Access to female contraceptives by Rohingya refugees, Bangladesh

Abstract Objective To determine the prevalence of the use of contraceptives among female Rohingya refugees in Bangladesh and its associated factors. Methods We conducted our cross-sectional survey at the Kutupalong refugee facility located in Cox’s Bazar in November 2019. We used univariable and multivariable logistic regression models to determine the association between the use of contraceptives and our various predictor variables, including women’s age, age at first marriage, education level and employment status. We also considered factors such as whether previous pregnancies were planned or unplanned, and the occurrence of non-consensual sex with husbands. Findings We found that 50.91% (251/493) of the survey participants used contraceptives, and that injection (169/251; 67.33%) and oral contraceptives (75/251; 29.88%) were the predominant modes. Of the women who did not use contraceptives, the main reasons were reported as disapproval by husbands (118/242; 48.76%), actively seeking a pregnancy (42/242; 17.36%) and religious beliefs (37/242; 15.29%). An increased likelihood of using contraceptives was found to be positively associated with women’s employment outside their households (odds ratio, OR: 3.11; 95% confidence interval, CI: 1.69–6.11) and the presence of a health-care centre in the camp (OR: 3.92; 95% CI: 2.01–7.67). Women who reported an unplanned pregnancy during the previous 2 years were less likely to use contraceptives (OR: 0.02; 95% CI: 0.01–0.05). Conclusion To increase the acceptance and use of contraceptives, we recommend programmes targeted at women of reproductive age and their husbands, religious and community leaders, and providers of family planning and child and maternal health-care services.


Introduction
The women of forcibly displaced populations worldwide face a substantial degree of adverse health outcomes as a result of arranged or forced marriage when young, unprotected sexual intercourse and limited access to health-care services. These situations result in large numbers of unplanned pregnancies and unsafe abortions, and the associated complications. 1,2 Contraception is highly recommended to prevent such adverse outcomes, and is an essential component of basic sexual and reproductive health responses in humanitarian emergencies. 1 Such health-care services include emergency contraception, long-and short-term contraceptive methods, menstrual regulation services and post-abortion care. 3 The provision of contraception services also offers women many other health-improving associated benefits, such as the autonomy to determine the number and timing of their children, and to access opportunities related to their education and livelihoods. Awareness of contraception can also empower families to manage scarce resources and reduce the burden of maternal and child malnutrition. 4 To achieve the third sustainable development goal, that is ensuring healthy lives and promoting well-being for all at all ages, by 2030, the World Health Organization prioritizes contraception services in refugee settings to improve maternal health. 5,6 The Rohingya people living in refugee camps in Bangladesh began to migrate from Myanmar in 1970. However, the largest numbers arrived in 2017 following a widespread operation by Myanmar's military that was later declared genocide in a hearing at the International Court of Justice. 7 While living in Myanmar, the Rohingya people have historically been denied citizenship and basic human rights, severely restricting their access to education and health services. These restrictions have had a substantial impact on their knowledge of the use of contraception and family planning, 8 meaning that overall fertility and adverse health outcomes related to pregnancy, including maternal and child mortality, were extremely high. 9 The situation has remained essentially unchanged following their forced migration to Bangladesh. 1,3 The Ministry of Health and Family Welfare of the Government of Bangladesh, along with around 150 national and international development partners such as nongovernmental organizations (NGOs), United Nations agencies and other international agencies (e.g. Cooperative for Assistance and Relief Everywhere International and Save the Children), are now offering health and family planning services in the refugee camps. 10,11 Under this initiative, family planning health-care workers visit women's homes at a recommended frequency of every 2 weeks to provide family planning information and counselling, and/or dispense contraceptives. 3,12 Medical clinics and dispensaries with facilities for minor surgeries are also provided within refugee camps, and some over-the-counter drugs are available from shops and groceries around the camps accessible to both local residents and refugees. Patients requiring secondary and tertiary care are transferred to local government medical college hospitals in either Cox's Bazar or Chattogram.
However, little is known regarding whether such initiatives have made any impact on the use of contraceptives among female refugees. 8,13 We therefore used a cross-sectional survey to explore the prevalence of contraceptive use and to determine the factors associated with the use, or barriers to the use, of contraceptives among female Rohingya refugees in Bangladesh.
Objective To determine the prevalence of the use of contraceptives among female Rohingya refugees in Bangladesh and its associated factors. Methods We conducted our cross-sectional survey at the Kutupalong refugee facility located in Cox's Bazar in November 2019. We used univariable and multivariable logistic regression models to determine the association between the use of contraceptives and our various predictor variables, including women's age, age at first marriage, education level and employment status. We also considered factors such as whether previous pregnancies were planned or unplanned, and the occurrence of non-consensual sex with husbands. Findings We found that 50.91% (251/493) of the survey participants used contraceptives, and that injection (169/251; 67.33%) and oral contraceptives (75/251; 29.88%) were the predominant modes. Of the women who did not use contraceptives, the main reasons were reported as disapproval by husbands (118/242; 48.76%), actively seeking a pregnancy (42/242; 17.36%) and religious beliefs (37/242; 15.29%). An increased likelihood of using contraceptives was found to be positively associated with women's employment outside their households (odds ratio, OR: 3.11; 95% confidence interval, CI: 1.69-6.11) and the presence of a health-care centre in the camp (OR: 3.92; 95% CI: 2.01-7.67). Women who reported an unplanned pregnancy during the previous 2 years were less likely to use contraceptives (OR: 0.02; 95% CI: 0.01-0.05). Conclusion To increase the acceptance and use of contraceptives, we recommend programmes targeted at women of reproductive age and their husbands, religious and community leaders, and providers of family planning and child and maternal health-care services.

