From 1978 until 1997, female family welfare assistants in Bangladesh delivered contraceptives to women in their homes. This service was stopped in 1997, in part because of the arguments of observers who believed that doorstep delivery of contraceptives may prevent improvements in women’s status by reinforcing the customs of patriarchy and purdah, or female seclusion. When doorstep delivery of contraceptives ended, women who wished to use contraception had to travel to centralized clinics to obtain it.
Enhancing or diminishing status?
Population Council demographer James F. Phillips and his Morgan State University colleague Mian Bazle Hossain questioned the qualitative research evidence cited to support this change in policy. They noted that other qualitative research had demonstrated that home services enhance the status of women over time. The delivery of contraceptives gives women control over their fertility and allows them to interact with other women, the family welfare assistants. The assistants, in turn, benefit directly by receiving cash wages and indirectly by gaining mobility, prestige, and authority from their work. Moreover, the large-scale deployment of female family planning workers changed people’s perceptions of women’s roles. Critics of centralized services argued that ending door-to-door delivery of contraceptives would not only put tens of thousands of female family welfare assistants out of work, but would increase the fertility of their former clients, who would be unlikely to travel to centralized clinics. Phillips and Hossain conducted a large-scale statistical analysis to determine which perspective was supported by quantitative evidence.
Criticism misplaced
Phillips and Hossain’s analysis showed that criticism of home-based services on grounds that they reinforce women’s traditional roles is not supported by evidence. In fact, home services improve women’s status, largely by improving the effectiveness of family planning and lowering fertility They examined data on 3,783 rural women from two cross-sectional surveys on women’s status conducted in 1988 and 1993 and longitudinal data assessing the impact of visits with family welfare assistants between 1982 and 1993. By linking data from the two surveys to the longitudinal histories of contact with family welfare assistants, the researchers created a powerful tool for examining the relationship between workers’ contact and the change in women’s status over the period from 1988 to 1993. The researchers also prepared an index, based on 19 indicators from the 1993 survey, to represent women’s status. Using this index and controlling for women’s status in 1988 allowed them to statistically analyze change over time and to determine the cause of that change.
Phillips and Hossain demonstrated that home delivery of family planning services improved women’s status. Further statistical analysis revealed that the positive effects of outreach by family welfare assistants are attributable mainly to the effect of fertility regulation rather than to the effect of social interaction during the visit. These results indicate that reducing unwanted fertility fosters improved mobility, autonomy, and household authority for rural women in Bangladesh.
Resumption of services
In 2003, the Bangladesh Ministry of Health reinstated the doorstep delivery of contraceptives. Phillips believes, however, that program managers should not simply resume the former approach to delivering family planning services to the home. This program, as it had been practiced for decades, likely met only a limited number of needs of the women it served. The services provided, for example, did not include general health care for adults and children.
To more fully meet the needs of clients and make the program as successful as it can be, researchers should conduct in-depth interviews and focus groups with clients and then design programs based on the needs that are revealed. “These new programs should be tested and adjusted to local conditions before large-scale operations are implemented,” Phillips states. “Planners should base the design of the program on sound scientific evidence that the strategies pursued are appropriate for the setting,” he concludes.
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