1. 1
Qualitative ResearchtoImprove ReproductiveHealthServices inRural
Kirsharagonj, Bangladesh
Results froma PEER Study
Eleanor Brown (Options)
With
Tangina Ahmed (MSIBangladesh)
Dr.ShanazPervin (MSIBangladesh)
Shahida Akter Mitu (MSIBangladesh)
Shahid Hossain (MSIBangladesh)
November 2012

2. 2
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3. 3
Disclaimer
The viewsandopinionsexpressedinthisreportare those of the authorsand do notnecessarily
representthe opinionof UKAid(DFID).

4. 4
ACKNOWLEDGEMENTS
The authors wouldlike tofirstlythankthe PEERresearcherswhogave theirtime,effortsandfull
heartedsupporttothisPEER study.
We are also verygrateful toEmma Garoushe andCristinGordon-MacleanfromMarie StopesLondon
for theirinvaluable supportinsettingupthe study,alongwithShahidHossainandDr.Pronabfrom
Marie StopesBangladesh.We alsothankRachel Grellier,KirstanHawkinsandSarahHepworth(all
fromOptions) fortheirhelpinpreparingforthisstudy.

5. 5
Contents
Executive Summary ...................................................................................................................... 8
INTRODUCTION ........................................................................................................................ 8
METHODOLOGY........................................................................................................................ 8
KEY FINDINGS AND CONCLUSIONS............................................................................................. 8
PROGRAMME IMPLICATIONS.....................................................................................................9
1 INTRODUCTION ....................................................................................................................... 12
1.1 METHODOLOGY........................................................................................................... 12
2 BACKGROUND......................................................................................................................... 12
2.1 Marie Stopes Bangladesh’s Programme.............................................................................. 12
2.2 PEER Research Objectives.................................................................................................. 12
3 RESEARCH METHOD................................................................................................................. 13
3.1 Introduction to the PEER Method....................................................................................... 13
3.2 Study Location .................................................................................................................. 14
3.3 Recruitment and Training of PEER Researchers ................................................................... 14
3.4 Data Collection and Analysis .............................................................................................. 15
3.5 Research Ethics................................................................................................................. 18
3.6 Limitations to the Study..................................................................................................... 20
4 FINDINGS: THEMES FROMTHE NARRATIVES.............................................................................. 21
4.1 Information....................................................................................................................... 21
4.1.1 Formal Sources of Information.............................................................................. 21
4.1.2 Informal sources of information................................................................................... 22
4.2 Decision-Making.......................................................................................................... 25
4.2.1 Factors Influencing Decision-Making...................................................................... 25
4.3 Implicationsfor MSI..................................................................................................... 30
4.4 Starting a Family.......................................................................................................... 31
4.4.1 ‘Ideal’ Family Size and Composition.............................................................................. 31
4.4.2 The first child.............................................................................................................. 32
4.4.3 Reasons for Delaying the First Child.............................................................................. 33
4.4.4 Deciding to have other children ................................................................................... 35
4.5 Stopping having children.................................................................................................... 39
4.6 General Factors Affecting the Use of Family Planning .......................................................... 41
4.7 Attitudes towards Different Family Planning Methods ................................................... 43
4.7.1 Short-term methods.................................................................................................... 44

6. 6
4.7.2 Long-term methods..................................................................................................... 46
4.7.3 Implicationsfor MSI.............................................................................................. 48
4.8 Unwanted Pregnancies ................................................................................................ 49
4.8.1 Attitudes towards abortion.......................................................................................... 49
4.8.2 Reasons for abortion ............................................................................................ 52
4.8.3 Decision-making.......................................................................................................... 52
4.8.4 Treatment-seeking Patterns......................................................................................... 53
4.8.5 Cost............................................................................................................................ 55
4.8.6 Perceptions of Service Providers.................................................................................. 57
4.9 Implicationsfor MSI..................................................................................................... 61
5 CONCLUSIONS......................................................................................................................... 62
6 PROGRAMME IMPLICATIONS.................................................................................................... 64
6.1 Beliefs to Reinforce and to Change..................................................................................... 65
APPENDICES............................................................................................................................... 71
ANNEX I: PEER RESEARCHER QUESTIONS ..................................................................................... 71
ANNEX II: Personas..................................................................................................................... 73

7. 7
ACRONYMS
CAC ComprehensiveAbortionCare
D&C Dilatationandcurettage
DFID DepartmentforInternational Development
FP FamilyPlanning
FWV FamilyWelfare Visitor
GOB Governmentof Bangladesh
IUD/IUCD Inter-uterine device/Intra-uterine contraceptivedevice
MMR Maternal MortalityRatio
MSI Marie StopesInternational
MSB Marie StopesBangladesh
OCP Oral contraceptive pill
PAC Postabortioncare
RH Reproductive Health
RTI Reproductive tractinfection
SRH Sexual andReproductive Health
STI SexuallyTransmittedInfection
TFR Total FertilityRate

8. 8
Executive Summary
INTRODUCTION
ThisreportpresentsfindingsfromaDepartmentforInternational Developmentfundedstudy
undertakenonbehalf of Marie StopesInternational andMarie StopesBangladesh byOptions
ConsultancyServices. The focusof investigationwastoobtaindataon community levelbeliefs,
knowledge andpracticeswhichimpactonmaternal healthandaccesstoreproductive health
servicesin Kirshargonj,inBangladesh.
The purpose of the researchwasto enable MSI Bangladesh touse the findingstoscale upthe supply
of appropriate andaccessible reproductive healthservices,andforthisto be matchedby an
increaseddemandforservicesamongmarriedmenandwomen. Marketingplanswill be usedto
educate potential clientsaboutreproductivehealthservicesinordertoincrease women’s
opportunity,ability,andmotivationtodetermine theirfertility.
METHODOLOGY
PEER (ParticipatoryEthnographicEvaluationandResearch) isa participatoryqualitative research
methodwhichcapturesthe voicesof ordinarymembersof acommunityandobtainsaninsider's
viewof social relationships,health-relatedbehaviourandbeliefs,andchannelsof communication.
Questionsare askedinthe thirdpersontopreventnormative responses.
Eighteenmarriedwomenfromanurban communityin the townof Kirshargonj,BottrishDistrict
workedwith OptionsandMS Bangladesh researcherstodevelopaninterview scheduleduringa
three-dayparticipatorytraining.EachPEERResearcherinterviewedtwofriendsonwhatother
people doorsay about:havingchildren,preventingunwantedpregnancy,anddealingwith
unwantedpregnancy.
The narrative interview datawere analysedthematicallyandkeyfindingstriangulatedwith PEER
ResearchersandMS Bangladesh programme staff. Resultsare presentedinSection4,and
implicationsdetailedinSection6,witha particularfocuson accessibility,affordabilityand
acceptabilityof services.
KEY FINDINGS AND CONCLUSIONS
The PEER researchhasgeneratedrichinsightsintothe complexitiesof women’srolesanddecision-
makingonreproductionandfertilitycontrol inasemi-urbansettinginBangladesh.Thisopensupfor
explorationthe everydaydecisionsandconversationsthat women,theirspousesandextended
familyneighbourshave aroundcontrollingfertility,includingthroughaccesstoabortion.The
researchpaintsa mixedpicture,withtraditionandwomen’srole withinthe householdplayinga
central role,butwithevolvingideasandpressurescomingintoview,whichare leadingtoacomplex
social contextforwomen’sdecision-making.
The PEER researchshowsthatwomeninterviewedfeltthatthere wasinformationandeffective
service provisionavailable,principallythroughthe governmenthealthsystem.Informalfemale
networks,includingfemale in-laws(the ‘b’habi’) andneighbourswere veryinfluentialinwomen’s
decision-making.There werenonethelesspersuasiveaccountsof providerbias,lackof information
and of contraceptive counselling,aswomenare providedwithcontraceptionbutwithlittlemeansof
understandingit.The currentcontextof women’sdecision-makingclearlydemonstratesthatittends

9. 9
to routinelyfavourshort-termmethodsoverothers,andthatthisdoesleadtounwanted
pregnanciesandeventually,tounsafe abortions.The PEERresearchthusconfirmsthat there isa
strategicneedforbetterdemandcreationactivitiesformore effective contraceptivemethods,and
that gainsincouple yearsprotectionratherthancontraceptionprevalence ratesshouldbe akey
focus.
The PEER researchalsorevealseverydayreproductivedecisionswithinfamiliesare broadlyinline
withnational goalsonfertility.There wasclearconsensusaroundfamilyideals,suchasnumberof
children(twotothree) andspacingbetweenthem(3-5years).Emergingideas,suchasthe
desirabilityof womenchild-bearingover18years of age (whichisa governmenttarget),alsofeature
stronglyinwomen’snarrativesof covertresistance topressurestohave children.These drivers
appearto supportwomen’sdecision-makingonreproduction,butclearlyhave potential tobe made
betteruse of,bothto delaypregnancyandto stophavingfurtherchildren.
Thisreportalso clearlyshowsthatattitudestowardsabortionare mixed.Strongcultural and
religious-basedsocial normsexistalongsideanacceptance thatabortion(orMenstrual Regulation)
can be justifiedaspartof soundandresponsible economicplanningforfuture families.Wider
societal perceptionsthatabortioncanbe conductedsafely,withfew repercussions,have been
importantin'normalizing’accesstosafe abortion.The PEERresearchhoweveralsodemonstrates
that inBangladesh,asinothercontexts,itispoorerwomenwhoare more likelytoaccessunsafe
abortion,andto consequentlyneedrapidaccesstopost-abortioncare.While there waswide
consensusthattraditional methods,suchasherbal remedies,were unsafe,itwasalsoclearthat
there isan on-goingneedtostill signpost womentosaferproviders.
MSI has a strong and potentiallyvital roletoplayinprovidingsafe andnon-discriminatory
reproductive healthservices,includingabortion,towomenintheseareas.Keychallengestodothis
include:the diversificationof the marketandstrongcompetitionfromotherproviders;ineffective
referral networkswhichdonotworkwell tosignpostwomentosafe andeffective providers
(especiallyforabortion);significantdemand-side barriers,includingwidespreadperceptionsthat
long-termmethodscause severe sideeffects;andgender-basednormswhichrestrictmobilityand
make women’saccesstoservicesalone difficult.
PROGRAMME IMPLICATIONS
ThissectionpresentsrecommendationsforMSIB’sprogramme.These are meantasdiscussion
pointsforstrategicprogramme developmentandfuture service delivery:
1. Low awarenessof MSIprovidingabortions:itwasfoundthatmostof the PEER researchersand
theirintervieweeswere unaware thatMSIprovidesabortions,andmostlyassociateditwith
anotherproject(amaternal healthvoucherscheme).Low costmeansof raisingawarenessof
thiscrucial service include:publicizingMSI’sabortionservice provisionthroughother
community-basedactivities;workingwithprofessional associationssuchas pharmacy
associationstoimprove referral networks,andmakingsure thatclientsaccessingfamily
planning/ante-natal care are alsoaware of MSI’sother services.
2. Improvingthe service offer:
- There wasa cleardemandformedical abortionsamongthe PEER researchers,and
EMA isscheduledtoreceive approval fromMOHpartnersimminently.There isa

