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Public health
Original research
Role of community-level emergency contraceptive pills awareness and possibilities of long-acting reversible or permanent methods in reducing unwanted births in Bangladesh: evidence from a nationwide cross-sectional survey
  1. Md Mahabubur Rahman1,
  2. Zannatul Ferdous2,
  3. Tasnim Ara3,
  4. Mahfuza Mahi4,
  5. M Moinuddin Haider1
  1. 1Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research Bangladesh, Dhaka, Bangladesh
  2. 2Institute of Health Economics, University of Dhaka, Dhaka, Bangladesh
  3. 3Institute of Statistical Research and Training, University of Dhaka, Dhaka, Bangladesh
  4. 4Mathematics and Natural Sciences, BRAC University, Dhaka, Bangladesh
  1. Correspondence to Md Mahabubur Rahman; mrahman4{at}isrt.ac.bd

Abstract

Objective This study aims to investigate the role of community-level emergency contraceptive pill (ECP) awareness in reducing unwanted births (UWBs) in Bangladesh and explore the regional variation in women’s appropriateness to adopt long-acting reversible contraceptives or permanent methods (LARCPMs) based on their child desire.

Design, settings and participants We used data from the cross-sectional Bangladesh Demographic and Health Survey 2017–2018. We analysed the planning status of the last live birth 3 years preceding the survey of 20,127 ever-married women of reproductive age.

Methods Considering women were nested within clusters, a mixed-effect multiple logistic regression was implemented to investigate the association between community-level ECP awareness and UWB by controlling for the effects of contextual, individual, and household characteristics.

Results Only 3.7% of women belonged to communities with high ECP awareness. At the national level, 2% of women had UWB. About 2.1% of women who resided in communities of low ECP awareness had UWB, while UWB was only 0.5% among women residing in high ECP awareness communities. The odds of UWB was 71% lower among women who resided in high ECP awareness communities than among those who resided in communities with low ECP awareness. However, community-level ECP awareness could not avert mistimed birth. Dhaka, Chattogram and Rangpur held the highest share of UWB. Fertility persisted for 89% of the women who wanted no more children. Among women who wanted no more children, 15% were not using any method, 13% used traditional family planning methods and only 13% adopted LARCPM. These women mostly resided in Dhaka, followed by Chattogram and Rajshahi.

Conclusion This study highlights the significant positive role of ECP awareness in reducing UWB in Bangladesh. Findings may inform policies aimed at increasing LARCPM adoption, particularly among women residing in Dhaka and Chattogram who want no more children.

  • health policy
  • public health
  • sexual medicine
  • reproductive medicine
  • risk factors

Data availability statement

Data are available upon reasonable request. This study used secondary data from Bangladesh Demographic and Health Survey 2017–2018. The dataset can be obtained from the DHS website (https://dhsprogram.com/data/available-datasets.cfm) and it is publicly available upon reasonable request.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2022-066477

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • This study uses representative nationwide data for estimating unwanted births and uses of family planning methods.

    • Mixed-effect logistic regression is employed considering women were nested within the clusters, as it can control for the cluster-level variation.

    • Survey weight and survey design characteristics of the Bangladesh Demographic Health Survey 2017–2018 have been adjusted, as it can reduce bias from the estimates and yield robust standard errors.

    • Establishing any causal relationship is beyond the scope of this study.

    Introduction

    Unwanted birth (UWB) is a global public health concern that has serious consequences for mothers and their children. Unsafe abortions resulting from unintended pregnancies are a significant contributor to maternal morbidity and mortality.1–3 Women who experience an UWB are less likely to have prenatal and postnatal check-ups and more likely to experience preterm birth and psychological adverse conditions.4–9 A child of an unwanted conception has a higher risk of being born with low birth weight and dying during infancy.8 9 The consequences of an UWB extend beyond maternal and child health. It affects all segments of society.9 An UWB imposes an appreciable burden on social, health and economic outcomes like conjugal relationships, formation of family ties and receiving sufficient resources for healthy development; and it may lead to physical and mental abuse toward women and children as well as economic hardship in families.9–11