Research
Use of contraceptives by female Rohingya refugees, Bangladesh Md Nuruzzaman Khan et al.

Study setting
We conducted our study at the Kutupalong refugee makeshift facility located at Ukhiya, Cox's Bazar, Bangladesh. This facility was established in 1991, and most of the Rohingya refugees have resided there since they departed Myanmar in 2017. Around 700 000 Rohingya refugees and their temporary homes are crowded into an area of only 13 km 2 , making it the world's largest refugee settlement in terms of both size and population density. Administratively, the facility is divided into 34 camps comprising a total of 208 blocks; on average, each block supports 892 households. 14

Study design
We conducted our cross-sectional survey during the second week of November 2019. We first randomly selected two blocks from each of four randomly selected camps. Women who had married or given birth during the previous 2 years were invited to participate in the survey, and we endeavoured to interview as many eligible women as possible within the selected eight blocks during the week of our survey. To identify all eligible participants for whom pregnancy was an option, we excluded women who were already pregnant, and women who had not been sexually active during the month before the survey. Six female interviewers conducted the interview, all of whom had completed a university or equivalent degree and had experience of interviewing Rohingya people. The interviewers conducted the survey using a structured questionnaire. We developed the primary version of our questionnaire by incorporating relevant questions from the Demographic and Health Survey. 15,16 Before the survey, we piloted our questionnaire with 15 Rohingya women to ensure its appropriateness. We addressed some inconsistencies at this stage, mostly in the answer options to some questions and in terms used to identify health-care providers in the camps.

Outcome variable
We derived data on women's use of contraceptives from the question: "Are you currently doing something or using any methods to delay or avoid getting pregnant?" The response options to this question were "yes" or "no." Women  a Attended no formal educational institutions, although some had attended institutions such as madrasah (a mainly religious and basic education provider). b Including social pressure, being asked to re-attend health-care facility at a later data to collect contraceptives, no opportunity, no need and having a stomach ulcer.
Use of contraceptives by female Rohingya refugees, Bangladesh Md Nuruzzaman Khan et al.
who responded "yes" were then asked to identify the methods they use from the following list: contraceptive injection, oral contraceptive pill, implant, female sterilization, intrauterine device, periodic abstinence, male sterilization, condom or withdrawal. We also provided a free-text response option for use if their contraceptive method was not included in this list. Where women reported the use of multiple contraceptive methods, the method used most frequently was identified as the usual method of contraception. Women who responded "no" were asked about their reasons for not using contraception.

Predictor variables
We identified potential predictor variables from previously published literature on contraception and family planning in refugee settings, 4,17,18 including the continuous variables women's age, age at first marriage and number of live births, and the categorical variables education level and employment status. Regarding employment status, Rohingya refugees can engage in work within the camp under the cash-for-work scheme run by some NGOs, albeit on a limited scale. 19,20 We asked whether each woman had had a live birth within the previous 2 years and, if yes, whether this pregnancy was planned or unplanned. We also asked whether women had nonconsensual sexual intercourse with their husbands, by posing the question "Does your husband force you to have sex without your consent?" If the answer was positive we asked whether such incident was occasionally or frequently (We note that WHO defines all non-consensual sex as rape). We included husband's age, education level and employment status as possible predictor variables. Finally, we considered the availability of health-care services in the camp as a dichotomous predictor variable.

Statistical analysis
We used descriptive statistics to characterize the demographic profile of women included in our analysis. We used univariable and multivariable logistic regression models to determine the association between the outcome variable and predictor variables. We included all available predictor variables associated with the use of contraceptives in our multivariable model. We performed all statistical analyses using the software Stata version 15.1 (StataCorp, College Station, United States of America), and report all associations as odds ratios (OR) with 95% confidence intervals (CIs).

Ethics
We received ethical approval for this survey from the Institute of Biological Science at Rajshahi University (approval number: 123/320/IAMEBBC/IBSc), Bangladesh. We obtained verbal consent from all participants before interviews. The interviewers endeavoured to ensure the confidentiality of the selected respondents by conducting private interviews either in the participants' houses or outside, excluding others. To ensure privacy was obtained, interviewers occasionally visited some houses more than once.