10. 10
clearwindowof opportunityforMSIto be able topromote EMA service provision
overotherservice providers,andtobe able toprovide itsafely.
- The PEER researchhighlightsthe needforbettersignpostingtoPAC,asit appears
that commonlywomenwhoaccessunsafe methods(especiallyfrompharmacies)
are thenlikelytoaccessexpensive privatemedical care whencomplicationsarise,
and usuallywhenfacingsevere medical problems.MSI’smessagingshouldfocuson
a ‘fixed’price,emphasizingthatanyroutine follow-upcare isincludedinthe price
(andtherefore willnotincurextracosts),andshouldtargetthismarket.Working
withpharmaciststoensure goodaccess topost-abortioncare isa firstentrypoint.
There isalso a clearneedforwomentohave a betterunderstandingof the signsand
symptomsof a needforpost-abortioncare.
- Newcouple counselling:there isclearneedfor‘new couple counselling’,thoughitis
a potentiallysensitive areawhichunderminesthe role of the widerhousehold.A
potential entrypointiswhencouplesconsiderswitchingfromcondomstoother
short-termmethods,androutine screeningforRTIs/STIsaspart of ‘new couples’
services.
3. Social marketingprogrammessupportingreproductivehealthdecision-making:thesecan
potentiallyreinforce currentdecision-makingthroughoutthe reproductive lifecycle:
- For newcouples,‘beliefstoreinforce’include:
a) Delayingthe firstchild:the importance of women’seducation(‘amore
educatedwomanisa bettermother’),the desirabilityof startingafamilyonce
the womanis 20 yearsor older,couplesare responsibleandcanmake good
financial decisionsfortheirfamilies,anda new couple shoulddelaythe first
childinorderto enjoytheirmarriedlife togetherfirst(includingsex).
- Afterthe firstchild,keymessagesshouldfocuson:
b) Birth spacing:methodswhichare safe andappropriate touse for birthspacing
(includinglong-termmethods),the importance of couplesactingresponsiblyto
space the birthsof theirchildren,reinforce ideal familysize(twochildren),as
well asbirthspacingintervals(3-5years),andaddressmisconceptionsonthe
undesirabilityof 2 girl children.
- Afterfamilycompletion,keymessagesshouldfocuson:
c) Permanentmethods:appropriate methodsforuse afterfamilycompletion,
includinglong-termmethods(especiallythe implant/IUD),andpositive
messagingonwomen’smobilityasessential foraccessingreproductive health
care.
- Addressinggender-basednorms:
d) Gender-basednormsworktoconstrictwomen’saccesstoreproductive healthcare
and decision-making.Insome cases,womencouldaccesscontraceptionbuthad
not decidedtodoso (thishadoftenbeenprovidedbyothers,suchas
husbands).Itisthusvitallyimportantthatanymessagingonreproductive
healthinclude:validationof womenas decision-makers,whocanmake sound
economicchoiceswithinthe familyandaboutitsfuture,emphasisonthe
importance of the woman’sstatus(suchas age,and education) toensure the
healthandwell-beingof the family,andlastly,the necessityof womenbeing
able to accessreproductive healthcare,eveninmore distantlocations(at

11. 11
centresof excellentcare),andreinforcingideasof women’ssuperiorknowledge
inthese areas.
- Addressingproviderattitudes:
e) The importance of accessto contraceptive counsellingwasfoundthroughoutthe
research,andwomenthemselvesrecognizedthe importanceandneedforthis.
Beliefstoreinforceincludethat:itisimportantto meetwithqualifiedmedical
staff to understandthe full range of contraceptiononoffer,andtochoose an
appropriate one,andthatchoosingcontraceptionisa jointdecisionbetween
patientandmedical provider.

12. 12
1 INTRODUCTION
1.1 METHODOLOGY
PEER (ParticipatoryEthnographicEvaluationandResearch) isaparticipatory qualitative research
methodwhichcapturesthe voicesof ordinarymembersof acommunityandobtainsaninsider's
viewof social relationships,health-relatedbehaviourandbeliefs,andchannelsof communication.
Questionsare askedinthe thirdpersonto preventnormative responses.
Eighteenmarriedwomen fromanurban communityinKirshargonj,BottrishProvince,Bangladesh,
workedwithOptionsandMS Bangladesh researcherstodevelopaninterview scheduleduringa
three-dayparticipatorytraining.EachPEERResearcherinterviewedtwofriendsonwhatother
people doorsay about:havingchildren,preventingunwantedpregnancy,anddealingwith
unwantedpregnancy.
The narrative interview datawere analysedthematicallyandkeyfindingstriangulatedwithPEER
ResearchersandMSI Bangladesh programme staff. Resultsare presentedinSection4, key
conclusionsinSection5, andimplicationsdetailedinSection6,withaparticularfocuson
accessibility,affordabilityandacceptabilityof services.
2 BACKGROUND
2.1 MarieStopesBangladesh’sProgramme
In Bangladesh,Marie StopesInternational(MSI) isworkingtoensure thatwomenare able to
exercise theirrighttochoose pregnancypreventionandsafe abortion. MSIisdeliveringa
programme whichfocuseson service deliveryandcapacitybuildingtoincrease the numberof
providersandsitesable toeffectivelydelivercomprehensive abortioncare/MR,postabortioncare
and familyplanningservices.The programme aimstomeetitsdeliverablesthrougharange of
activities,includingafocusonsocial marketingwhichwill ensure greatercoverage andreachfor
womeninneed.The programme activitiesinclude doublingthe numberof social marketingoutlets,
trainingsocial marketingproviders,carryingoutdemandcreationworkandstrengtheningreferral
networksbetweenfacilitiesacrosssectors.
2.2 PEERResearchObjectives
The purpose of the PEER study,whichtookplace inSeptemberandOctober 2012, wasto fill existing
gaps inknowledge andtoprovide informationonthe followingissues thatinfluence fertility
decision-makingatlocal level:
 Understandinglocal social andcultural contextsof reproductive healthdecisionmaking
 Understandingwomen’sperceptionsof differentreproductive andmaternal services and
providers
 Understandingfactorscontributingtoawoman’schoice aboutusingdifferentmethodsof
fertilitycontrol.
The findingsof the researchare intendedtoresultinactionable recommendationstoinformhealth
programmingforproviders,pharmacists,andmembersof the community.Theyshouldalsoenable
well-targetedcommunications,advocacystrategiesandprogrammesefforts,basedonabetter
understandingabouthowcouplesmake decisionsaboutaccessingFPandSRHservices.

13. 13
3 RESEARCH METHOD
3.1 Introductionto the PEERMethod
The PEER methodisderivedfromthe anthropological approachwhichviewsbuildingarelationship
of trustwiththe communityasessential forresearchingsocial life.The PEERmethodisa wayof
trainingmembersof the targetcommunity(called‘PEERresearchers’)tocarry outin-depth
conversational interviewswithindividualsselectedbythemfromtheirownsocial networks.Asthe
PEER researchersalreadyhave establishedrelationshipsandtrustwiththe people theychose to
interview,the interviewscantake place overa relativelyshortperiodof time.Animportantaspect
of the methodisthatall interviewsare carriedoutinthe thirdperson.PEER researchersaskthe
intervieweestotalkaboutwhat‘otherpeople likethem’ doorsay.Theyare neveraskedtotalk
aboutthemselvesdirectly.Thisenablespeopletotalkfreelyaboutsensitive issues.The aimof the
interviewsistocollectnarratives,storiesandquoteswhichprovide insightsintohow interviewees
conceptualise andgive meaningtothe experiencesandbehaviourof ‘others’intheirsocial network.
All interviewsare confidential andPEERresearchersdonotidentifywhotheyhave talkedto,nordo
intervieweesidentifywhotheyare talkingabout.
One of the key aspectsof the PEER methodisthatit revealsthe contradictionsbetweensocial norms
and actual experiences.Thisprovidescrucial insightsintohow people understandandnegotiate
behaviour,andthe,sometimeshidden,relationshipsof power.1
The PEERapproach elicitsarich and
dynamicsocial commentaryinthe formof the peernarratives.
The PEER methodwaschosenforthisstudyfor the followingreasons:
 It generates in-depth, contextual data on a range of issues related to the research topic;
 Existingrelationshipsof trustbetweenpeerresearchersandtheirinformantsmeanthatfindings
are more detailed and insightful than if they had been gathered by an outside researcher;
 PEER involves the participation of the target group from the early stages of the research,
building ownership and ensuring that questions are contextually relevant and worded
appropriately;
 The methodisparticularlysuitable forcarryingoutresearchonsensitivetopicsdue tothe use of
‘third person’ questions, which enable respondents to talk about sensitive issues without
personal attribution.
In studies such as this one, the PEER method has several advantages over other methods of
formative research. Focus group discussions often produce normative statements (which refer to
what people should do according to local norms) or reflect dominant voices within the group.
Quantitative sample surveys are useful for many purposes but cannot explain the how or why of
social issues.Inaddition,people are oftenunableorunwillingtotalkaboutsensitive issuesopenlyin
front of focus group moderators or survey interviewers, while they tend to be more comfortable
discussing such issues with their friends.
1Price,NL and K Hawkins (2002) “Researchingsexual and reproductivebehaviour: A peer ethnographic
approach”,Social Science & Medicine, 55:8, 1327-1338.

14. 14
3.2 StudyLocation
The study tookplace inKirshargonj,BottrishProvince,Bangladesh.The studysettingisurban,butas
a small conurbationthe surroundingareasare peri-urbanand rural.
3.3 Recruitmentand TrainingofPEERResearchers
MS Bangladesh recruited eighteenmarriedwomentobe trainedasPEER Researchers. Their
selectionwasbasedonthe followinginclusioncriteria:
 Bangladeshi national;
 Have no previous involvement with the MSI programme;
 Married women between ages of 20-40 years, with or without children;
 Resident in target area and available for the duration of the study;
 Available and willing to attend PEER Interviewer training;
 Agrees to participate and is willing to be a PEER Researcher.
The PEER Researchersattendedathree-dayworkshopwhere they developedinterviewingskillsand,
inpartnershipwithaPEER specialist,and three femalesupervisorsfromMSIBangladesh,developed
a seriesof thematicquestionsandpromptsappropriate forguidingconversational interviewswith
othersintheirsocial circle. All trainingandworkshopswere heldin Bengali (translatedinsitufrom
English). Participatorydesignof the researchtool ensuredthatthe studywasframedwithinthe
conceptual understandingof the PEERResearchers.All interview topics,questionsandprompts
were producedinthe local Bengali dialect,usingwordsandphraseswhichthe PEERResearchers
mostcommonlyusedwhentalkingtotheirfriends. Thisparticipatoryprocessalsoensuredthatall
PEER Researchersandthe supervisorswere clearaboutthe specificmeaningof wordsandphrasesin
bothBengali andEnglish.
Neitherthe PEERResearchersnorthe intervieweesreceivedfinancial incentivesforparticipation.
The PEER Researchersreceivedatravel allowanceandasmall perdiemforattendingtrainingand
de-briefingsessions. Intervieweeswere boughtasoftdrinkorsnack by the PEER Researchersasa
small tokenof gratitude forparticipating.
The characteristicsof the PEER Researchersandthe friendstheyinterviewedare showninTable 1.
PEER Researchersandintervieweeswere all married, andall exceptone hadbetween 0-3children
(twohad nochildren). FemalePEERResearchersandintervieweeswere generallyunemployed
housewives–only3identifiedthemselvesashavinga profession,andthree saidthattheywere still
studying.
Table 1: Characteristics of PEER Researchersand interviewees (n=18)
No. of
participants
 18 PEER Researchers
 36 interviewees(all women)
Age  18–38 witha meanof 28 yearsof age (PEERresearchers)
 20– 38witha meanof 27 yearsof age (interviewees)
Marital status  All peerresearchersandintervieweesweremarried.
Other socio-  PEER Researchersandintervieweeshadbeenmarried
for a meanof 11 years,meaningthatwomenwere on