    Bangladesh, a highly dense South Asian low- and middle-income country (LMIC) grapples with approximately 0.27 million UWBs annually.12 13 Similar to other LMICs,4–7 the adverse effect of UWB on maternal and newborn healthcare during pregnancy and even after birth is evident in Bangladesh.14–17 Despite under-reporting, about 1.2 million abortions were reported in 2014.18 Preventing unwanted conception is deemed essential to reduce the increasing number of abortions in Bangladesh.18 19 Moreover, reducing UWB could lead to a sharp decline in the total fertility rate (TFR) which has been stagnant at 2.3 since 2011.12 20

    Describing a reproductive behavioural epidemiology framework, Tsui et al documented the benefits of contraception on unintended pregnancy and reproductive health.8 UWB can be avoided through ‘preventive’ and ‘curative (postevent management measures)’ approaches. Usage of long-acting reversible contraceptives or permanent methods (LARCPMs) such as Intrauterine contraceptive device (IUDs), implants or sterilisation can be ‘preventive’ approaches that can effectively lengthen the protection period and make contraception management easier and more affordable. Usage of the emergency contraceptive pill (ECP) can be the ‘curative’ approach that has 89% efficacy in averting unintended conception if taken within 72 hours after unprotected intercourse.21 ECP is another form of modern contraception, which is a single dose of levonorgestrel 1.5 mg that averts unintended conception by delaying ovulation, preventing fertilisation and implantation or hindering tubal transportation of sperm and ovum.22

    ECP awareness is critically low (18.4%) among ever-married reproductive-aged women in Bangladesh.12 Suggesting the government and developing partners to raise ECP knowledge among people requires evidence of ECP awareness's role in reducing UWB in Bangladesh. Measuring the effect of ECP awareness on reducing UWB requires data on ECP awareness at the time of conception of that UWB. A study conducted in USA used surveillance data on ECP awareness before conception which enables measurement of the effect of ECP awareness on UWB.23 However, most of the national-level women’s data in Bangladesh only contains information on the current family planning (FP) method used and current knowledge of ECP at the individual level. Thus, no national-level studies have examined the role of ECP awareness in reducing UWB in Bangladesh.

    According to Bronfenbrenner’s socioecological theory, a woman’s contraceptive use behaviour is shaped by the individual, household and community context in which she lives.24 25 Community demographic factors, fertility behaviour and gender norms influence sexual debut and modern contraceptive use in LMICs.26 27 These allow us to assess the influence of ECP awareness on UWB at the community level. Consider a hypothetical reproductive-aged woman who is aware of ECP and whom we shall follow for 3 years. Over the 3 years, she may have a planned birth, or a mistimed birth, or an UWB or no birth. As she is aware of ECP, she would be likely to prevent unwanted conception by taking ECP in times of an emergency. Thus, if her desire for children was fulfilled before starting the 3-year follow-up, ECP awareness may help prevent an UWB and move her towards ‘no birth’ at the end of the follow-up. Otherwise, if her desire for children is not complete, ECP awareness may help prevent a mistimed birth and move her towards a ‘planned birth’ at the end of the follow-up. Aggregating this hypothetical scenario at the community level, we conceptualised that women living in high ECP awareness communities would be less likely to have an UWB than those living in low ECP awareness communities.

    Along with community-level ECP awareness, other contextual factors where a woman lives can also shape UWB. For example, a woman living in a community where women’s education and exposure to mass media are low, child marriage and early motherhood are prominent and women have less autonomy is likely to have less knowledge and poor management of contraception and limited access to modern FP methods. Thus, studying the impact of community-level factors on UWBs is imperative for the design of structural-level interventions aimed at reducing UWBs. However, earlier studies mostly focused on the influence of individual-level (ie, women’s age at childbirth, education, occupation, autonomy, parity), household-level (ie, religion, socioeconomic status) and child-level (ie, parity, sex of last child) factors on UWBs in countries like Bangladesh, India, Nepal and Pakistan and countries of sub-Saharan Africa.28–32

