely to accept sterilization (Kamal and Sloggett 1993; Cleland et al. 1996). Uneducated women below 30 years were more likely to be acceptors, as were women from non-islamic faiths. In Bangladesh, where Islamic beliefs are practiced, sterilization is viewed by many people as a sinful act against the will of God. However, the insignificant association in this study of a woman s religion with use of other modern, reversible contraceptive methods may indicate that Islamic opposition is perceived for sterilization alone and not for all contraception. Previous studies have also observed similar patterns (Kamal and Sloggett 1993; Kamal et al. 1996). In this model, women who earn cash are more likely to accept sterilization. This may be because those earning money may be more assertive about their reproductive choices or because they may have a lower socioeconomic status. Women who are members of an NGO are more likely to accept sterilization, a finding also observed in other studies. This may be due to the extra emphasis given to sterilization in group discussions held by NGO officials in rural Bangladesh (Kabir and Amin 1995). Role of husband s approval among those intending to use modern contraception in future The frequency distribution of women used in this model is presented in Table 3. Only women who are currently not using any modern contraception and who are not infertile have been considered in this model. Thirty-six percent of the women reported that their husbands disapproved of FP. The outcome variable here is binary (intend to use modern contraception in future, coded 1, 0 otherwise) and ordinary logistic regression is used. The results of logistic regression are presented in Table 3. Variables were introduced according to their relative contribution to the reduction of the loglikelihood of the model. The addition of the demographic variable age of the woman produced very significant changes in the log-likelihood of the model. Two models are therefore presented in Table 3, the first excluding the demographic control (age) and the second including it. In model 1, husband s approval of family planning was the most influential predictor of future use of modern contraception. Model 1 shows that the odds of intention to use contraception increase 4.66 times if the husband approves of FP. Here other significant variables are a woman s higher socioeconomic status and visit to the satellite clinic. Divisional differences are significant; women from Barisal and Khulna are less likely to be future users compared with women from Dhaka division. Women from Chittagong also have lower odds of use, but higher than for Barisal and Khulna. This may be because most eligible women in Barisal and Khulna are already users, whereas more women from Chittagong division would like to be future users. The model finds that women who are more mobile are less likely to be users in future. This effect disappears in model 2 when the model is controlled for age. Older women generally enjoy greater freedom of movement than younger women in Bangladesh, and they will be less likely to be future users. Model 1 also finds that visit to a satellite clinic is a significant positive predictor of use in future, which indicates that the establishment of these clinics may be having the desired effect. In Model 2, which includes age of the woman as another predictor of use, husband s approval of FP takes second place as a predictor, and age of the woman has an overriding effect over all variables. Compared with women aged over 40, younger women are most likely to be future users. However, in this model, odds of use double (compared with model 1) for a woman if the husband approves of FP. Both socioeconomic status and mobility become insignificant predictors of future use of modern methods. Divisional differences remain, except that Khulna division no longer differs from Dhaka division. A visit to the satellite clinic is still significant but its predictive power is diminished.

48 Nashid Kamal Table 3. Results of logistic regression of women intending to use modern contraceptive methods in future on selected socioeconomic and demographic variables, Bangladesh 1993 94 Variable Frequency (%) Model 1 Model 2 Odds ratio Significance Odds ratio Significance Husband approves of family planning Yes 64 4.66 <0.001 7.25 <0.001 No a 36 1.00 1.00 Woman s education Some 63 1.19 <0.34 1.06 <0.75 None a 37 1.00 1.00 Husband s education Secondary or higher 27 1.64 <0.05 1.45 <0.14 Primary/None a 73 1.00 1.00 Woman allowed to travel Alone 32 0.59 <0.001 1.03 <0.83 With child 38 0.49 <0.001 1.07 <0.63 Not allowed a 30 1.00 1.00 Visited satellite clinic in previous 3 months Yes 20 2.32 <0.001 1.50 <0.01 No a 80 1.00 1.00 Region of residence Chittagong 30 0.48 <0.001 0.52 <0.001 Barisal 8 0.63 <0.001 0.57 <0.01 Khulna 11 0.49 <0.001 0.68 <0.10 Rajshahi 20 0.86 <0.23 1.04 <0.77 Dhaka a 31 1.00 1.00 Woman s age 30 years 52 170.50 <0.001 30 40 years 22 16.80 <0.001 40 years a 26 1.00 n 2539 2Log Likelihood 1881.5 <0.001 2994.1 <0.001 a Reference category. In this study, among those who are currently not using any methods, 74% report that their husbands approve of FP. However, when husbands do not