Microfinance participation and contraceptive use and intention in Bangladesh

Abstract

This study assessed the association between microfinance participation and contraceptive use and intention among 46,639 women between the ages of 15 and 49 years from the Bangladesh Demographic and Health Surveys (BDHS) 2007, 2011, and 2014 using chi-square tests and multinomial logistic regression. The multivariate model revealed that the model explained 14 percent of the variance in contraceptive use and intention. Adjusted beta coefficients revealed that when microfinance participation increased by one unit, use of modern methods of contraception significantly increased by 0.32. The study findings suggest that women are more likely to use modern methods of contraception when they participate in microfinance.

Keywords

Bangladesh contraceptive use intention to use contraceptives microfinance

Introduction

Microfinance, a widely accessed and deeply saturated financial institution in Bangladesh, is known for targeting low-income women, who are able to access a range of financial services. For example, with microloans they are able to become entrepreneurs of microbusinesses, through which they may be able to contribute to family income as well as their own health and well-being (Counts, 2008; Isangula, 2012; Vaessen et al., 2014; Yunus, 2003).

Amidst debate about the extent to which women are benefited by such gendered institutions with patriarchal norms, particularly in terms of poverty and empowerment, the literature from Bangladesh indicates that microfinance participation increases women’s use of contraceptives (Cons and Paprocki, 2010; Goni and Rahman, 2012; Karim, 2014; Mazumder and Wencong, 2015; Murshid and Ely, 2016; Pitt et al., 2006; Schuler and Hashemi, 1994; Schuler et al., 1997; Steele et al., 2001; Taylor, 2012). This is perhaps because (1) microfinance participants have larger social networks from whom they can learn about contraceptives, (2) microfinance participants, given increased mobility, have greater access to contraceptives which are available over the counter, and (3) contraceptive use allows women to remain in the workforce, including as micro-entrepreneurs, while ensuring a degree of freedom in their lives (Buviníc et al., 2008; Gill and Stewart, 2011; Murshid and Ely, 2016; Rathnam, 1995).

Contraception can be defined as the use of methods or acts intended to prevent reproduction occurring as a result of sexual intercourse (Hubacher and Trussell, 2015). Contraception plays an essential role in the process of family planning, which is the managing of the timing and spacing of pregnancies with the goal of reducing morbidity and mortality from early, repeated, or numerous pregnancies (World Health Organization, n.d.). Family planning, which includes contraception and abortion, is a human right that facilitates the global advancement of women, and it is an essential component of economic independence for women and families (National Association of Social Workers, 2015).

Abortion is also a vital part of family planning. An estimated 50 million abortions occur annually worldwide, and women in developing nations have higher rates of abortion compared to their counterparts in more developed geographic areas (Guttmacher Institute, 2016). The 2010–2014 abortion rate in Asia was 36 per 1000 women aged between 15 and 44, which is lower than the rate in Latin America, yet somewhat higher than the rate in Africa (Guttmacher Institute, 2016). Abortions are frequently performed under unsafe conditions, and this is more common in developing nations (Guttmacher Institute, 2016). The need for abortion often arises due to unmet contraceptive needs, which is defined as the percentage of women who want to avoid pregnancy, but are not using contraception to prevent it (Bradley et al., 2012).

Contraception can be categorized as modern or traditional. Modern methods of contraception include the following: (1) sterilization, (2) intrauterine devices (IUDs), (3) subdermal implants, (4) oral contraceptive pills, (5) condoms and other barrier methods, (6) injectables, (7) emergency contraceptive pills, (8) contraceptive patches, (9) spermicidal foams and other agents, (10) vaginal ring, and (11) the contraceptive sponge (Hubacher and Trussell, 2015). Traditional methods of contraception include (1) the rhythm method and other types of awareness of one’s bodily fertility cycle, (2) withdrawal of the penis prior to ejaculation, (3) lactational amenorrhea, and (4) abstinence (Hubacher and Trussell, 2015).

Rates of contraceptive use vary, and rates of modern contraception vary in comparison to traditional rates. For example, in India, sterilization is the most common type of modern contraception, and rates of traditional contraception are at approximately 7 percent, yet up to a quarter of married women aged between 15 and 49 who are not pregnant report use of traditional contraceptives in some geographic locations (Ram et al., 2014).