Results
A total of 508 women were interviewed, and our final sample of eligible participants consisted of 493 women.
The women who participated in our survey had a mean age of 23.34 years (standard deviation: 5.14) and had a mean of 2.55 children (Table 1). We found that almost three quarters (367/493; 74.44%) had received no formal education, and around two thirds (329/493; 66.73%) reported that their husbands had received no formal education (Table 2). Over three quarters of the women (376/493; 76.27%) reported that they did not work outside of their homes. Most of the women reported that their husbands were either day labourers (226/493; 45.84%) or were engaged in voluntary jobs and services (176/493; 35.70%).
Although the recommended frequency of home visits by health-care workers is once every 2 weeks, only 10.95% (54/493) of the women reported receiving such frequent visits during the 3 months immediately before the survey. More than half of the women (255/493; 51.72%) reported no visits, and around one quarter (121/493; 24.54%) received only 1-3 visits (Table 3). Women who received a visit that included both a family planning consultation and provision of contraceptives (57/493; 11.56%) were more likely to use contraceptives (41/57, 71.93%) than women who either (i) participated in a consultation, but were not supplied with contraceptives (75/144; 52.08%) or (ii) were supplied with contraceptives, but did not receive a consultation (23/37; 62.16%). Of the women who received a single visit by a family planning health-care worker, 46.15% (12/26) reported using contraceptives; this proportion increased to 57.14% (20/35) among women who received five visits ( Table 3).
The use of contraceptives by women varied with several sociodemographic properties (Table 4). We noted that the level of education received by either the women or their husbands was not associated with the women's use of contraceptives. However, the 117 women engaged in additional work outside their household were more likely to report the use of contraceptives (71/117; 60.68%) compared with the 376 women who did not work outside their home (180/376; 47.87%). A large proportion of the 244 women whose last pregnancy was planned reported using contraceptives at the time of the survey (190/244; 77.87%). We also recorded a greater use of contraceptives among women who: (i) reported no non-consensual sex with their husbands in the year before the survey (113/213; 53.05%) compared with women who reported occasional or frequent non-consensual sex (138/280; 49.29%); and (ii) resided in a camp with a mobile health-care centre (213/409; 52.08%) compared with women whose camp did not have such facilities (38/84; 45.24%).
From our multivariable regression model, we observed that five variables were significantly associated with the use of contraceptives: two positively and three negatively ( Our study has revealed that around one half of the female Rohingya refugees do not use contraceptives, mainly because of their husbands' disapproval and their religious beliefs. The scale of the challenge facing family planning advisors is illustrated by the fact that almost all of the women who experienced an unplanned pregnancy within the 2 years before the study were still not using contraceptives. 13,25 The Rohingya people have deeprooted misconceptions regarding the use of contraceptives; indeed, the majority of these people incorrectly believe that the religion of Islam does not permit the use of contraceptives, and that such use may even put women at risk of developing health issues. 3 In addition, given that they do not have residency status in Bangladesh, many believe that the contraceptives provided are intended to cause irreversible sterilization. 25 A further challenge is that the Rohingya people often do not have any plans regarding their reproductive lives; they consider children to be a gift from God and want as many as possible. 25 However, our estimated significant association between women who used contraceptives but also viewed their most recent pregnancy as planned may be indicative of changing attitudes. Increased autonomy among the women regarding their reproductive lives, increased participation in activities outside their homes and greater access to reproductive health-care services could significantly increase the use of contraceptives and result in fewer unplanned pregnancies, particularly among women  who have not received any formal education or who married at a young age. 4,18,26 In addition, increasing awareness of their sexual and reproductive rights may also help to improve the situation, 27 as has been found in research conducted in other refugee settings. 23,28 Our estimate of contraceptive use by Rohingya women is higher than that made in 2018 (757/2227; 33.99%), 3 a result of a wide range of programmes such as counselling and the provision of free contraceptives offered by various health-care stakeholders working in the Rohingya camps. 3 However, the majority of the women who participated in our survey had not received the government-recommended six or more visits by family planning field workers. 29,30 More work therefore needs to be done to achieve the current international and national targets of ensuring effective contraception for every woman. 6,31 Our study revealed that, of the Rohingya women who do use contraceptives, the contraceptive injection or oral contraceptive pill are preferred. 3 Permanent or long-term methods, such as sterilization and intrauterine devices, respectively, as well as the use of condoms, are uncommon; 25 however, these are the very contraceptive methods that are often considered to be priorities by health-care providers working in the camps. 3 Targeted programmes that tackle this potential discrepancy between the preferences of the contraceptive users and the priorities of the health-care providers would therefore appear to be critical in increasing contraceptive use. Community leaders could also play an important role in promoting the use of alternative methods to the contraceptive injection or pill. 32 The main strength of our study is our primary data set collected from the Rohingya population. However, our study also had several limitations. As our study is based on data from a cross-sectional survey, our findings are correlational only. Moreover, we could not include all potential confounders in the model that may have a significant influence on decisions regarding current contraceptive use, such as the opinions of husbands or past use of contraceptives. Finally, we analysed self-reported data without any scope for validation by the interviewers; our data may therefore be subject to reporting or recall errors.
To conclude, we recommend further study to obtain more precise information about contraceptive use and its associated barriers and facilitators. We also recommend programmes targeted at women of reproductive age and their husbands, those who have received no formal education, and religious leaders. Finally, the inclusion of women's husbands in family planning services, 3 and the integration of maternal and child health-care services with family planning services, 33 could also help to increase the use of contraceptives. ■