approve, women are unlikely to use modern contraception in the future. Discussion and conclusions In all three categories of use of modern contraceptive methods considered in this study, husband s approval of family planning led to the increased use of any method used by females. This is to be expected, as Bangladesh is a traditional society where women are expected to be guided by their husband s opinion in every sphere of life. The same is true for other societies where traditional female gender roles mean they have little say in sexual matters and lack the status to influence their partner s behaviour (Fort 1989; Dixon- Mueller 1993). In some senses, the effect of this variable as an independent predictor of contraceptive use is therefore diluted. Previous studies have remarked that women in Bangladesh have a tendency to use contraception only when they perceive that their husbands do not object (Kamal and Sloggett 1993). The same study also remarked that in many cases, those women who are non-users use husband s opinion as an excuse for being a non-user in future. Even in a high-use country like Jordan, 20% of women who were never users reported that the main reason was their husband s opposition (Fatima 1991). This analysis used only one variable husband s opinion of family planning, as perceived by the wife, to capture the attitude of the husband and this may have produced a limited and narrow view. However, there are several instances in the literature where the same variable has been used as an independent predictor in regression models on contraceptive use and probabilities of getting pregnant. For example, in Kenya, the same variable was found to be an important predictor (not the most significant) of use of modern contraception (Lasee and Becker 1997). In urban Indonesia, husband s approval was the most important determinant of contraceptive use, followed by number of living children and wife s education (Joesoef et al. 1991). In Sri Lanka, where the population is mainly non-muslim and women s literacy rate is the highest in the sub-continent, women whose husbands disapproved of contraception had a four times higher risk of unwanted pregnancy compared with those whose husbands approved (De Silva 1992).

Husband s approval of family planning in Bangladesh 49 Based on several international surveys, Gallen et al. (1986) concluded that men generally favour family planning. Such is the case for Bangladesh, where the most recent BDHS (1996 97) found that more men (60 %) reported being a user compared with their matched cases of women (55%). Figure 1 gives the rates of male contraceptive use. Since 1993 94, the fertility preference of matched cases of men and women has also shown more symmetry. Figure 2 shows that only 11% of couples disagree in their desire for more children as compared with 12% in the 1993 94 BDHS. Moreover, in the 1996 97 BDHS, 96% of both men and women report that their spouses approve of FP, indicating a bright backdrop for future use. However, there is a need to involve Bangladeshi men more extensively in the current national FP programme. After the 1994 International Conference on Population and Development, a more holistic approach to reproductive health is being advocated for the developing countries. As a step towards this the HAPP-5 (GOB 1998) has been introduced in Bangladesh. In this, one-stop services will not only provide FP methods but will also include other aspects of reproductive health, child care, nutrition and common illnesses. However, no specific measures have been taken to increase the use of male methods of contraception or to increase spousal support for female users, or to provide more information to them. In Bangladesh, where men frequently join prayer groups, religious leaders have been found to be key informants on many issues, especially health and family planning (Aziz and Figure 1. Trends in use of male contraceptive methods in Bangladesh, 1975 94 5% 6% 28% 51% Neither wants more children Infecund/undecided Both want more children Wife wants more husband doesn't Husband wants more wife doesn't 10% Figure 2. Fertility preferences among married couples, BDHS 1996 97

50 Nashid Kamal Maloney 1985). Two NGOs, BRAC and the Family Planning Association of Bangladesh (FPAB), are involved in sensitizing religious leaders. BRAC (1996) has introduced group sessions (male/female seminar and newly-wed orientation) of counselling in certain project areas, producing higher contraceptive prevalence rates in those areas. Another project, Jiggasha, uses existing rural communication networks to make discussion of reproductive health more culturally acceptable and to foster more communication among men and women (Piotrow et al. 1997). These projects may be spread nationwide. Understanding the influence of gender and portraying positive images of shared responsibility in the mass media is urgent. In 1985 Profamilia adopted a new strategy that emphasized male responsibility. By being gender sensitive the number of vasectomies doubled and tripled (Plata 1998). To provide spousal support, men may be asked to accompany women when they visit health centres so that the management and side effects of the modern contraception