    Women who want no more children are at risk of UWB if they are not using an effective FP method with compliance. Thus, policy should focus on these women. National FP programmes need to understand women’s contraceptive patterns and ensure access to and availability of a wide range of contraceptive methods. National-level programmes are mostly rooted at the administrative division level. Therefore, it is crucial to know in which divisions these high-risk women mostly reside and their contraceptive status. To reduce UWB through strengthening the FP programme, the policy planners need to know administrative region-wise women’s appropriateness to adopt LARCPM based on their desire for children. Appropriateness refers to method use that is specific to the desire for more children. For instance, a woman who does not want any more children can adopt a permanent method, which is not appropriate for those who want more children. To the authors’ best knowledge, existing literature does not convey these critical programmatic points.

    Therefore, the present study aims to investigate the role of community-level ECP awareness in reducing UWBs in Bangladesh. Furthermore, based on women’s child desire, we attempt to explore the regional variation in their appropriateness to adopt LARCPM in order to avert UWBs.

    Materials and methods

    Study area

    The first administrative unit of Bangladesh is comprised of eight divisions that are divided into 64 districts and then further divided into upazilas. Each upazila is divided into wards and unions. Wards form urban areas, and unions form the rural areas of Bangladesh.12 For health service provisions, the unions are then divided into rural wards. There are different health service provisions for different levels of health facilities. Bangladesh is the residence of 46 million reproductive women33 and has made an enviable success story of fertility decline, from a high level of 6.3 births per woman in the mid-1970s to 2.3 births per woman in 2011.12 20

    Data

    Data from the latest nationwide cross-sectional Bangladesh Demographic and Health Survey (BDHS) 2017–2018 was used.34 A total of 20,127 ever-married women of reproductive age (15–49 years) were interviewed using two-stage stratified sampling. In the first stage, 250 and 425 enumeration areas (clusters) were selected from urban and rural areas, respectively. In the second stage, on average, 30 households were selected from each cluster making the data representative at the national level, separately at the rural and urban level, and separately at the administrative division level. The analytical sample includes 20,127 ever-married women (unweighted) of reproductive age. We analysed the planning status of their last live birth 3 years preceding the survey.

    Conceptual framework

    We aimed to examine the association of community-level ECP awareness with UWB. The conceptual framework presented in figure 1 helps with understanding the factors influencing UWB. We conceptualised the pillars of UWB into two broad groups—contextual factors and individual, household-level factors. Pillars of contextual factors include community-level ECP awareness, community demographics, fertility norms, gender norms and area. Community demographic factors such as women’s education and media exposure may increase FP awareness among women and help prevent UWBs. Community-level high levels of education and media exposure may contribute to reducing UWBs via enhancing community-level ECP awareness as well. Community fertility norms such as child marriage and child motherhood may increase UWBs in that community. A community with a conservative attitude towards women may pay less attention to a women’s desire for children. Administrative region-wise differentials in FP programmes and access to FP may also create differentials in the incidence of UWB. We considered women’s current age, education, television watching, empowerment and husband’s education as individual-level factors. Religion and wealth status comprised household-level factors.

    Figure 1
    Figure 1

    Conceptual framework of unwanted birth. ECP, emergency contraceptive pill.

    Outcome measures

    To serve the first objective, we constructed two outcome variables based on the birth status 3 years preceding the survey. We categorised the first outcome variable as follows: UWB (including women whose last live birth was not wanted at the time of conception) and others (including women who had planned birth or mistimed birth or no birth). Furthermore, we disaggregated the ‘other’ category into three groups and constructed the second variable in the following way: planned birth (including women whose last live birth was planned), mistimed birth (including women whose last live birth was mistimed), UWB (including women whose last live birth was unwanted) and no birth (including women who did not give birth 3 years preceding the survey).