While modern methods are often considered preferable, it is suggested that practitioners should not assume that all modern methods are more effective when compared to the traditional methods (Hubacher and Trussell, 2015), as there is evidence that, with proper knowledge and dedication, the effectiveness of traditional methods can be comparable to some modern methods (Johnson-Hanks, 2002). That said, in addition to pregnancy prevention, modern contraceptives, particularly condoms combined with contraceptive pills, can lead to myriad preventive health benefits, in terms of sexual, reproductive, and maternal health, as well as well-being, autonomy, and choice in family planning across the world (Adebowale et al., 2013; Fotso et al., 2013; Khawaja et al., 2004; Paregallo et al., 2011; Rajpurohit et al., 2014; Tiruneh et al., 2016). Furthermore, modern contraceptives can offer medical benefits, including reduced cancer risk, control of ovarian cysts, and management of dysmenorrhea, among others (Dhont, 2011). Fewer supplemental benefits are noted in traditional methods of contraception, such as the rhythm method or withdrawal, and the need for high levels of knowledge and regimen adherence that is required for traditional methods can create problems, which in turn puts maternal health at risk, and in certain contexts this could include the risk of unsafe abortions.

Given the potential benefits of microfinance as a social development program and the importance of family planning as a tool for economic independence, it follows that the impact of microfinance on contraceptive use should be examined in greater detail. Currently, little is known about the type of contraceptives that women are more likely to use in Bangladesh, while there is a dearth of information on the intention to use contraceptives among non-users. This is important to assess given research indicating that despite the wide use of contraceptives by women in Bangladesh, unmet need remains among low-income groups (Rashid, 2006, 2009).

Thus, it is important to assess whether anti-poverty tools such as microfinance allow women to take control over their own bodies and lives by the use of modern methods of contraception, and whether it encourages contraceptive use among non-users.

Therefore, this study assesses the association between microfinance participation and contraceptive use and intention using Demographic and Health Survey (DHS) conceptualization of contraception that categorizes it into modern methods, traditional methods, intention to use among non-users, and non-intention to use among non-users. This study uses Bangladesh DHS data from three periods – 2007, 2011, and 2014 – thus controlling for the year of observation, along with potential confounders: desire for more children, whether pregnancy was wanted, and the demographic variables age, husbands’ age, education, husbands’ education, employment status, urban versus rural residence, media exposure, presence of wealth assets, and whether women had children under the age of 5 years (see Table 1).

Table 1.

Characteristics of the study population.

	Sample size	Population distribution (%)^a
All	46,639	100
Key dependent variable: Contraceptive use and intention
Uses modern method	22,587	48.6
Uses traditional method	3769	08.1
Non-user intends to use	10,924	23.7
Non-user with no intention to use	9359	19.5
Independent variables
Microfinance participation	14,645	31.3
Year of observation
2007	10,969	23.6
2011	17,824	38.1
2014	17,846	38.3
Desires more children	13,931	29.9
Wanted last child	44,430	95.1
Respondent age (years)
15–24	14,049	30.7
25–34	16,012	34.5
35–44	11,764	28.9
45+	4722	9.91
Respondent education
No education	12,358	28.1
Primary	13,808	29.6
Secondary	16,449	34.8
Higher	4024	7.4
Husbands’ age (years)
15–24	2441	5.9
25–34	12,810	30.6
35–44	13,460	31.6
45–49	9862	23.0
55+	3997	9.1
Husbands’ education
No education	13,841	31.4
Primary	12,564	27.0
Secondary	13,335	28.3
Higher	6899	13.3
Wealth assets
Poorest	8116	18.7
Poorer	8691	19.4
Middle	9130	20.0
Richer	9735	20.8
Richest	10,967	21.1
Urban dweller	16,150	26.1
Employed	11,214	25.3
Has media exposure	27,414	58.3
Children under 5 years	23,769	51.1

Weighted sample; numbers rounded up to 1 decimal point and may not add up to 100.

Materials and methods

Data

Data for this study were obtained from the 2007, 2011, and 2014 Bangladesh Demographic and Health Surveys (BDHS). BDHS are nationally representative surveys conducted every 4 years, approximately. Study protocol and other details are available publicly from the BDHS reports.

The study reported a sample size of 46,639 women aged between 15 and 49 years, of which 23.6 percent were surveyed in 2007, 38.1 percent in 2011, and 38.3 percent in 2014.

Measures

The key outcome variable of interest was contraceptive use and intention. Women were asked whether they used contraceptives, and if so whether they used modern or traditional methods. Women who indicated that they were non-users of contraceptives were asked whether they intended to use contraceptives in the future. The DHS used these responses regarding contraceptive use and intention to create a single variable in which women were coded according to their use of modern methods of contraception, traditional methods of contraception, as intending to use contraception among non-users, and not intending to use among contraception among non-users.