15. 15
demographic
information
average marriedat 16 yearsof age.
 Religion:2intervieweeswere Hinduand16 were
Muslim.
 Education:2 intervieweeshad noeducation;1 had not
finishedprimaryschool;5had some secondaryschool
edcaution;8 hadachievedthe middle secondaryschool
qualification(the SSC),and2had the highersecondary
school qualification(the HSC).
3.4 Data CollectionandAnalysis
Data collectionwascarriedoutovera two-weekperiod.Duringthistime eachPEER Researcher
interviewedtwofriendsonthree topics(table2).Interviewingthe same persononseveral occasions
allowsforintensive probingof eachinterviewee aroundthree identifiedkeythemes.Allof the PEER
Researchersspoke totwofriendsonthree occasions,andall 18 completedthe study.Bythe endof
the studya total of 72 interviewnarrativeswere obtained.
Throughoutthe data collectionperiodthe PEERresearchersregularlymetwiththe supervisors ina
neutral location,inthiscase at a recognizedNGOtrainingcentre inKishargonj.Supervisorsaskedthe
PEER researchersin-depthquestionsaboutthe interviewstheyhadcarriedoutsince the previous
supervisionsession. These debriefings all tookplace between24hours aftereachinterview.The
debriefingswere heldinBengali(withinsitutranslationswhende-briefingswereledorundertaken
by English-speakingresearchers). The debriefingswerenotrecordedbutthe narrativeswere,
instead,eithersimultaneouslytypedintolaptops,ornotes were takenbyhandandthentypedup
laterthe same day.
Duringthe supervisionprocessthe supervisorswere abletobuildupa strongrapport and
relationshipof trustwiththe PEER researchers. Thisenabledthe supervisorstoprobe more deeply
intoissuesraisedbythe interviews.
Table 2: Interviewtimetable
Week Interviewtheme
1 Havingchildrenwithinmarriage
2 Preventingpregnancy
3 Dealingwithunwantedpregnancy
The main themesof the interviewswere (Table 3):
 Having children within marriage
 Preventing pregnancy
 Dealing with unwanted pregnancy
Table 3: Summary of interviewthemesand questions

16. 16
Interview Theme Questions
1 Having
children
What do womensayabout1st
pregnancyaftermarriage?
What do womensayabouthaving otherchildren?
What do womensayaboutstoppinghavingchildren?
2 Preventing
pregnancy
If someone wantstopreventa pregnancywhodotheytalkto, to get
information?
What methodsdo womencurrentlyuse topreventpregnancy?
What methodwould womenprefertouse?
What do womensayaboutothermethodsusedtopreventpregnancy?
3 Dealing
with
unwanted
pregnancy
What do womensayaboutdiscontinuinganunwantedpregnancy?
How doesa husband/wife decide whattodoaboutan unwanted
pregnancy?
What do womendoto discontinue apregnancy?
How can discontinuingapregnancybe made better?
Ratherthan askingforpersonal information,PEERResearchersaskedtheirfriendsquestionsinthe
thirdperson:aboutwhat otherpeople say ordo inrelationtoparticularissues(see Annex 1). The
reportmakesmuch use of the narrative data obtainedbythe PEER Researchers.Quotesare used
extensivelythroughoutthe report,andquotesare attributedtoeachPEER Researcher.PEER
Researchers are differentiatedbyacode number(e.g. PEERResearcher1).
A final workshopwasconductedwiththe PEERResearchersafterdatacollection.Theygave
feedbackontheirexperiences,andhelpedtoanalyse the databytakingpart indiscussiongroups
and participatoryexercises whichincludeddevelopmentof ‘personas’of typical womenwhowould
benefitfromadditiontargeting (see Annex 2).A final workshopwasalsoconductedwithMSI
programme staff,andparticipantswere guidedthroughaseriesof participatoryanalysisactivitiesto
developthe service implications.
De-briefingnotesandresultsfromtheseworkshopsformthe final dataset. Althoughall training,
debriefingsandworkshops(withthe exceptionof the final MS Bangladesh programme staff
workshop) were heldinBengali,translatedfromEnglishbythe MSIB facilitators, additional
facilitatorsandMSIB staff providedon-the-spottranslationstothe Englishspeakingresearchers. All
data (inthe formof conversationsanddebriefings)were typed upinEnglishastheytookplace.
It isrecognisedthatitis not possible tointerpretqualitative datawithoutbeinginfluencedby
theory.The analytical frameworkunderpinningthisstudyisthatreproductionisnegotiatedwithin

17. 17
gender-basedpowerrelationsandthe influence of local knowledgeandhealthsystems. 2
Asa
result,the datawere analysedthematicallyaccordingtoapre-existinganalytical framework
(developedaccordingtothe objectivesof the research) whichtookintoaccountboththe needfora
gender-sensitive,culturallycontextual analysisof reproductivedecision-makingbutalsosupply-side
issuesof importance toMarie StopesBangladesh. These includedspecificissuessuchasknowledge
of pricesof familyplanningcommoditiesandservices, andhow bestto‘message’ social marketing
activities. Emergingthemesandinsightswereincorporatedintothisframeworkbyassigningacode
to each theme,labellingandcuttingandpastingdataintotextunits(byparagraph) and assigning
these withinthe codingframework. Datawere thenre-read,andquotationsselectedtocapture the
essence of eachcode.
PEER researchersthemselvesalsofiltertheirunderstandingof the datatheycollectthroughtheir
ownworldview. Toovercome this,during the final PEERResearcherworkshop,the PEER
Researchersandresearchteamdiscussedthe dataandtheirimplicationstoidentifykeyissues
emergingfromthe interviewsandwhichwere importanttofeedbacktoprogramme staff. This
processalsohelpstopreventresearcherbiasinadvertentlydistortingthe significanceof specific
issuescontainedwithinthe interview narratives.
One of the characteristicsof the PEER methodologyisthatitis(relatively)rapid,particularlyinterms
of movingfromdatacollection,throughdataanalysis,topresentationof initial findingsat
participatoryworkshopsheldwithresearchparticipantsandprogramme staff. Thismeansthata
substantial amountof dataanalysisiscompletedwithinaperiodof approximatelyfourdays. Itis
essential thatthe rigourof data analysisisnotdilutedbythispragmaticapproachbutinsteadthata
balance isreachedbetweenproducingvalidandreliablefindingsbutwithinashortperiodof time
for themto be utilizedinparticipatory workshopsthatforman intrinsicpartof the PEER process. An
additional characteristicof PEER isthat itis a ‘low-tech’methodologythatcanbe usedby
organizationsfollowingthe initial capacity-buildingthattakesplace duringastudyledby Options
PEER specialists. Asa resultquantitativesoftwareare notusedfordata analysis. Instead,analysisof
data isundertakenbyhand,focusingonidentifyingthemesandpatternsof belief/behaviour
describedbyresearchparticipants(thematicanalysis). Thisapproach to data analysisiscommon
withinethnographicresearch –on whichthe PEER methodisbased.
Data are categorizedintoemergingpatterns,with‘exceptional’examplescontradictingapparent
normsalso recordedtoavoidover-simplificationof the researchfindingsandtoillustrate the
contextual complexitieswhichimpactonpeople’slivesanddecisionmaking.Once keythemeshave
beenidentifiedthe datawithineachtheme are categorisedintolayersof sub-themeswhichare all
inherentlyconnectedyetprovide informationondifferent,discrete aspectsof thattheme.Thisis
looselybasedonathematicanalysisof datausingopenandaxial codingprocesses.3
Opencoding
involvesreadingthroughthe datato increase familiarityandrecord‘theoretical memos’asanalytical
remindersformakinglinksbetweendifferentdata.Axial codingdescribesthe processof organising
opencodesintothemesandsub-themes.
2Hawkins,K, Price,N. (2002) Researching sexual and reproductive behaviour:a peer ethnographic approach.
Social Science& Medicine 55 (2002) 1325–1336
3Crang, M (1997) “Analysing qualitative materials”. In: R. Flowerdew and D. Martin (eds.) Methods in Human
Geography, Harlow: Longman, 183-196

18. 18
A simple exampleof thisrelatingto‘childbearing’isshownbelow andreportedonfullyinSection
4.3:
The appropriatenessof the identifiedthemeswastestedbythe researchteamwithboth the PEER
Researchersandthe MSIBprogramme teamduringtheirrespectivefinal workshopsbyensuringthat
PEER Researchersrecognizedthe themes(raised as‘issues’bythe researchteam) asaccurately
reflectingwomen’sormen’sliveswithinthe community;andthatthe programme staff viewedthe
themesasuseful infacilitatingdevelopmentof actionable outcomesrelevanttosocial franchising,
social marketingandclinic-basedservices.
Extensive use of quotationsismade throughoutthe report. All PEERResearchersandtheir
intervieweesare represented. Thisisreflectedinthe proportionof quotesattributedtoeachwithin
the sectionsof the report. In addition,all datawere obtainedviathe PEERResearchersduring
debriefingsessionsheldwiththe researchfacilitators. Some PEERResearchers,not surprisingly,
were more articulate thanothersandprobedmore deeplyforexplanationsduringinterviews. This
isreflectedwithinthe reportbythe numberof quotesattributedtoeachPEER Researcher. Many
quotes,while beingusedtoillustrate one particularissue alsorefertoa numberof relatedissues
discussedelsewhereinthe report. Thisreflectsthe interconnectednessof multiple factorsin
individualdecisionmakingandbutalsoensuresthateachquote is setwithinabroadercontextual
background.
3.5 ResearchEthics
Researchethicsapproval toundertake thisstudywasobtainedfromthe Marie StopesInternational
EthicsReviewCommittee (Approvalnumber 001-12A).
PEER worksto a rigorouscode of ethical practice thatis adaptedforeach study’s unique contextin
orderto protectboth PEER Researchersandinterviewees. These principles were incorporatedinto
the Bangladesh PEERstudyin a numberof ways. Keyexamplesare shownbelow:
Ethics issue Implementation
Informed consent PEER Researchers:
Verbal consent agreeing to participatein the study was obtained a number of
times throughout the initial three-day trainingworkshop. Written consent was
obtained on completion of the trainingworkshop (non-literatureparticipants
Theme:
Childbearing
Sub-Theme 1:
First Pregnancy
Sub-Theme 2:
Having other
children
Men's perceptions
of birth-spacing
Women's
perceptions of
birth-spacing
Son Preference
and number of
children
Sub-Theme 3:
Stopping having
children