    To achieve the second objective of this study, IUDs, female or male sterilisation, implants and norplants were considered as LARCPMs. The short-acting modern methods included pills, condoms, injections, ECP and other modern methods. Women who were not using any FP method because they were not engaging in sexual intercourse, were in menopause or had a hysterectomy, were subfecund or infecund or in postpartum amenorrhoea were considered as not at risk of conception.

    Covariate of interest

    The concentration of any attribute in a cluster is defined as high if more than half of the women of that cluster have that attribute and low if otherwise.35 Considering clusters as representative of communities, the main covariate of interest (community-level ECP awareness) for the first objective was categorised based on the concentration level of ECP awareness in the cluster as follows: high (if more than half of the women in the cluster were aware of ECP) and low (if otherwise).

    The description of other control variables is presented in table 1. The wealth quintile is constructed via a principal components analysis based on the number and kinds of household goods, ranging from a television to a bicycle or a car, and housing characteristics such as the source of drinking water, sanitation facilities and flooring materials. Husband’s education was asked only to currently married women. Forty-four women could not report the educational level of their husbands. There were 1232 women who were widowed, divorced or separated from their husbands. Thus, their husband’s education was missing. The education of women’s husbands was not our primary covariate of interest. Thus, rather than dropping these 1276 women from the analyses, we made a category named ‘unknown’ for their husband’s education.

    View this table:
    Table 1

    Description of control variables used

    Statistical analysis

    The Rao-Scott χ2 test was employed to explore the association between community-level ECP awareness and UWB. Considering women were nested within clusters, a series of mixed-effect multiple logistic regression models were implemented to control for community-level variation, while examining the association between community-level ECP awareness and UWB. Model I was constructed with only the main covariate of interest, ‘Community-level ECP awareness.’ For controlling for the effects of contextual factors, Model II was constructed by adding contextual factors to Model I. To also control for the effects of women’s individual and household characteristics, we constructed Model III by adding the respective variables to Model II.

    To achieve the second objective, the distribution of adopted FP methods among women who want no more children was estimated at the national level. Further, we estimated the administrative region-wise distribution of adopted FP methods among women who want no more children but are at risk of conception.

    Appropriate sampling weights were incorporated that adjusted for the complex survey design characteristics of BDHS. All the analyses were done using Stata V.14.0 (Stata SE V.14, Stata Corp, College Station, Texas, USA).

    Patient and public involvement

    Patients and/or the public were not involved in the design, conduct, reporting, or dissemination plans of this research.

    Results

    Results on the prevalence of unwanted birth

    Table 2 describes the distribution of sociodemographic characteristics of the women (analytical sample). The majority of women belonged to communities where ECP awareness was low. Nearly half (48%) of the women came from low education communities, one-fourth (27%) came from low media exposure communities, two-third (66%) came from low wealth status communities, 93% came from high child marriage communities and one-fifth (21%) came from high fertility communities. Half of the women and their husbands never attended a secondary level of schooling, one-third did not watch television and nearly half (44%) of the women were not empowered. The majority of the women were Muslim and from rural areas.

    View this table:
    Table 2

    Distribution of analytical sample

    Two percent of women had an UWB 3 years preceding the survey. Figure 2 illustrates the prevalence of UWB by community characteristics and statistical significance results from the Rao-Scott χ2 test. The prevalence of UWB was considerably higher among women from low ECP awareness communities than among women living in communities where ECP awareness was high (2.1% vs 0.5%). The Rao-Scott χ2 test suggests that UWB was independent of other community characteristics except for community-level fertility and women’s autonomy. The prevalence of UWB across sociodemographic groups is presented in online supplemental table 1. Women’s and their husband’s education seemed to be associated with a lower prevalence of UWB. UWB was high among Muslims and poor women but did not vary much by residence type.

    Figure 2
    Figure 2

    Prevalence of unwanted birth by community characteristics. **p-value <0.01; *p-value <0.10 from Rao-Scott χ2 test. ECP, emergency contraceptive pill.