The key independent variable of interest in this study was microfinance participation, measured through a question asking whether women participated in Grameen Bank, Brac, ASa, Proshika, BDRB, Mother’s Club, or any other microfinance organization. We coded women as microfinance participants if they indicated participation in any of these organizations.

The study controlled for year of observation, desire for more children, whether the pregnancy was unwanted, age, education, husbands’ age and education, urban residence, employment status, media exposure, and having children under the age of 5 years, based on studies indicating the need for controlling for husbands’ characteristics and potential confounders when examining predictors of contraceptive use and intention (see Table 1) (Adebowale et al., 2013; Babalola et al., 2015; Campo et al., 2012; Jain et al., 2014; Kamal, 2015; Nasir and Hinde, 2011; Tiruneh et al., 2016; Wang et al., 2008).

Analytic plan

Population-based sample characteristics were computed using survey methods. Bivariate associations between independent and dependent variables were computed using chi-square tests and unadjusted beta coefficients from multinomial logistic regression. In the multivariate model, all the independent variables that were significantly associated with the dependent variable in the bivariate model were retained. In the multivariate model, multinomial logistic regressions were used to examine the association between microfinance participation and contraceptive use and intention, controlling for confounders identified in the bivariate analyses. Specifically, the multivariate model tested the association between microfinance participation and contraceptive use and intention, adjusting for year of observation, desire for children, pregnancy wantedness, and demographic factors: age, education, husbands’ age and education, family wealth, media exposure, and employment status.

Results

Sample characteristics

Sample characteristics of the study population revealed that 48.6 percent of the sample reported using modern methods of contraception, 8.1 percent reported using traditional methods of contraception, 23.7 percent indicated they were non-users but intended to use contraceptives in the future, while 19.5 percent indicated that their intention was to not use contraceptives (see Table 2). At the same time, approximately 31 percent reported participating in microfinance. In terms of year of observation, 23.6 percent were surveyed in 2007, 38.1 percent in 2011, and 38.3 percent in 2014.

Table 2.

Characteristics of women who reported contraceptive use and intention (based on population estimates).

All variables	Contraceptive use and intention (N = 46,639)
	Use modern contraceptive	Use traditional contraceptive	Non-user w/intention to use	Non-user w/no intention to use
Microfinance participation
No	45.1	8.1	26.2	20.7***
Yes	56.5	8.2	18.3	17.1
Year of observation
2007	44.5	7.7	28.7	19.1***
2011	48.8	8.6	23.8	18.8
2014	51.0	7.9	20.5	20.5
Desire for children
No	50.8	9.3	15.3	24.6***
Yes	43.5	5.4	43.4	7.8
Wanted last child
No	59.8	9.6	22.0	8.6***
Yes	48.1	8.1	23.8	20.1
Respondent age
15–24	47.4	4.5	41.7	6.4***
25–34	58.1	6.8	24.4	10.6
35–44	46.8	13.5	8.9	20.3
45+	24.0	10.3	2.3	63.4
Respondent education
No education	43.8	9.1	14.2	32.8***
Primary	49.4	8.4	23.0	19.2
Secondary	51.0	6.5	31.1	11.4
Higher	52.5	10.8	27.6	9.0
Husbands’ age
15–24	44.3	5.3	48.0	2.4***
25–34	52.8	4.4	39.0	3.8
35–44	59.6	7.7	25.5	7.3
45–54	50.9	12.1	11.1	23.9
55+	35.1	13.9	4.8	46.3
Husbands’ education
No education	47.4	7.8	18.8	26.0***
Primary	49.8	7.4	25.5	17.3
Secondary	48.1	7.7	27.4	16.8
Higher	50.3	11.2	23.8	14.8
Wealth assets
Poorest	48.1	7.3	23.1	21.6***
Poorer	49.6	7.8	22.8	19.9
Middle	49.0	8.1	24.2	18.7
Richer	48.1	7.8	24.9	19.2
Richest	48.5	9.4	23.5	18.6
Urban
No	47.8	7.8	24.7	19.6***
Yes	50.8	9.1	20.8	19.3
Employment
No	47.9	8.1	26.1	17.9*
Yes	50.9	8.2	16.6	24.3
Media exposure
No	46.6	8.2	22.0	23.3*
Yes	50.1	8.1	24.9	16.9
Children under 5 years
No	42.3	9.4	21.2	27.2*
Yes	54.7	6.9	26.1	12.2

p < 0.001.

In terms of potential confounders, 29.9 percent reported a desire to have more children, and 95.1 percent reported that their last pregnancy was wanted, that is, not mistimed or unplanned.

