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Bangladesh: Clients and Providers See Benefits of Emergency Contraception Pills
OR Summary no. 48

Background

Although contraceptives are widely available in Bangladesh, unmet needs for family planning persist, and unplanned pregnancies are common. Women with unwanted pregnancies may suffer serious consequences, including injury or death from unsafe abortion. In 2001 FRONTIERS collaborated with the Bangladesh Directorate of Family Planning, Pathfinder International, and John Snow Inc. to test the feasibility of introducing emergency contraception pills (ECP) as a backup method for existing family planning and a way of preventing unintended pregnancies following unprotected sex.

The study compared the relative effectiveness of two alternative models for delivering ECP (prophylactic and on-demand) with findings from four clinics serving as control. Providers in the eight intervention clinics received two days of training on ECP counseling and a day of refresher training one month after beginning services. At four of the intervention clinics, clients were given a brochure on ECP and two packets of emergency contraceptive pills during the consultations (prophylactically); at the other four, they were instructed to return
for ECPs, if needed (on demand). At the control clinics, clients received routine family planning services and no information on ECP.

Researchers assessed changes in providers’ and clients’ knowledge through pre- and post-intervention testing of providers (n=290) and focus group discussions and interviews with 2,600 consenting women in the intervention clinics as well as 1,300 women in the control clinics.

Findings

• Both providers and clients supported the introduction of ECP. Providers reported that unprotected sex is common. In interviews, 18 percent of women in experimental areas and 14 percent in the control areas said that they had had unprotected sex during the nine-month intervention period, mainly because of method failure or non-use of contraception. In focus group discussions, most women said that they were willing to pay for ECP.

“Sometimes I do not have pills. Even in 
such [a] situation my husband . . . says, I
can’t wait to have sex till you get the
method. What can I do in such a situation?”

—Focus group participant

• In the experimental areas, 176 women (about 10% of clients) used ECP. About half of these women reported that they used ECP correctly in all respects. Ten women—one who reported correct use, and nine who reported incorrect use—became pregnant.
   

• Most of the women who used ECP (84%) were using a family planning method before unprotected intercourse occurred. After using ECP, 96 percent of these women went back to their previous method. Of the 16 percent of women who were not using any method, 68 percent adopted contraception after using ECP. The majority of ECP users (91%) used ECP only once during the intervention period. This finding refutes concerns that ECP may replace regular family planning use.
   

• Women’s knowledge of ECP increased substantially in the intervention area. Over 60 percent of women in the intervention clinics, compared to only two percent in the control area, were aware of ECP. However, only 12 percent of women in the intervention areas correctly answered all questions about the doses and timing for correct ECP use (see Figure).

 

• Providers’ knowledge of ECP increased substantially following training; all 208 providers in the intervention areas knew of ECP (compared to only 12 of the 82 providers in the control area). Four months after training, knowledge about correct use and dosage of the pills remained high among all types of providers, including those with lower levels of education.
   

• The proportion of women using ECP was much higher in the prophylactic area (75%) than in the demand area (47%). Analysis revealed that the probability of ECP use was more than five times higher if women received the ECP brochure, and almost twice as high if the husband also saw the brochure.
   

Utilization

• Based on these findings, the government of Bangladesh decided to introduce emergency contraception in the National Family Planning Program in phases. Postinor-2 will be provided at a cost of 8 Taka (US$ 0.13). Following introduction in 17 districts, covering a population of 52 million, the government began nationwide introduction of ECP for the country’s full population of 139 million. FRONTIERS is providing technical assistance in the scale-up, while UNFPA is supporting training and procurement of the EC pills.

Policy Implications

• ECP are an effective and acceptable backup method for preventing pregnancy. However, achieving correct use on a larger scale will require effective counseling about ECP and functional knowledge about their use. Study findings show that the prophylactic approach is the most effective. A broad educational campaign, as well as comprehensive training for providers, will be necessary to support scale-up.
   

 September 2004

Source: Khan, M.E., Sharif Mohammed Ismail Hossain, and Moshiur Rahman. 2004. “Introduction of emergency contraception in Bangladesh: Using operations research for policy decision,” FRONTIERS Final Report. Washington, DC: Population Council.
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