19. 19
provided a thumb-print rather than their signature)
Interviewees:
Duringthe trainingworkshop PEER Researchers were instructed, verbally and by
means of role-plays,howto explain the study and obtain informed consent from
interviewees. Role plays performed by the research team and the PEER
Researchers themselves focused on ‘obtaininginformed consent’ and ‘potential
consequences of not obtaininginformed consent’. Considerabletimewas also
spent practicingseeking informed consent by pairing-up PEERResearchers to act
out the roles of interviewer and interviewee.
Duringdata collection PEERResearchers confirmed interviewees’ willingnessto
participateatthe startof every interview.
Developing interview
questions
The broad research themes were identified in advanceof the PEER Researcher
training. Duringthe three day trainingworkshop,however, PEER Researchers
participated in development of specific interviewquestions to ensure that no one
had to ask questions that were either inappropriate,or that they were
uncomfortable asking. PEER Researchers also translated the questions into
colloquial Bengali usingnon-technical words commonly used within the
community.
Interview skills Duringthe three day trainingworkshop emphasis was placed on providingPEER
Researchers with good interview skillse.g. avoidingleadingquestions,facilitating
full explanationsetc. They were instructed usingmixed methods including:
spoken information;roleplays led by the research team; roleplays acted out by
PEER Researchers,practicinginterviewingeach other, question and answer
sessions.
Cultural norms Gender norms:
Role plays arean intrinsic partof PEER Researcher training. All trainingtook place
in a woman only trainingroom, though male MSB staff infrequently attended for
limited sessions.
Women’s mobility:
Women’s mobility outsidetheir home is very limited due to cultural norms. The
location of PEER Researcher training,interviews and debriefings took placein a
neutral location – a well recognized NGO training centre. Women often chose to
travel to and from this venue in pairs.
Women’s social networks:
Women’s social networks are very small. PEER overcomes this challengeby
askingthatall interviewees should already bepartof each PEER Researcher’s
social network and that the PEER Researcher and interviewee should have a high
level of mutual trust. As a result,female PEER Researchers were ableto
undertake interviews without raisingsuspicionswithin their household about
unusual movements or talkingto people they would not normally engage with.
Women’s domestic duties:
The timing of the PEER Researcher trainingand final workshops,interviews and
debriefingsessions were arranged to take placeattimes when women were able
to leavetheir houses without neglecting their routine domestic and other work.
Reimbursement Financial and in-kind incentives were provided to all PEERResearchers. These
equated to coveringany incidental costs incurred due to participation,rather
than being a ‘wage’ earned i.e. it was the equivalent of a day’s casual labour. In
addition all PEERResearchers were provided with snacks and meals on the days
when they attended trainingor workshop sessions,and atthe end of the study
they each received a small gift(men received a clock and women were given a
cookingpot). PEER Researchers were also given sufficientmoney to buy each
interviewee a soft drink and a snack as a small ‘thank you’ for their participation.
Provision of
reproductive health
information
Duringthe course of the study both PEER Researchers and interviewees revealed
incorrectknowledge on a number of reproductive health issues. As a result, at
the end of the final PEER Researcher workshop,MSB provided female PEER
Researchers with correct information on these and other reproductivehealth

20. 20
issues. This was followed by a question and answer session.Information
provision and Q&Asessions wereheld separately for men and women. PEER
Researchers were asked to sharethis information with their interviewees and
anyone else they thought might be interested. Itwas not possiblefor the
research team to hold a wider community meeting to sharethis information
sinceitwould have risked PEER Researchers becoming anxious thatinformation
they had given the research team in confidence would be revealed; and it might
arousesuspicion or hostility amongolder members of the community who had
not been involved in the research.
3.6 Limitationsto the Study
Some minorlimitationswere encounteredinthe studydesign. These didnotimpactonthe quality
of data obtained:
 The aim of qualitative andethnographicresearchistoprovide detailed information about a
research topic. Qualitative analysis allows for a thematic analysis, but rarely allows for
quantification of these themes. Where possible and appropriate, qualification of the
prevalence of themes and opinions have been made through the use of terms such as ‘a
majority of…’, ‘most…’, ‘many’, and ‘few…’.
 Thisis a reasonablysmall sampleof researchparticipantslivingwithins,and findings cannot
be generalised beyond the study area. However, the detailed information does provide
indicative findings that may be programmatically relevant to other rural programme
implementationareas.Previousexperience fromalarge number of PEER studies shows that
thisnumberof PEER Researchersprovidessufficient and appropriate information to enable
effective improvements to delivery of reproductive health services.
 Data collection and analysis processes uncover people’s beliefs, perceptions, actions,
behaviours and knowledge. This may not all be scientifically factual, but this ‘local
knowledge’isoftenconsideredas‘fact’to people thatholdit.Forthisreason,itis important
to reflect on and report on these issues to inform the design of relevant and appropriate
programming.
 A few of the PEER researchers (about 5 women) hailed from more than the recommended
distance in PEER recruitment from the urban centre of Kirshagonj, meaning more than half
an hour away by public transportation. However, given the small size of the urban centre,
manyof the PEER researcherscame fromsimilarly peri-urbanorrural communities. Despite
greaterdistancestravelled,all PEERresearcherscame fromcommunitieswithinthe range of
MSI Kirshargonj’s catchment area.
 It is possible that due to the restrictions on women’s mobility that the women recruited
were slightlymore educated than the ‘average’ woman in Kirshargonj, and therefore more
able to assertsome independence.Great efforts were made by the MSB team to overcome
any potential samplingbiasbysystematicallyrecruiting in public areas such as markets, and
giventhe time constraintsandsmall overall sample forthisqualitativestudy,othersampling
techniques would not have been possible.

21. 21
4 FINDINGS:THEMES FROM THE NARRATIVES
Thissectionprovidesanoverviewof the keyfindings. Issuescoveredare:
 Formal and informal social relationships affecting fertility-related health;
 Circumstances within which decisions and actions are taken to have children and to stop
having children;
 Family planning strategies used to prevent pregnancy within marriage;
 Attitudes about abortion, and strategies used to deal with unwanted pregnancies.
Discussionof the dataincludessuggestedimplicationsof the findingsforkeystakeholders.Thisis
includedinresponsetorequeststhatstudyfindingsshouldbe made asrelevantaspossible tothe
on-goingdevelopmentof MSIprogrammes,andis supportedbyothertoolsinthe Appendices(e.g.
service userarchetypes;beliefstoreinforce,beliefstochange).
QuotationsfromPEER researchersmainlyrepresenttypical examplesof responses. Where a
quotationillustratesanunusual perspective raisedbyonlyone ora veryfew PEERResearchersthisis
highlightedwithinthe narrative text. Quotationshave beeneditedforclarity,butremainasclose to
the original language andsense aspossible.
4.1 Information
It was clearfromthe narrative data that womenhave accessto a varietyof formal andinformal
sourcesof informationon:the importance of familyplanning;informationondifferent
contraceptionmethodsandtheirside effects;and where contraceptioncouldbe accessed. Aswillbe
explored,inpractice women’saccesstoinformationwasverylimited,andwasmediatedby
women’s status,decision-makingpowers, social relationshipswithinandoutsideof the household,
and service providerengagement.
4.1.1 Formal Sources ofInformation
Thoughmass mediawasinfrequentlymentionedbythe PEERresearchers,governmentmessaging
aroundfamilyplanningand‘ideal’familysize wasevidentlywidespread,anddataon decision-
makingonnumbersof childrencorroborate thatthese messagesare pervasive.Aswillbe explored,
these informationcampaignscarrya strongeconomicmessage,whichisreinforcedbyfamily
planninghealthworkerswhovisitwomenintheirhousehold.
“Their neighboursand relativeshavecometo know that 2 children is good fromtheradio,tv
and also fromthe healthworkerswho come to our house.Dueto the currenteconomic
condition,they prefertwo children and when they hear the governmentpublishing thisnews
thattwo children is good through television and health workersand then they thinkthatit is
good to havenotmore than two children. Someof my friendscometo visit us and say that
you haveonechild so you can takeanotherone,butyou cannottake3 becauseit will be a
greatproblemfor your family becausenowadayseverything isexpensive”.(PEERResearcher
4)
‘Healthworkers’ (familyplanningfieldworkers)are afrequentlycitedsource of informationin
women’snarratives.Thisincludesfamilyplanninghealthworkerswhovisitwomenwithintheir
households,aswell asfamilywelfare visitorswhoare available throughhealthcentres(‘Family
Welfare Centres’)atprimaryhealthcare level. Familyplanninghealthworkersinparticularwere

22. 22
oftenviewedasaverytrustworthysource of advice andinformationoncontraception. Thesehealth
workershave alsobeensuccessful inworkingwithinfemale socialnetworks, asPEERresearchers
oftendescribedtheirinformationas mostfrequently comingfromboththeirownfemalesocial
networksandhealthworkers.
“They usually talkwith the health workerwho comesto visit their houseand also thelocal
governmenthospitalhowto stop having children.They usually also talk to the
neighbourhood women and sometimesthey decidethemselves”. (PEERResearcher2)
In women’snarratives,however,the actual informationprovidedonthe range of contraceptionis
scant, andparticularlyfocusesonshorter-termmethods,suchasthe oral contraceptive pill. Thisis
broadlyreflective of the waysinwhichwomenaccessinformationaboutcontraception,andaswill
be exploredbelow,providerbias,gendernorms(particularly thosewhichrestrictmobility) andsocial
networksdetermine thisaccess,
“The healthworkersgive information thatothermethodsareIUD/condomand theimplant,
pill – they only say the nameand afterthat they askwhatmethod do you preferand then
they say that we wantto take either pill or injection”. (PEERResearcher 4)
Thiscorroboratesrecentresearchand policywhichhasfoundthatexpandingcontraceptive
prevalence isthe maindriveroffamilyplanningprogrammes inBangladesh,andnotempowering
womentohave more choice (andknowledge)aboutmethodsthatmaybe more appropriate4
.
A fewPEER researchersalsoassertedthataccesstoinformationoncontraceptionwasdifficultfor
poor women,whowere more likelytobe overlookedandtreatedbadlybyservice providers,andas
the respondentbelowfelt,lesslikelytobe targetedforgovernmenthealthcampaigns,especiallyin
rural areas,
“The governmentstaff arenotinterested to givethem enough,and theirattitude is not
positive,they look at thestatusof the patientand see if they are fromthehigh or lowerclass,
and they give half information,likethey say ‘thisis the pill, you can usethis and it may help
you’butthey do notgive the detailed information, theirattitudeis thatwhen they see that
the client is notfroma high statusthey don’ttalk with her very well, if any poorpeople
comesto the hospitaland saysto the staff that“I tookthe pill 2-3 daysago and now I have
vertigo”,they say,“justtake it, you haveonly taken it for2 or 3 days,it may happen,just
keep taking it”… (PEER researchersays) if you go 30 minutesfromthis place, then you will
find a differentscenario,thepeople are trying to find information butthereis no oneto
properly guidethem… The governmenthastaken initiativebutthe peopleof my area are not
informed of the campaign day.Vaccination programmeisokbut thefamily planning
programmetherearenot receiving information in their area”.(PEER Researcher8)
4.1.2 Informal sources ofinformation
Informal sourcesof information –fromclose female relatives,‘neighbourhoodwomen’ and
sometimes,the husband –were veryimportantforwomeninaccessinginformation,and
contraceptiondecision-making. Sister-in-lawslivingwithinthe same household –the ‘B’habi’ – were
4 Centre for Policy Dialogue (2003) “Re-thinking Population Policy in Bangladesh”, available from
http://cpd.org.bd/html/Publications.asp, accessed 27.09.12