    Association between community-level ECP awareness and unwanted birth

    Model I in table 3 shows the unadjusted association between community-level ECP awareness and UWB. Statistically significant evidence of the negative association between community-level ECP awareness and UWB was observed in Model I. The direction and magnitude of the association remain almost the same after controlling for the effect of contextual factors in Model II. The association remains significant with little less magnitude after controlling for the contextual, individual and household-level characteristics in Model III. Based on the AIC (Akaike information criterion), BIC (Bayesian Information Criterion) values and results from the likelihood ratio test, we relied on the results of Model III. The odds of UWB was 71% lower among women living in communities where ECP awareness was high as opposed to those living in communities where ECP awareness was low.

    View this table:
    Table 3

    Association between community-level ECP awareness and unwanted birth: results from mixed-effect multiple logistic regression

    The measures of association (adjusted odds ratio) of other factors are presented in online supplemental table 2. Women’s education, media exposure and empowerment were not associated with UWB. Compared with women ages 15–19, older women were at a higher risk of UWB. However, the higher risk of UWB starts to decline after age 34 and with a similar level among women ages 45–49 years. The husband’s higher education and better household wealth status were protective against UWB. Muslim women were more likely to have an UWB than non-Muslims.

    Further, to explore the role of community-level ECP awareness in reducing mistimed birth, we fitted mixed-effect multinomial logistic regression considering planned birth as the base of the outcome variable (table 4). Covariates were taken from Model III. Results showed that community-level ECP awareness has no significant role in reducing mistimed births. Relative to planned birth, the odds of having an UWB was 74% lower among women who resided in high ECP awareness areas than women from low ECP awareness communities. Full results are shown in online supplemental table 3.

    View this table:
    Table 4

    Association between community-level ECP awareness and planning status of birth: results from mixed-effect multinomial logistic regression

    Regional variation in LARCPM adoption

    Dhaka division held the largest share of UWB (25.5%), followed by the Chattogram (18.2%) and Rangpur (12.5%) divisions. The pie chart in figure 3 depicts that among 11 376 women who wanted no more children, 89% can still conceive in the future, 15% used no FP method and 13% used traditional FP methods which indicate a high risk of UWB among them. Only 13% of women who wanted no more children adopted LARCPM. In summary, among women who wanted no more children, 76% were fertile but did not adopt LARCPM. The bar chart in figure 3 shows the administrative division-wise distribution of these women. Among women who wanted no more children, those who were at risk of conception but did not adopt LARCPM mostly lived in the Dhaka division (19.1%), followed by Chattogram (13.2%) and Rajshahi (10.6%). Among women who wanted no more children, those who were at risk of conception but used no method or traditional methods mainly resided in Dhaka (7.2%), followed by Chattogram (5.7%) and Rajshahi (3.6%).

    Figure 3
    Figure 3

    Administrative division and family planning methods among women who want no more children. LARCPM, long-acting reversible contraceptives or permanent method.

    Discussion

    Main findings

    This is the first cross-sectional study that assesses the role of community-level ECP awareness in reducing UWBs in Bangladesh using national-level data. Findings indicate low-level ECP awareness with substantial community-level heterogeneity. High coverage of ECP awareness was negatively associated with the risk of UWB. Dhaka division held the largest share of UWB followed by Chattogram and Rangpur. More than one-quarter of the women who wanted no more children, adopted no FP method or using traditional FP methods, and they mostly resided in Dhaka, followed by Chattogram and Rajshahi.

    Family planning in Bangladesh

    Family welfare assistants (FWAs) across the country are the backbone of the government’s FP programme in Bangladesh. They were introduced in 1976 and numbered 19 600 in 2017.36 FWAs are permanent staff of the Directorate General of Family Planning (DGFP), are female and must have at least 10 years of schooling. Each FWA is supposed to visit households once every 2 months. During her visit, she updates the couple registers containing information of all currently married women ages 15–49 and their husbands in her catchment area. The primary responsibilities of FWAs are to counsel couples on FP; distribute oral contraceptive pills, condoms and misoprostol; and refer couples to appropriate health facilities if they express interest in LARCPM. Ensuring availability of LARCPM without stockout at any time point, strengthening LARCPM services in hard-to-reach areas through the regional service package programme, building the capacity of service providers, activating quality improvement teams to strengthen monitoring and clinical supervision for both the public and private sector and providing the necessary support to non-governmental organisations are the recognised activities taken by the government of Bangladesh to strengthen LARCPM services.37