Regarding demographic factors, we notice a wide range. In terms of age, 30.7 percent were between 15 and 24 years, 34.5 percent were between 25 and 34 years, 28.9 percent were between 35 and 44 years, and 9.91 percent were 45 years or older. In terms of the respondents’ husbands’ age, a small percentage, 5.9 percent, were between 15 and 24 years, 30.6 percent were between 25 and 34 years, 31.6 percent were between 35 and 44 years, 23 percent were between 25 percent and 49 percent, and 9.1 percent were 55 years or older. In terms of education, 28.1 percent had no education, 29.6 percent had primary education, 34.8 percent had secondary education, while 7.4 percent had higher education. Concerning respondents’ husbands’ education, 31.4 percent reportedly had no education, 27 percent had primary education, 28.3 percent had secondary education, and 13.3 percent had higher education. In terms of family wealth, 18.7 percent were categorized as poorest, 19.4 percent as poorer, 20 percent as middle, 20.8 percent as richer, and 21.1 percent as richest. About 26 percent lived in urban areas, 25.3 percent were employed, 58.3 percent had media exposure, and 51.1 percent had children who were 5 years old or younger.

Bivariate and multivariate models

The chi-square tests revealed that women who participated in microfinance were significantly more likely to use modern contraceptives than non-participants (56.5% vs 45.1%), as well as more likely to use traditional contraceptives, compared to non-participants (8.2% vs 8.1%). However, among non-users of contraception, intention to use contraceptives in the future was found to be higher among non-participants of microfinance than microfinance participants (26% compared to 18.5%), while among non-users of contraceptives, the intention to not use contraceptives was found to be higher among non-participants of microfinance (17.1% indicated no interest in using contraceptives and participated in microfinance and 20.7% indicated no interest in using contraceptives and did not participate in microfinance).

Similarly, results from the unadjusted model of the multinomial logistic regression revealed that microfinance participation was significantly associated with higher use of modern methods of contraception and traditional methods of contraception, and reduced intention to use contraceptive in the future (see Table 3).

Table 3.

Multinomial logit examining association between microfinance participation and contraceptive use and intention controlling for confounders.

Multinomial logitN = 46,639Wald χ² = 7606.7Prob > χ² = 0.00Pseudo R² (adjusted model) = 0.14	Using modern method		Using traditional method		Non-user, intends to use later
Independent variables	Coeff.	CI	Coeff.	CI	Coeff.	CI
Microfinance participation (unadjusted)	0.42*	0.35, 0.49	0.22*	0.12, 0.32	−0.16*	−0.24, −0.08
Microfinance participation (adjusted)	0.32*	0.23, 0.41	0.09	−0.02, 0.19	−0.14	−0.23, −0.03
Year of observation
2007 (ref.)	–		–		–
2011	0.11	−0.02, 0.24	0.08	−0.07, 0.24	−0.26*	−0.39, −0.14
2014	−0.12^	−0.25, 0.19	−0.26*	−0.42, −0.09	−0.69*	−0.83, −0.55
Desire for children	−1.23*	−1.38, −1.09	−0.97*	−1.16, −0.79	−0.53*	−0.69, −0.36
Wanted last child	−0.57*	−0.81, −0.33	−0.66*	−0.94, −0.37	−0.83*	−1.09, −0.56
Respondent age
15–24 (ref.)	–		–		–
25–34	−0.31*	−0.52, −0.10	−0.23*	−0.33, −0.00	−0.61*	−0.83, −0.40
35–44	−1.18*	−1.40, −0.91	−0.59*	−0.87, −0.30	−2.07*	−2.30, −1.83
45+	−2.27*	−2.51, −2.03	−1.48*	−1.78, −1.17	−3.67*	−4.00, −3.33
Respondent education
No education (ref.)	–		–		–
Primary	0.21*	0.11, 0.31	0.22*	0.07, 0.37	0.26*	0.13, 0.34
Secondary	0.44*	0.31, 0.58	0.23*	0.01, 0.45	0.49*	0.33, 0.65
Higher	0.84*	0.59, 0.109	0.83*	0.53, 1.12	0.84*	0.58, 1.12
Husbands’ age
15–24 (ref.)	–		–		–
25–34	−0.57*	−0.94, −0.19	−0.86*	−1.29, −0.43	−0.57*	−0.94, −0.19
35–44	−1.09*	−1.45, −0.72	−1.06*	−1.49, −0.62	−1.16*	−1.54, −0.78
45–54	−1.77*	−2.14, −1.41	−1.31*	−1.78, 0.82	−2.08*	−2.46, −1.70
55+	−2.32*	−2.70, −1.19	−1.62*	−2.12, −1.12	−2.82*	−3.25, −2.39
Husbands’ education
No education (ref.)	–		–		–
Primary	0.21	–0.11, 0.11	0.06	–0.09, 0.22	0.02	–0.11, 0.15
Secondary	0.44	–0.18, 0.08	0.16*	0.01, 0.32	–0.05	–0.21, 0.12
Higher	0.84	–0.13, 0.24	0.49*	0.28, 0.71	–0.09	–0.29, 0.11
Wealth assets
Poorest (ref.)	–		–		–
Poorer	0.07	−0.09, 0.23	0.02	−0.20, 0.25	−0.05	−0.20, 0.11
Middle	0.06	−0.12, 0.24	0.04	−0.23, 0.30	−0.00	−0.17, 0.16
Richer	−0.08	−0.25, 0.82	−0.17	−0.41, 0.07	−0.09	−0.24, 0.07
Richest	−0.12	−0.31, 0.04	−0.19	−0.43, 0.06	−0.09	−0.28, 0.09
Urban	0.18*	0.08, 0.29	0.20*	0.06, 0.34	−0.09	−0.22, 0.02
Employment	0.24*	0.12, 0.37	0.17^	−0.01, 0.34	−0.14*	−0.28, −0.00
Media exposure	0.17*	0.07, 0.27	0.12^	−0.01, 0.25	0.16*	0.06, −0.28
Children under 5 years	0.45*	0.33, 0.57	0.26*	0.11, 0.41	0.05	−0.08, 0.18
Constant	3.75*	3.25, 4.24	1.77*	1.18, 2.35	4.17*	3.74, 4.79