23. 23
oftendescribedasthe firstpersonwhowassoughtoutfor advice andinformationabout
contraception.Otherwomenwere especiallyimportantforyoungwomenwhowere newlymarried,
but womenatall stages of theirreproductive lifedescribedrelyingonthe ‘b’habi’,andfemale
networksinthe firstinstance,andlateraccessingfurtheradvice throughfamilyplanninghealth
workers.
“They usually like to talk with thesame agewomen and sometimesthey preferwomen a bit
older than themselves(5 years).If they consultwith the health workersand local government
hospitalthey will give good information and itwill begood fortheir health”. (PEER
Researcher2)
Womenoftenpreferred toconsultwith womenwhowere alsomarriedandslightlyolderthan
themselves,asthese womenhadmore experience andwouldbe able togive goodadvice on
contraception.Inmanyinstances,itwasclearthat usingfemale networksforcontraceptionwasfully
sanctionedbythe husband oftenonce the decisiontocontrol fertilityhadalreadybeenmade,as
they viewed contraceptionas‘female’knowledge.
“When thehealth workervisited her homeand she knew about(thepill) and she asked other
neighboursisit good formy health and is it right thatI can takethis? And my other
neighbouralso said thatI take thisand it is good foryou and you can takeit, and then I
asked my husband thatif we don’twantto haveanotherchild then whatshould wedo?And
my husband said thatI don’tknow anythingaboutit,and hesaid find outwhatthe other
women do and whatis good foryou,and so whateveryou decideto do you should do it, and I
said that I had heard aboutthispill and thatthe health workersaid thatI could take it, and I
also asked the neighboursand they said thatthey don’thaveany problems,and hesaid ok,if
it is good foryou then I can getit foryou,and I will buy it for you fromthepharmacy,it’s
called ‘Shuki’.Firstof all, my husband boughtitbutnow I amgetting it fromthe health
worker”. (PEER Researcher11)
“Her friend told her thatyou can use pill and so she tried with thepill but shehad some
problemswiththe pill and then she wentbackto the b’habiand said I cannottakepills and
do you knowany othermethodsthatare suitableforme, and shesaid thatthere are
injectablesand there are ‘kati’(implant),and thereareso many methodsand shesaid no I
cannot,Iam scared of using thosemethodsand then shesaid you can ask yourhusband to
use condoms”.(PEERResearcher11)
As can be seenfromthe quotesbelow,‘information’passedthroughthese networkscan more
accuratelybe viewedasinformationthatsociallysanctions accesstocertainformsof contraception
overothers.Most commonlyinthese narrativesfemale peersprovide adviceonwhichmethodsare
deemedtobe the most‘safe’,andcommonlyusedbyotherwomenintheirlocal area.
“Her sister in law used to takethe pill so that’swhy sheheard fromher and other neighbours
thatthis is good (interviewer:whatdid they say aboutthepill?)(they said that) it is not
harmfulfortheir body,it is good,and it is easier to take they can take it every night”. (PEER
Researcher14)

24. 24
Informationaboutthe negative side effectsof contraceptionclearly wassharedwithinnetworks
veryquickly,andmostof the data onall forms of contraceptioninthisprojectconfirmsthis.
Conversely, informationaboutnew methodswasalsoquicklysharedthroughnetworks.For
instance,inone case a respondent’sintervieweehadusedthe ‘ujol’(withdrawal method) tocontrol
fertilityafterpregnancy.Asanewmethodwhichwasapparently‘safe’,the interviewee immediately
sharedthisinformationwithherfemale peers,
“Her husband gottheinformation fromhisfriend who wasa doctor.And then her friend
wentto tell her ‘b’habi’aboutthe‘ujol’method”. (PEERResearcher6)
The quote above alsoillustratesthatina few cases,menwouldbe the active partnerinseekingout
informationaboutcontraception,butthismostlyseemedtobe immediatelyaftermarriage,when
women’sself-reportedknowledge wasmuchlower.Inthese situations,male partnerstendedto
supplytheirwiveswithamethod,andgave littleinformationaboutit.
“In her firstday of her married life, her husband gavehera pill, to preventpregnancy,
becausethey are notready to take thechildren, they wantto improvetheir socio-economic
statusfirstfor 1-2 yearsand afterthatthey will wantto takechildren. Her second friend
asked her husband ‘why do you givemethispill?’ buther husband said “no weare notready
to takethis child, and when the baby comesmy socio-economicstatusisnotgood,and the
wife said,if this pill doesany harmto my uteruswhatwill happen?”And thehusband said,
“ok therewill be no problem,you justtakethis pill””. (PEER Researcher6)
In a fewcases,intervieweesrecognizedthatwomenwhoreliedontheirfemale social networks
wouldconsequentlynothave routine accesstomore reliable sourcesof information.Thiswas
confirmedinthe final PEERworkshop,whenPEERresearchersidentifiedthe ‘ideal’scenariofor
accessinginformationtobe talkingtohealthstaff asa firstline foraccessinginformation.
“Someof themdo not wantto talk aboutIUDand othermethodsbecausetheirknowledgeis
notproperso if someoneasksthemquestionson IUDthen the neighbourscannottellthem
any information becausethey only usethe pill, and then will say ‘usethis method becauseI
amusing it and I don’tfaceany kindsof problems’.Actually the ‘b’habi’hastoo much
influence,and aftertalking with thema woman will talk with her husband and hewill say “if
the b’habihassaid this then it’s really good and you should continuewith this method”.
(PEER Researcher4)
As will be exploredlater(see Section4.2.1),thisreliance onfemalenetworksalsoaffected
treatment-seeking.Inmanyinstances,the datashowsthatwomenhadalreadydecidedwhich
methodtheywantedtouse basedoninformationwhichtheyhadreceivedthroughtheirlocal
networks,and furtherinformationonothermethodswastoa large extentnotsought,evenwhen
talkingwithhealthstaff where more methodswereavailable,
“But all the women of the community nowadays only use the pill. If anyone wants to know
aboutprevention of pregnancy then elder‘b’habhi’ and friends prefer the pill. So they do not
want to even ask the government hospital about other methods. They ask only about the
adverse effects of pill”. (PEER Researcher 11)

25. 25
These findingsdonotimplythatitisthe use of social networkswhichworktopreventwomen
accessinginformation,butthatthose womenwhorelyexclusivelyonthe social networkswill be less
informedandmayfavourcertainmethods(suchasthe pill).Women’smobility,andthusaccessto
widerresources(suchasbetterinformation),isakeyissue.Inthe PEERdata, youngerandnewly
marriedwomenhadlessaccessto informationandpreferredcloserfemalepeers,until they
developedthe confidencetotalkmore openlyaboutcontraception,usuallyafterthe firstchild.
“Beforeher married life she asked forthis information fromhersister in law and they usually
tell themaboutthe pill, and that’sthe reason thatthey mostly know aboutthismethod and
notothers,butusually after married life they do not feel shy anymoreto talk to their family
planning method and askadvicefromtheir neighboursand to talkaboutthis”. (PEER
Researcher7)
4.2 Decision-Making
4.2.1 Factors InfluencingDecision-Making
Thissectionconsidersthe overall themesinthe datawhichwere foundtoimpactondecision-
making.PEER providesrichandinsightfuldataintohow decisionsare taken,andwomen’sposition
and decision-makingcapacitieswithinthesedecisions.These dataare useful forunderstandinghow
people canbe bettersupported intakingreproductive healthdecisions.
Women’sPositionwithinthe Household
Womeninthe PEER researchbroadly acknowledged that reproductive decision-making was a joint
decision, almost always involving their husband and often involving their in-laws. Women also
broadlyacknowledgedthatforthe first few children at least, they were often pressured into child-
bearing, with the husband being the ultimate decision-maker.
“About most of the time decision is taken by the husband and mother in law. If they want
child earlier then a woman have to conceive. This is because a woman usually doesn’t earn
and the husband doesn’t accept their opinion. As a result mother in law can also pressurized
her”. (PEER Researcher 17)
Social pressure from the husband and/or the mother in law was also often described as being very
strong for the first child after marriage, which women found hard to resist, due to social pressure,
and in some cases, threats of violence,
“In this type of cases mother in law also pressurized for the 1st
child earlier. Because if they
use any method after marriage then infertility may develop and as they don’t have a
financialproblemthen the son also preferhis motherand a women cannotsay no.If she says
no then her motherin law mentally tortures her and sometime her husband also uses a stick
to hurt her”. (PEER Researcher 10)
In narrativesarounddecision-makingoverthe numbersof childrentohave,women’spositionand
involvementindecisions clearlybecamemore overt.Thiswasdescribedas partlydependingonthe
numberof childrenthatthe familyalreadyhad – womenwere more involvedindecisionsto have
furtherchildrenafterthe first,andalsocouldmore clearlyasserttheirrightstopreventfurther

26. 26
pregnanciesaftertwochildren.Decision-makingbythe couple alone wasstronglysupportedbytheir
economicresponsibilitiestowardstheirfuture children.
“So mostof the men and women thinkonly for 2 children.And motherin law and fatherin
law nowadaysusually supporttheiropinion. Becausenowadaystheproblem arisedueto the
pooreconomiccondition.Asthey cannothelp supportthemwith money so they support
husbandsand wivesopinion”. (PEERResearcher15)
“When shecame to herhusband’shouse,then hermotherand fatherin law pressurized her
and wanted to see the grandchild and said thatthey wantto havea baby.When shestayed
in her parents’housesheused the pill, she tookadvicefromher sister in law, her husband
knewabouthertaking the pill buthe agreed with her decision becauseher husband and her
were the sameage,her husband said to herthatwe are too young and weneed to save
money and wewill arrangeourhouseand it will take sometime, so after thatwe will have
ourchildren”. (PEER Researcher18)
In cases where there were disagreementsbetweenthe husbandand in-lawsondecisions relatedto
takingfurtherchildren,economicargumentsappearedtobe oftendeployedtoresistthese
pressures.
“After taking decision women usually discuss with their husbands and sometime mother in
law wants the grandchild earlier. Inthesecases the husband manages his mother by saying
this that actually I need time to earn more, now with what I earn I can’t manage a child”.
(PEER Researcher 10)
In some of the narratives,womenassertedthatthe role andpowertopersuade of the motherinlaw
was changing. Tellingly, this seemed to be when in-laws accepted that the couple faced strong
economic pressures and that consequently limiting family size made good financial sense,
“Nowadays in our community, mothers in law also prefer 2 children. It is actually tough to
providegood education and food to two.Butstill than they prefer2 becauseif someonehave
only one she or he feel alone. So more than two is quite expensive”.(PEER Researcher 12)
“So most of the men and women think only for 2 children. And mother in law and father in
law now a days usually support their opinion. Because nowadays the problemsarise due to
the poor economic condition. As they cannot help to support them with money so they
support husbands and wives opinion”.(PEER Researcher 15)
“Her friend consulted withher mother-in-law,and shetold herthatme and my husband have
decided that wewill conceive oursecond child 2-3 yearslater than the first child whatdo you
say?And her motherin law said thatyou can decide we will not be with you all of the time,
so it is betterto give priorityto yourown decision becauseyou haveto give food,education
and answerto yourchild, I can’thelp you”. (PEER Researcher4)
Women’srelationshipwiththeirhusbands was a pivotal factor which supported their reproductive
decision-making.Where womenwere ‘listened to’ by their husbands, external pressures including
from the in-laws and others, could be effectively resisted,

27. 27
“…she can be happy if there is problemwith her motherin law; butshe cannotcontinueher
happy married life if there is a disagreementwith her husband,and theirmarried life
becomesa bad situation”. (PEERResearcher7)
In some casesintervieweesandPEERresearchersassertedthatwomen’s ownrole indecision-making
was changing, and attributed this in part to the effect of better education for women. This theme
occurredthroughoutthe research,andin the final workshopPEERresearchersidentified continuing
education as a principle factor in supporting women’s reproductive decision-making, supporting
Bangladesh’s current policy focus on education for women5
,
“Her friendssay thatwho is illiterate they will haveto depend on their mother’sdecision and
motherin laws decision,they cannotsay anything.Butnowadays,butthosewho are
educated they can influence their husband and areableto maketheir own decision.Those
who are literate they knowaboutthefamily planning methodsclearly and they usually take
contraceptiveforpreventivepurpose…Forilliterate women actually shecould notbelieve in
herself,in this town she alwaysthinksthatmy motherin law knowsbetterthan me because
she hasso many children,and sometimesthe illiterate women also believe in superstition”.
(PEER Researcher5)
Early marriage
Reducingearlymarriage (beforethe age of 18 years) isa statedtarget of Bangladesh’sfamily
planningprogramme,andPEERresearchers were aware of thisandof effortstoraise the age of
marriage.
Beingtooyoungwas a reasoncitedquite frequentlybyPEERresearchersfordelayingthe first
pregnancy,andthere wasofteninthese casesa stated conflictbetween the womanwhowantedto
continue studying,andherhusbandandwiderfamily,
“In Kirshargonj parentspreferto getmarry off their girls beforethe ageof 18 years…the
parentsthoughtthatitis betterto get their daughtermarried earlier becausea man is
needed to supportherso in termsof earlier it is easier to find a better husband,theboy
prefersgirls who are this age fortheir wife.If they are married before18 they usually did not
completetheir studiesand mostof themwantto completetheir study,and mostof the
peopleof Kirshargonj arepoorso mostof themwanted to resolve their economicsituation”.
(PEER Researcher5)
“Becauseshe wastoo young atthattime, she was19 yearsold. It is good to havechildren
after20 years,their family and their relatives told them this,and so did thehealth workers
and it is written in the booksalso.Asshewasvery young,herrelativesgaveher advicenot to
takechildren too quickly,so first of all she disagreed with her husband butafterthather
husband and otherin lawspressurized her and shejustagreed”. (PEER Researcher18)
There were alsosome individual instanceswhere,inthesesituations,otherwomenwouldfacilitate
the youngwoman’saccessto contraceptionandeveninone case,to abortion. Inthese narratives,
5The GOB has recently announced that all primary education for girl children is free, in an effort to raise
education levels and through this, increase women’s use of contraception.