    Role of ECP awareness in reducing unwanted births

    Despite remarkable improvements in the national FP programme, ECP awareness is low in Bangladesh with individual and regional variations.12 Except for community-level ECP awareness, no other contextual factors were associated with UWB. Structural interventions such as increasing women’s education, reducing child marriage and ensuring equitable gender roles have a tremendous impact on achieving maternal and child health outcomes. However, our findings suggest that these may not work well in reducing UWB. We found that residing in communities with high ECP awareness protects women against UWB. Our findings provide evidence of the pressing need for designing specific programmes to promote ECP awareness. Our findings also showed that although ECP awareness helps prevent UWB, this could not avert mistimed births. This possibly indicates that when a woman suspects a mistimed pregnancy but wants a child later, she does not take ECP. Not taking ECP may be due to her weaker drive to avert the mistimed pregnancy than if it was an unwanted pregnancy. These findings warrant further investigation of the reasons for not taking ECP when there is a risk of mistimed pregnancy.

    The benefits that could have been gained in terms of reducing TFR through the FP programme to the community level shrinks due to low levels of ECP awareness. In Bangladesh, 82% of women receive at least one antenatal care visit from medically trained providers, and 50% had facility births and postnatal care. FP counselling during maternity care is already established in the Bangladesh FP programme.12 Integrating the ECP awareness generation component in the FP counselling programme during maternity care could be an approach to make women aware of ECP. However, currently the coverage of FP counselling during maternity care is low.12

    Child desire and family planning

    Our results reveal that fertility persisted for the majority of women who want no more children in the future. The concerns are those women who use no method, traditional method use and non-compliance in short-acting methods use. Regrettably, 13% of women who want to limit their family size are using traditional FP methods, and more importantly, 15% are not using any FP method. These findings highlight the weakness of FP programmes in regards of reaching every woman effectively. In this regard, we identify the divisions in which these high-risk women mostly reside. We found that Dhaka division held the largest (19%) share (figure 3). Dhaka also held the largest share of UWBs. Though the prevalence of UWB in Sylhet and Barishal are the highest (online supplemental table 1), their small population sizes contribute less to the national prevalence of UWB. In contrast, a small prevalence in Dhaka can substantially contribute to the national prevalence, because the population of Dhaka is five times that of Sylhet and Barishal. Thus, though the prevalence of UWB in Dhaka is equal to the national prevalence (online supplemental table 1), we found that one-fourth of UWBs occurred there. Therefore, Dhaka should be the centre of attention while planning a roadmap to reduce UWBs. Similarly, for the volume of UWBs, Chattgoram and Rangpur also warrant attention.

    Why LARCPM?

    Usage of ECP can be a ‘curative’ approach, but regular dependency on ECP cannot be the permanent solution because of its adverse health effects. Thus, to achieve a sustainable improvement in averting UWBs, increasing the coverage of modern FP methods is deemed essential. In Bangladesh, the median age for completing desired family size is 26 years among women and the median age for menopause is 46 years.12 This indicates that on average a Bangladeshi woman would need to use a FP method for almost 20 years if she completed her desired family size by the age of 26. Ensuring a continuous supply of FP methods and their proper management for the rest of the reproductive period might not be an easy task for women from all sociodemographic groups. The pill is the predominant FP method in Bangladesh,12 and women who have achieved their desired family size continue pills for the rest of their reproductive life. However, compliance (ie, regularity) with pill use is sometimes troublesome. Another emerging concern for using pills is the increasing burden of hypertension among women of reproductive age.12 38 The WHO recommended not using pills for hypertensive women,39 while in Bangladesh, 51% of hypertensive women ages 18 years or above are unaware of their hypertensive status.12