can also be explained to them. A successful couple may also be assigned to new users to enable frequent consultation on a one-to-one basis in the absence of fieldworkers or satellite clinics. More sensitization and motivation on the use of condoms should be advocated, and their usefulness as a safeguard from AIDS as well as contraception during pregnancy should be included. Although such programmes do exist in Bangladesh in the form of efforts by NGOs, they need to reach the entire country, especially remote areas where mass media (TV, radio, newspaper) coverage is limited. For such purposes, multi-media messages, including village dramas and group discussion sessions, have to be developed for the illiterate masses. Forming men s clubs in every village for the discussion of various issues related to reproductive and sexual health may be another way of sensitizing men. In southern India more than 25 000 barbers have been trained as community health workers; village men say they feel more comfortable talking to their barbers than to clinic workers (Associated Press 1997). Experiences in Uganda, Brazil and Colombia suggest that men will accept information and services from either male or female counsellors as long as they are knowledgeable and respectful (Green et al. 1995; AVSC 1997). Similar concerted efforts in Bangladesh will certainly help towards a better understanding by men of reproductive health problems in general and contraceptive use in particular, and this may be true for other developing countries of the region where similar socio-cultural conditions prevail. Endnotes 1 In this survey, only 0.6% of non-users state their own opposition to FP as the reason for non-use. 2 Calculated as: Husband approves of FP in Dhaka division * Husband approves of FP in Chittagong division = 5.21 * 5.74 = 29.90. References Amatya R, Akhter H, McMahan J, Williamson N, Gates D and Ahmed Y. 1994. The effect of husband counselling on NOR- PLANT contraceptive acceptability in Bangladesh. Contraception 50(3): 263 73. Amin S, Diamond I, Steele F. 1995. Contraception and religiosity in Bangladesh. Paper presented in the Continuing Demographic Transition. The John C Caldwell Seminar, Australian National University, 14 17 August. Associated Press. 1997. Barbers and condoms. AP wire service, Hyderabad, India. AVSC International. 1997. Profamilia s clinics for men: A case study. New York: AVSC International. Aziz KMA, Maloney C. 1985. Life Stages, Gender and Fertility in Bangladesh. International Centre for Diarrhoeal Disease Research, Bangladesh. 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Dixon-Mueller R. 1993. The sexuality connection in reproductive health. Studies in Family Planning 25(5): 269 82. Fatima NB. 1991. The plight of rural women. In: Raj SL (ed). Quest for Gender Justice: A critique of the status of women in India. Madras, India: Satya Nilayam Publishers. Fort A. 1989. Investigating the social context of fertility and family planning: a qualitative study in Peru. International Family Planning Perspectives 15(3): 88 95. Gallen ME, Liskin L, Kak N. 1986. New focus for family planning programs. Population Reports, Series J, No 33. Population Information Program. Baltimore, USA: John Hopkins School of Public Health. Green CP, Cohen SI, Belhadj-el Ghouayel H. 1995. Male involvement in reproductive health, including family planning and sexual health. New York: United Nations Population Fund. GOB. 1998. Programme Implementation Plan, Fifth Health and Population Programme 1998 2003, HAPP 5. Ministry of Health and Family Welfare. 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Husband s approval of family planning in Bangladesh 51 Lasee A, Becker S. 1997. Husband wife communication about family planning and contraceptive use in Kenya. International Family Planning Perspectives 23: 15 20. Mitra SN, Ali MN, Islam S, Cross AR, Saha T. 1991. Bangladesh Demographic and Health Survey 1993 94. Mitra and Associates, Dhaka, Bangladesh. Plata MI. 1998. Personal Communication, July. Population Reference Bureau. 1993. Pakistan: Family Planning with male involvement project of Mardan. Washington DC: Population Reference Bureau. Population Reports. 1998. New perspectives on men s participation. Communication is key to accurate perceptions. Series J, No 46. Baltimore, USA: Johns Hopkins University School of Public Health. Piotrow PT, Kincaid DL, RimonII JG, Rinehart W. 1997. Health Communication: lessons from family planning and reproductive health. Westport, CT, USA: Praeger. Schuler SR, Hashemi SM. 1994. Credit programs, women s empowerment, and contraceptive use in rural Bangladesh. Studies in Family Planning 25(2): 65 76. Biography Nashid Kamal has a PhD in Medical Demography from the London School of Hygiene and Tropical Medicine, UK (1996), an MSc in Statistics from Carleton University, Ottawa, Canada (1982) and a BSc (hons) in Statistics from Dhaka University, Bangladesh (1980). He is Associate Professor and Head of the Department of Population-Environment, School of Environmental Science and Management, Independent University, Bangladesh (IUB). Correspondence: Dr Nashid Kamal, House 19 Rd 3, Baridhara, Dhaka 1212, Bangladesh. Email: nkamalwz@iub-bd.edu