28. 28
female relativessecretlytookthisdecisiondue tothe youngwoman’sage,andherlack of physical
capacityfor child-bearing,
“Then her husband said,“meand my motherwant you to conceiveas early aspossible”.So
thatthey didn’tuseany method but the motherof the girl gaveher the pill and said that
“you shouldn’tsharewithany onethatyou are taking pill”. Butone of her husband’srelative
sawto takeher pill. Thatrelative said thatshe will notshareanyonethatyou aretaking pill.
But sheshared with themotherin law of thatgirl. Afterthat her motherin law informed her
son and her son said thatI told you beforethat I wantto take baby so why are you taking the
pill, if you wantto take pill then go to yourfather’shouse.Afterthat thatgirl stopped taking
the pill and 5 monthsago sheconceived”.(PEERResearcher17)
Women’sill health,whenmarriedandpregnantattooyoungan age, wasalsorecounted instories
collectedbythe PEER researchers,
“A girl who is only 15 years old got married,afterher marriagesheconceived when shewas
only married for5 monthsand afterherfirst child she again conceived within 2 yearsand this
time she faced so many problemsso thatshe consulted with the doctorand he asked herto
do a lot of testsand after doing thatthedoctorsaid thatthe girl hasuteruscancerand after
thather husband admitted herto a governmenthospitalin Kumilla as he wasan army officer
so besthospitalfacilities were given to his wife, butafter6 months,of admission,thegirl
died”.(PEERResearcher17)
In a veryfewcases,widerfemalenetworkswouldfacilitate accesstocontraceptionforwomenwho
had themselvestakenthe decisiontodelaypregnancy,butthe nervousnessof these womenin
doingso wasevidentin the narrative.The pill wasclearlyveryvaluableinbeingwidelyavailable
amongwomeninthe community,andstoriesof the pill beingsharedandsuppliedrecurred
throughoutthe research(see Section4.7below).
“Interviewer:whatare the good methods to useif they wantto keep (contraception use)
secret?”
“PEER Researcher: “thepill, at first all of thewomen they like the pill very much.The husband
doesnotsee it, the ‘b’habi’and theneighbourhood women and somepeoplelike the ‘jal’
(sister in law) they justbring thatpill, and some peopleare scared becausethey say if your
husband knowsaboutthis,hewill be angry with me. And then after3-4 monthsshewill be
pregnantbecauseno onewill bring it to her, (Q:can shego herself to get thepill), no because
she is scared to go outside,she hasto take permission fromher husband and in lawsto go
outside,and shedoesnot knowanything aboutthepill, (Q:family health worker),they come
very irregularly, sometimesthescript is finished,and they run outof pills and then they don’t
come”.(PEER Researcher16)
BeliefsaroundControl of Fertility
Fear of infertilitywasamaintheme thatemergedfromthe data,and waspervasive around
discussionsof decision-makingatall stagesof a woman’sreproductive life. Thissectionwill examine

29. 29
howthese beliefsactas barrierstowomen’sdecision-making,andshape the decisionsthatthey
make aboutwhichformsof contraceptiontouse.Beliefsaroundinfertilityandspecificformsof
contraceptionare discussedinmore detail inSection 4.6.
Fear of infertilityismostcommonlyattributedtocontraceptionuse.Thisfearwasveryclearwhen
womenwhohadbeenunable toconceive talkedwith the PEERresearchers,
“Afterher marriagethey usually used thepill, and she used this for2 years,within this time
she heard thatif anyoneused thepill continuously then infertility may arise so her husband
used condomsafterthat.Asshewasa studentshethoughtshewould conceiveafter
completing her degree,then she did notuseany type of method,butnowadaysshecannot
conceive.Then they wentto several doctorsin Dhaka and hereand the doctorstold her that
her uterusis not capableto bear a child. And herfriend is notclear why this problemhas
arisen in her life, is it naturalor hasit developed dueto using pill or condoms.Herfriend
asked whatis the problemand why can I nothavea child”. (PEER Researcher9)
The sanctionsagainstwomenwhowere infertilewere discussedasbeingsevere,andinclude threats
of andexperience of physical andverbal punishment/abuse,andthreatsof divorce andre-marriage
by the husbands.
“Someof thewomen wantto havechildren aftermarriage.But someof them who are
engaged withstudies,someof themthink thattheir health will be broken and their husband
saysthatthey should havechildren with some gap.On theother hand someof the women
who do not havechildren;their husbandsarecrazy to get married again”. (PEERResearcher
3)
Fearsof infertilitywere oftenseenasamain reasonfornot usingcontraceptionimmediatelyafter
marriage:evenmethodsthatwere widelyseenashavingnoside effectsand‘safe’inlaterstagesof
a woman’sreproductive life cycle,suchasthe pill,were viewedaslikelytocause infertilityif taken
at thistime.The importance of social pressure of the widercommunitywasalsoevident–once a
womanhas notconceivedwithinacertaintime,neighboursandothercommunitymembersfeltthat
theycouldstart to make commentsaboutthe suitabilityof thiswoman,andquestioningherposition
withinthe family.
“Neighboursalwayssay thatyourson’swife,maybeshehassomeproblem,so maybehe
should getmarried withanotherwoman,then (themotherin law) gets motivated and says
this to her son and daughterin law…(Interviewer:when they teasethemotherin law, what
do they say?) they said thatyourson’swifehassome problem,somephysicalproblem,that’s
why sheis notpregnant”.(PEERResearcher11)
“Someof thewomen also told thatwoman thatsheis the ‘atkur’(infertilewoman) so don’t
lookat her face,it will be unlucky foryou.Then the woman feltvery sad but shecouldn’t
shareher feelingswith anyoneeven with husband”.(PEERResearcher4)
“Becauseif anyonetakes too many pills before the 1st
pregnancy than there may arise some
problems in the lower abdomen (Tal pate chorbijomejaby) so infertility may arise. Actually
there are some women in their community who develop infertility due to taking the pill
immediately after marriage”. (PEER Researcher 15)

30. 30
In several instances,women’slackof boychildrenwasexplicitlyreferredtoas ‘a kindof infertility’
(PEER Researcher3). Inone instance,a PEER researchertalkedabouttraditional beliefswhich
createdacceptance of a woman’s infertilitywithinthe householdandwidercommunity.Itcan be
hypothesizedthatthese mythsworkinaveryovertand publicwayto re-assertaninfertilewoman’s
rightto remainwithinahousehold,andtoexplainherinfertility.Inthisnarrative,itis interestingto
note howwidelydiscussedthe infertilityandthe justification foritis,
“She hassomesevere pain beforemenstruation and itis very severebeforemenstruation,
like giving birth pain,and shetooksomemedicine fromthe ‘kobiraj’ (traditionalhealer),and
he advised thatshehassome leech in her tummy and I amgiving you the medicine and that
leech will come outfromyourbody and then you will get pregnant.Now,sheisnottaking
thatmedicine, becausesheis thinking thattheleech will comeoutand then shewill get
pregnant,and shewantsto delay pregnancy.(Interviewer:isshe taking any other
contraceptivemethod?) they believethatif this leech is inside yourbody then you will not
need to take any othermethod.(Interviewer:wheredoesthisleech come from?) it is God
gifted.It’scalled ‘jok’(leech).God had blessed her,that’swhy it’s insideher. (Interviewer:
why did God give her this gift?) it is God’swill, if God wishesto give this in someone’sbody,
he can give this. And it also happened with me(PEERresearcher),I wassuffering with severe
pain and I wastaking medicine fromthe ‘kobiraj’(traditionalhealer) and it came outof my
body and Igot pregnant.(Interviewer:did sheseeit?) yes it’s justa small piece of blood (clot)
and it’s broken,and it comesoutof her body during menstruation.(Interviewer:when her
friend went to talk with the kobiraj,did shetell otherpeople?) 2.5 yearsaftermarriageshe
wentto the ‘kobiraj’,shediscussed itwith her neighbourand otherwomen and shediscussed
it withme (PEER researcher) and they said ‘oh in theold times this typeof thingshave
happened withotherold people in ourfamilies’ and they believed it. Her husband also knows
aboutall of these thingsbecause firstof all she hasto sharewith herhusband and her
husband hasto knowaboutallof this, and herhusband ishappy becauseshedoesnotneed
to useany contraceptives…peoplethinkthat thisis good,and it’sAllah’sblessing,they don’t
mind aboutthis”. (PEER Researcher13)
Fear of infertilityalsoaffectedlatercontraceptivedecisions,particularlyaroundbirthspacing
methods.Aswill be explored(see Section4.6),womenwere unwillingtocontemplateusinglonger-
termmethodsthatmay cause infertility,especiallythose whichledtochangesintheirmenstrual
cycle. Certainsymptoms,suchasbeingoverweight,wereveryassociatedwithinfertility,
“She said thatshe hassomeimpression thatif any one usescontraceptivesshedevelopssome
extra fatin their tummy so pregnancy will be delayed.They haveseen many”. (PEERResearcher
3)
Thiswidespreadbelief thatcontraceptioncausesinfertilitywasalsoexploredinthe final PEER
workshop,where itseemsthatothercausesof infertilitywere notcommonlyknown.PEER
researcherswere specificallyprobedonthe linkbetweenSTIsandinfertility,butsaidthatthis link
was notknown,andthat diagnosedSTIswouldbe keptverysecretwithinthe community.
4.3 ImplicationsforMSI
Women’sinvolvementindecision-makingisstronglyreliantontheirreproductiverole,andclearly
increasedonce theyhadproduceda childandassuredtheirplace inthe household.Several shiftsin