    Women’s appropriateness to adopt LARCPM

    Thus, to avoid an UWB, women who want no more children can switch to LARCPM which can prolong the protection period. In this regard, this study reveals that only 13% of women who want no more children adopt LARCPM (figure 3). Above this, women who want to limit their family size but use short-acting methods (48%) can switch to LARCPM as well. Women who want no more children but use no method (4.1%), traditional methods (3.1%) or short-acting methods (11.8%) mainly reside in Dhaka. Findings suggest the pressing need for increasing LARCPM coverage, in particular in Dhaka and Chattogram divisions, to reduce UWBs.

    Limitations

    This study uses cross-sectional survey data which restrict making any causal relationship between significant covariates and UWB. ECP awareness was self-reported data which might overestimate ECP awareness among women. Whether women had knowledge of ECP before experiencing unwanted pregnancy was not in the data. One may argue that women heard about ECP after the UWB, which implies women might have a higher probability of learning about a method like ECP after the UWB. If that is so, then women living in high ECP awareness communities are expected to have more UWBs than women in low ECP awareness communities. However, we found women from the high ECP awareness areas had less UWBs which disproves the argument of the high possibility of knowing about ECP after UWB. We used the ECP awareness at survey time. This raises the issue that the communities with high ECP awareness at survey time may not have high ECP awareness before the survey. However, it is reasonable to assume that the communities with high ECP awareness at survey time were likely to have proportionally better ECP awareness than the other communities preceding the survey time. Some other potential factors, such as the availability of FP methods, method used before the conception of unwanted pregnancy that led to an UWB, and couple-level conflicts regarding the spacing or wanting children might significantly be associated with UWB. However, due to data unavailability, we missed controlling for these factors in the analyses.

    Conclusion

    The findings highlight the significant positive role of ECP awareness in reducing UWB in Bangladesh. This study also explores administrative regional variation in adopted FP methods based on women’s child desire and women’s appropriateness to adopt LARCPM. The Dhaka, Chattogram and Rajshahi divisions should be the prioritised regions for enhancing ECP awareness and LARCPM adoption, as the results reveal that the majority of UWBs occur there, and the majority of women who want no more children but use no FP method or use traditional FP methods and short-term methods reside there. We anticipate that the present study may serve as a base study for exploring the path of reducing UWB via promoting effective FP methods. In conclusion, this study may help policy planners when revitalising the FP-related sector programmes to reduce UWB.

    Data availability statement

    Data are available upon reasonable request. This study used secondary data from Bangladesh Demographic and Health Survey 2017–2018. The dataset can be obtained from the DHS website (https://dhsprogram.com/data/available-datasets.cfm) and it is publicly available upon reasonable request.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

    Acknowledgments

    We acknowledge the National Institute of Population Research and Training, ICF International, USA and Mitra & Associates, who conducted this nationwide survey. We acknowledge the contributions of Gabriela Maria Escudero and the Knowledge Management team from the Data for Impact project of the University of North Carolina at Chapel Hill for their help and support. Finally, icddr,b acknowledges the Government of the People’s Republic of Bangladesh and Canada for providing core/unrestricted support.

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    Supplementary materials

    Footnotes

    • Contributors MMR conceptualised the research problem. MMR compiled data and performed the formal analysis under the guidance of MMH. MMR, ZF, TA and MM prepared the original draft. MMH critically reviewed and provided constructive comments. MMR revised and edited the final draft. All authors reviewed the final draft and approved the final version. MMR is responsible for the overall content as the guarantor.

    • Funding The 2017–2018 Bangladesh Demographic and Health Survey (BDHS 2017–2018) was funded by the Government of the People’s Republic of Bangladesh, and the USAID Mission in Bangladesh. This publication was produced under a learning lab initiative with the support of USAID under the terms of Data for Impact associate award No. 7200AA18LA00008, though no specific fund allocation was made for this study. The views expressed here­in do not necessarily reflect the views of the US government or USAID.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.