31. 31
viewsonfamilyplanningappeartobe supportingwomen’s greaterinvolvementindecision-making
inchild-bearing.Firstly,there werewidespreadperceptionsthata smallerfamilysize was an
economicnecessity,whichisbroadlyinline withBangladesh’sconcertedfamilyplanningcampaign
to reduce populationgrowth.A smallerstated‘ideal’familysizetoa large extentappearstosupport
nuclearfamilydecision-making,thoughthereissome evidenceinthisresearchthatwiderfamily
membersare comingto support thisas well.Supportingtheseideasof responsible decision-making
for the betterfuture of the familycouldallow the nuclearfamilytoresistwidersocial pressure
withintheirextendedfamilyunitstohave childrenwhenwomenare tooyoung,or whenwomen
and a couple are not (financiallyandeducationally) prepared.Secondly,relatedtothisisthe
emergingconcernoverwomenchild-bearingata youngage, whichneedstobe targetedand
supportedthroughwidermessaging.
The PEER data highlightsthe pivotal importance of femalerelatives –the b’habi (sisterinlaw) –and
widerfemale networksinwomen’sdecision-making,anddemonstratesthatthis‘female knowledge’
of contraceptionishighlyvaluedbybothwomenandtheirpartners.Inpractice,these networkstend
to be veryrisk averse,sharingnegative perceptionsof contraceptive methodswidely,andineffect,
limitingwomen’schoice.MSI’smessagingonaccessto reproductive servicesneedstouse
approachesthatcan utilize femalenetworksmore effectivelytosupportaccesstowiderinformation
on reproductive health.
4.4 Startinga Family
The statedand widelypublicizedtargetof the BangladeshFamilyplanningprogramme istwo
childrenperfamily.Thisbenchmarksharplydemarcatesafamily’sdecisionaroundideal familysize
and control of fertilityat differentpoints.Thischapterconsidersdecisionsaround:the firstchild;
havingotherchildren;andpreventingunwantedpregnancy.Attitudestowardsunwantedpregnancy
are exploredin Section4.8.
4.4.1 ‘Ideal’Family Size and Composition
In the lightof a widespreadnationalgovernmentprogrammewhichaimstoreduce desire forlarge
numbersof children,viewsonthe ‘ideal’familysize of twochildrenwereexploredthroughthe PEER
research. There wasfrequentagreementwiththisstatednumberof children–‘Two is good’ - with
manyfamiliesinthe PEERresearchclearlyplanningtostaywithinthese limits.Thisagainappearsto
be drivenbya perceptionthatthe cost of livingisincreasing,aswell asaspirationstoprovide agood
educationfortheirchildren,
“They are quitehappy withtheir two children, they haveone daughterand oneson.So they
wantthemto give good education…Morethan two willbe create financialproblems,now
they are maintaining costsfortwo differentplaces.They haveto givehouserent for
Kishoreganj and herhusbandisliving in the village so they haveto bevery cautiousabout
their monthly expenditure”. (PEERResearcher6)
“Nowadayseveryonein my community is interested forthe small family and all of us support
two children only, so that we can provide best education and health and food to our
children”.(PEER Researcher 10)

32. 32
It was clearthat itwas sociallyacceptable tohave uptothree children.Caseswhichdeviatedfrom
thisnorm,where familieshadhadfouror more children,attractedsocial commentaryand
approbationfromotherswithinthe community,asthiscase highlights,
“Nowthey did notcontrol (usecontraception) fromthefirsttime, and now they havefive
children,and they cannotafford them,they arenotgiving themfood and clothes,the children
are all over the place.Other people,theneighbours,they say why don’tyou stop taking children,
whathashappened to you?Thesedays,peopleareonly taking 2 or 3 children,and you are
taking so many,why don’tyou stop?And then she (themother) started to take a method
(contraception)”.(PEERResearcher2)
Some PEER researchersdidmentionthatthere wouldsometimesbe disagreementsaboutthis
withinthe family,withthe in-lawspressurizingformore children.However,theywouldonlybe able
to pushfor 3 children,andafterthisthe couple couldasserttheirownviewsandlimitthe family
size,
“But nowadaysusually bothhusband and wifeprefer2 children and sometimes the motherin
law only askfor the3rd
pregnancy.Butafterthe 3rd
pregnancy themotherin law doesn’t
pressurizefor4 pregnancies,becauseof economicproblemand theexpenseof education,
food and almosteverything. And parentsprefer2becausethey think thataccording to their
incomethey can only maintain 2”. (PEER Researcher17)
4.4.2 The first child
It was evidentthatwomenwouldoftenface strongpressurestohave a childimmediatelyafter
marriage.Many of the PEER researchersdescribedhavinglittle choiceatthistime,withhusbands
and motherinlawsbeingthose whoprincipallywantedtohave achild,
“She had no choice becauseaftermarriagethe decision actually dependsupon men asher
husband prefersherto havethe first child earlier shethoughtthatit is better to conceive
earlier”.(PEER Researcher5)
There wasalso a widespreadbelief thatanyuse of female-controlledcontraceptioncouldpotentially
leadto permanentinfertility. Throughoutthe datastoriesaboutwomenwhohadill-advisedlyused
contraceptionandlaterfacedseveral yearsof unwanted infertilitywere common,andwere
converselythe mainreasongivenforhighcondomuse aftermarriage.The dataalsoshowedthat
thisbelief appliedtoall formsof female-controlledmethods,includingthe pill (eventhoughatlater
stagesof a woman’scycle thisisbelievedtobe the safestformof contraception).
“Her friend said that it is betterto havechildren earlier and it’s better to notuse any typeof
method aftermarriagebecausesometypeof infertility may arise.One of her neighbours
developed infertility dueto using injection afterher marriage.This idea they believe that’s
why they are notinterested to takeany typeof method aftermarriage.And they areusually
interested to take contraceptives(afterthefirstchild)”. (PEERResearcher 5)
It seemsthatthismythwas mostoftenpromotedbythe mother in law, who actively enforced non-
use of contraception. Sanctions against women who took contraception against their wishes could
be severe, with their rights to remain in the household rescinded,

33. 33
“Mostof the motherin laws also wanttheir daughterin law to take her1st
child within 1-2
yearsof married life. Becausemotherin lawsare also afraid of infertility. And they also
suggestnottaking pill or any other method immediately aftermarriage…But mostof my
communitywomen thinkthatafter2 yearsof married life it is betterto conceive.Because if
anyonetaketoo much pill before1st
pregnancy than theremay arise someproblemin lower
abdomen so infertilitymay arise. Actually there are somewomen in their community who
develop infertility due to taking pill immediately after marriage…My friend told me her own
story.Shewantsto conceiveafter5 yearsof her married life. So fordelaying pregnancy she
tookpill buther motherin law saw her to takepill. Afterthatshe scoldsher fortaking pill
and senther mother’shouse.Afterthatherhusband told hismotherthat thewill take child.
And nowadayssheisnottaking any method,so thatshecan be pregnant”.(PEERResearcher
15)
In manycases,the stateddesiredtime delayforwomentohave the firstchildwas2-3 yearsafter
marriage,whichclearlyconflictedwithsocial expectationsthatshe wouldbe pregnantwithin1year.
As fearof infertilitywassopervasive,inmanycaseswomenfeltthattheyhave littledecision-making
powerat thistime.Ina minorityof cases,difficultiesaccessingcontraceptionwasthe reasongiven
for earlypregnancyaftermarriage,especiallyamongyoungpeople/women.
“She did not agreewith her husband,and sheasked himto bring somepills to herbut her
husband did notbotherherand he told her thatit is necessary forme to havemy first child
earlier. She had no choice becauseaftermarriagethe decision actually dependsupon men as
her husband prefersherto havethe first child earlier she thoughtthatit is better to conceive
earlier”. (PEERResearcher5)
“Her friend told aboutherown life, and she becamepregnantafter3 monthsof marriage,
and they did notuse any typeof contraception,asthey gotmarried earlier, both her husband
and she wereteenagers,so thatthey had notconsulted with anyoneabout this,asa result
she becamepregnantafter2-3 months.Sheasked herhusband to bring pills forher, buther
husband feltshy to bring thisfromthe market,so hedid not provideany pills to her
wife”.(PEERResearcher9)
The quote above alsohighlightsthatyoungercouples,particularlywherethe husbandwasalso
young,face attitudinal barrierstoaccessingcontraception.Shynessintalkingaboutcontraception
withothersandwitheach other, andabout procuringcontraception,appearedquite frequentlyin
the data.
4.4.3 Reasons for Delayingthe First Child
Thissectionanalysesthe reasonsfordelayingthe firstchildgivenbywomenrespondents,andhow
these decisionweretaken.
Covertdecision-making,where womenchose touse contraceptiontodelaythe firstpregnancy,was
reportedinthe PEER data but appearedtobe relativelyinfrequent.Thisispossiblybecauseof
women’spoorindependentaccesstocontraception,aswell asfearsof long-terminfertility
describedabove.Furthermore,itwasalsoevidentthatinsome caseswomenbelievedthat covert
contraceptionuse wouldbecome visibletoothers,

34. 34
“Mostof the women they don’twantto havechildren immediately aftermarriagebut their
husbandswantto and sometimesthesewomen aretaking contraceptivessecretly,and then
sometimesthey gotfat and then sometimesthesehusbandswhen they thinkthatshewill not
be pregnantthen theirhusbandsleftthem.That’swhy they are scared to takeany
contraceptivesimmediately aftermarriageand they are quite interested to takea child
immediately after marriage”.(PEERResearcher16)
Decisionstodelaythe firstpregnancy were thenmostlydescribedasbeingajointdecisionbetween
husbandandwife.Ina fewcases,contraceptionuse wouldbe discussedbefore the marriage took
place.
“If they havesettle marriagethey decided at the firstday of their marriage,if it is love
marriagethey decided beforemarriageand they get ready forit”. (PEERResearcher6)
However,there were alsosome cases discussedwhere ahusbandwouldtake the decisionwithout
much apparentdiscussion withhiswife –eithersupplyinghiswife withpills,orusingcondoms.
Condomuse appearedtobe especiallyhigh,due tothe husband’swishtodelaypregnancy,and
fearsof infertilityrelatedtoanyfemale controlledmethod. Thiswasprobedinthe PEER workshop,
withPEER Researcherssayingthattheywere quite confidentthatcondomuse couldbe keptsecret
fromwiderfamily,andwaseasilyaccessible forme. Men’sreasons forusingcontraceptionatthis
time predominantlyfocusedonenjoyingtheirsexual life withtheirnew wife,andinsome cases,
economicreasons.Delayingthe firstchildinordertobe more financiallystableappearedtobe more
commonamong coupleswho were closerinage.
“When husband cameto knowthatshewaspregnant,thehusbanddid notagreewith that,
he said why?It’stoo early,you gotpregnantwithin 1-2 months(Interviewer:why did hesay
this?),the husband doesnotlikethis becausethey are newly married so her husband is
thinking thatif she getspregnantso early so it will hampertheir sexuallife so he will be
deprived fromthatso he doesnotlike it”. (PEER Researcher11)
“My friend told methat mostof the women of ourcommunity think thatit is good to
conceive of 1st
baby after2-3 yearslater after marriage.Becauseif they conceive
immediately then their husband do notfeelmoreinterest and the rate of doing sex also
decrease.The husbandsalso thinkthatif their wife conceivesimmediately aftermarriage
then they will notbe able to enjoy sex”.(PEERResearcher17)
Womenhad manyreasonsfordelayingthe firstpregnancy.There wasclearlyahighawarenessthat
earlychild-bearingcouldbe veryharmful towomen’shealth,butalsowomenoftenhadambitions
to maintaintheirstudiesandinsome cases,theirhusbandssupportedtheirambitions.There was
alsoquite a highdegree of consistencyinthe preferredtime delayforwomen:- between2and3
yearsaftermarriage.
“She said that in my community usually women prefer their first child2-21/2 years later after
marriage,becausein ourcommunity most of the women got married early before the age of
18. So if they conceive earlier so there may problems such less strength in the mother’s body
which can hamper a child’s life. And convulsion may also develop. Previously many mothers
and child died in their community and in this type of cases mother was pregnant at 3-6

35. 35
months after their marriage. So that now most of the women want to delay
pregnancy”.(PEER Researcher 10)
“She thinksthatit is better to havethe first child after 2-3 yearsof marriage,in somecases,
aftermarriagewomen may sufferhealth problemssuch aslosing weight and so on,and
women haveto becomea new family aftermarriageso sheneedstime to understand them
and organizetheir own family so it is better to havechildren 2-3 years later,and for
economicreasonsalso,and they can providea better environmentfortheirchild”. (PEER
Researcher5)
For some women,settlingintoanewrelationshipandenjoyingmarital lifewasalso,like men,a
goodreasonto delaythe firstchild,
“They wantto savemoney and they would like to enjoy with their husband,they wantto go
outsideand havesomefun.If they will havechildren immediately after marriagetherewill
be no chanceof enjoyment. Herhusband gaveherpills at the nightof her marriage”. (PEER
Researcher6)
There wassome consensusinthe data that thisrepresentsanevolvingpicture inthe Bangladesh
context.Again,ithasbecome more acceptedthatthe couple have sole economic(andother)
responsibilityforestablishingtheirfamily,andassuch,delayingthe firstpregnancyisasensible
decision.A fewrespondents alsotalkedaboutwomen’seducationasone factorwhichhas ledtoa
shifttowardsenablingcouplestomake theirownreproductivedecisions.
“The woman is studying in class 10, and she justdid her examand shedid notpass.Her
husband isa truckdriver, and heis noteducated buthe is earning a good living.They have
ambitionsbecausethey wantto depositmore money,and then afterthatthey will takea
child”. (PEER Researcher2)
“It is differentfrombeforebecausenowadayswomen areeducated so they usually delay
their first pregnancy in consultation with their husband,and theirhusband also supports
thembecausethey areeducated.Previously,women werenoteducated,and they were
pressurized by their motherin law. previously they had worry their motherin law’sdecisions
butnowadayseveryoneprefersa single family.So then husband and wifedecideabouttheir
first pregnancy”.(PEERResearcher7)
4.4.4 Decidingto have otherchildren
In Bangladeshthere isaclearlystatedgoal onthe ideal familysize –a maximumof twochildren -
whichwaswidelysupported byrespondents inthe PEERdata. Too manychildrenwere perceivedto
be due to ‘carelessness’bysome respondents,aswas‘notcontrolling’fortakingfurtherchildren.
There waswide consensusamongfemale respondentsthatthe ideal gapbetweenthe firstandnext
childwasat least2 years,butideally3years.Thiswas so that the mothercouldnotbe overworked,
recoverfullyfrompregnancyandchildbirth,andsothatchildrenwere close enoughinage toalso
supporteach other,

36. 36
“Her friend said that it is betterto conceive thesecond child 2-3 yearsafter thefirst child, if
the gap is less then it is easy fora motherto takecare of her children togetherand they will
growup together,afterthat,the motheris free”. (PEERResearcher 9)
“She told me that actually all the men and women also think it is better to have to children
and gap between 2 children is 3 years is very good.They think thatif children started to go to
schooltogether,then the elder onecan help youngeroneand they can go to school together.
So that their children can support each other in terms of danger in the way of school. And if
there is less differencebetween the ages then one will respect another one’s opinion”. (PEER
Researcher 10)
Concernsaboutthe gendermake-upof the familywasclearlyalsoaprime concern.Familiesclearly
aspiredtohave one childof eachgender.PEERrespondentsoftenreportedthatif thisgoal was
achieved,mostfamilieswouldthenwanttostophavingchildren.Conversely,enlargingthe family
beyondtwochildrenwasoftenperceivedtobe justifiedif the firsttwochildrenwere of the same
sex,inwhichcase,the familywouldtryfora thirdchild. There wasa clearand strongly stateddesire
for havinga sondue to a cultural biastowardssonpreference,butchild-bearinginordertohave a
daughterwasalsoconsistentlyreported.
“If they havegottwo sonsthen they expectfor daughter.Orif they haveonedaughterand
oneson then they don’twant(to takeanotherchild),in this situation mostof the third
childrenareaccidental.Normally mostof themare satisfied with two children…To keep the
family small”. (PEER Researcher6)
“They wanta boy becausewhen the parentswill older then a boy will give themshelter. And
boysare strongerthan girlsand any type of problemoutsidethe housea boy can supporthis
fatherwhereasa girl can’t,becausea girl can’tgo to everywhere.Itis notsafefor herbut a
boy can”.(PEER Researcher17)
“My friend thinksit is better to have2 children only but her 2 children are both sons,sheand
her husband really wanta girl. And nowadaysherhusband issaying thatit is better that4-5
yearslater to havea girl, and she is trying convinceher husband thatif our 3rd
child is a boy
whatwill we do,and hesaid thatwe havefaith in God, inshallah and our3rd
child will be a
girl, don’tyou worry.(Interviewer:why isit so importantto havea girl?) fatherslike
daughtersand hedoesnothaveany.Shealso mentioned thata girl usually lovesher parents
morethan a son when the parents are older usually thesonslike to be separated with their
wives,in this time, actually a daughtersupportstheirparents”. (PEERResearcher5)
Some of the storieselicitedinthe PEERresearchhighlightwomen’sfearthattheywill have togoon
producingmore childrenuntil theyreachthe desiredgenderbalance. Womenwhodonothave a
son are alsothreatenedwithexpulsionfromthe marital home,
“There is onewoman who hasseven daughtersexpecting a son.Herelder daughteris
married and she hasgotchildren also.Now this woman gavebirth of a son aftera long
time…There wasa lady who had 4 daughters.Herhusband warned herthatif the nextchild
will notbe a son then he will leave her forever.He will get married again expecting son”.
(PEER Researcher3)

37. 37
In decision-makingabouthavingmore children,women’svoice isinsome casespaidmore attention
to by theirhusbands,ortheyare more able to asserttheirowndecisionsindisagreementsabout
appropriate birthintervals,ortakingchildrenbeyondthe ‘magical’two. These decisionsare
describedasbeingjointbetweenthe couple,ortakenbythe womanalone whothenpersuadesher
husbandto followherownopinion.
“There is disagreement withherhusband butstill she is determined.Now herhusband is
misbehaving withher.He is saying that“are you camefroma rich family?Why you cannot
takecare of two children at a time?”So it will be difficult forher to continuelike this butshe
is planning somehowto continuelike this foranother2 yrs. Then she will havethe second
children and will stop having children.Sheknowsthatit will create severe disharmony
among theirfamily,butshe is feeling thatif sheobeyswhatherhusband issaying it will
create moredisaster forher family life”. (PEER Researcher8)
“First of all she decided by herown and then sheasked her husband and shesaid it is very
easy to convincehusbands,and whatshesaysherhusband willdo.Then thehusband will
convincethe motherin law.The husband and wifedecided togetherbecausethey are not
very wealthy and so that’swhy herhusband realized thatwhatshewassaying wasvery
right”. (PEERResearcher11)
“She thoughtthatwhen any motherhasgot2 children if both of themare sonsor both are
daughtersthen themotherin law or husband can pressurizeherforthe third one butforthe
fourthbaby,they cannotpressurethewoman.A motherknowshow much difficulty thereis
to bring up a child, so forthe third pregnancy,itis really their motherin law or husband who
pressuresthembutnot forthe fourth becauseshecan totally disagreewith her husband or
motherin law becausesheknowsthatshecan provideand bring up all of her children
properly.In this decision,she doesnotbotherto listen to any typeof pressure”. (PEER
Researcher7)
There wasalso some interestingevidence thatina few cases,a couple orwoman’sdecisiontolimit
familysize totwochildrenwhenthesewere girl childrenhadledtoa re-evaluationandashiftin
attitudesandvaluingof girl children. Itisnotclearhow widespreadthese shiftsare,howeveritdoes
demonstrate thatinsome cases,mothershave muchhigheraspirationsfortheirdaughters,
“Nowshe still feelsthat if she got the opportunity shecan still read (learn),and now shehas
2 daughters,shefeelsthat2 is enough and shewill not takeany more children and shewill
try her bestto makethem fully educated people.It is very bad situation in the Hindu religion,
worsethan the Muslim,becausetheHindu women do notgetting anything fromthefather’s
propertyaccording to the law”. (PEER Researcher8)
“NowthatI have2 daughtersIdon’twantany morechildren,and even if I could havea son,I
don’twantto haveanotherchild,and it will be my decision,but my husband issaying that
we are no longeryoung,and if we take anotherchild later it will be too delayed,I amgetting
old day by day so I do nothaveenough time to wait to takeanotherchild. Butit is my
decision…nowIam thinking thatI amstudying and if I continuewith this and completemy
study then I can get a job,justa smalljob,like a schoolteacherin a primary schoolthen I can

38. 38
becomeestablished and earn my own money and Iwill be happy and takecareof myself and
earn my own money and do anything formy family and daughters”.(PEERResearcher18)
For decisionsaroundbirthspacing,women’saccesstocontraceptionbecause of gender-based
normson mobilitywere clearlylessrestrictive thanindecision-makingforthe firstchild –women
were more able totravel furtherafieldtoaccessthe contraceptionthattheywanted.Theirviewson
whichmethodto use were alsovalued,thoughthiscouldalsobe interpretedaslackof intereston
the part of theirhusbands,
“In thesecases men also supportthegap of 3 years. Because most of the men think I’m busy
to earn money so I don’t know what is actually good but my wife talk with various women
and health workers in these aspects, so that their decision is right”. (PEER Researcher 12)
Women’schoice of contraceptionatthisstage was howevernoticeablyconstricted,andwhile there
were some exceptions, only3methods – pills,condomsandinjectables –were reportedasbeing
appropriate atthisstage. Fear of long-termeffectsof othermethodsandespeciallyof infertilityin
practice limitedwomen’schoice.Itwasalsowidelyacknowledgedthatmostmenwouldnotwantto
use condoms(incontrastto theirrelativelyhighuse aftermarriage),soineffect,onlytwomethods
remained.
“The peoplethink it is safeto takeinjection becauseit is a method for3 monthsso thatthey
are safefor3 months,and sometimesthey may forgetto takethe oral pill and they prefer
notto get pregnant,and thepeoplewho don’twantto takechildren and 2-3 years interval
they are taking the injection.They prefer this becausethey are scared to takethe implant
and if they take the pill they are scared to pregnant….Thewomen who arenottaking
children within 2-3 yearsare taking the injection,butif they thinkthatthey will take the
children shortly (within a year) so then they will usethe pill”. (PEER Researcher8)
It isalso interestingtonote thatinchoosingbetweenthesetwomethods,the oral contraceptive pill
was widelyacknowledgedtobe unreliable withhighuserfailurerates.Womendescribedfeeling
tense at thistime due tofearof conception,andthose whoforgottoregularlytake the pill would
thenfavourusinginjectables.Thesetwoformsof contraceptionare alsothe mostaccessible forms
of contraception,withOCPavailable tobe deliveredtothe woman’shousehold through
fieldworkers.
“(They use the) pill and injection – becausethey receive the pill at their household when the
family planning workervisits their houses,and it’sfree and it’scomfortable,peoplecan also
go to the healthcentre to get theinjection and it is also free of cost,when the woman are
thinking thatthey don’twantto havea child earlier, then they usethe injection”.(PEER
Researcher12)
"All the women prefer injection to prevent pregnancy. There are so many tensions on other
methods, such as the pill. For thepill, maintaining the time is very important and if any one
missesto take thepill one day then they may conceive, so thatall the women and men prefer
injection. They usually go to government hospital to take the service,becausethere is one in
every community. So that it is easier to find out the location and also convenient to go
there,because they can go there by walking”. (PEER Researcher 13)