CI: confidence interval

Base outcome: Does not use or intend to use contraceptives.

p < .05. ^p < 0.09.

However, when potential confounders and demographic variables were adjusted for, the results held only for modern methods of contraception. In other words, results from the multinomial logistic regression that accounted for potential confounders and demographic variables indicated that one unit increase in microfinance participation significantly increased the use of modern methods of contraception by 0.32 (p < 0.05) (with reference group being non-users with no intention to use). The adjusted multivariate model revealed a pseudo R² of 14 percent, indicating that the models explained 14 percent of the variance in the dependent variable and contraceptive use and intention.

Discussion

The results from this study based on a nationally representative sample of women provide evidence of the association between microfinance participation and contraceptive use, suggesting that the use of modern methods of contraception increases when women participate in microfinance. This is not surprising, in light of existing evidence of an association between microfinance participation and women’s overall empowerment (Kato and Kratzer, 2013), given that the use of contraception is a promising sign of empowerment, especially for women living in deeply patriarchal societies.

Our current findings are consistent with previous research specific to Bangladesh that suggests that women participating in microfinance programs were more likely to use contraceptives compared to those not in microfinance (Murshid and Ely, 2016) and that longer participation in microfinance is associated with increased use of contraceptives (Goldberg, 2005). Current findings are also consistent with other evidence suggesting that decreases in fertility are associated with microfinance programs in Bangladesh (Kuchler, 2012). Moreover, these findings correspond with another study from Haiti, suggesting that microfinance was associated with increased chances of condom use and reduced HIV-risk behavior (Rosenberg et al., 2011). Access to wealth has also been associated with increased contraceptive use in Ghana (Crissman et al., 2012), which is important to consider in the context of this study, given that participation in microfinance has the potential to increase personal wealth.

Findings from this study also suggest that intention to use contraception, among non-users, was lower in microfinance participants, which suggests that these participants are interested in having children or having additional children. Perhaps this is because an increase in resources, through microfinance participation, can increase couples’ desire to have children or more children because they perceive being able to better afford them. This would be consistent information suggesting that increases in income among microfinance participants is associated with greater desire for children and the ability to increase household spending on children (Anderson et al., 2002).

The study has several limitations. First, the cross-sectional nature of the data makes causal inferences difficult. Second, self-reported data is known to be fraught with social desirability bias. Third, microfinance participation is conceptualized in its ‘broad sense’, which means we have no information regarding whether microfinance success or loan amount makes a difference in women’s investment in their own health care; future primary studies are well positioned to estimate such associations.

Implications for policy and/or practice

Social work in Bangladesh is primarily focused on social development. Social development does not target services toward individuals or individual problems; it is instead designed to improve the well-being of the overall population through economic development that addresses social needs at a broad level (Hossain and Mathbor, 2014). Given the findings from this study suggesting that microfinance, which is a prominent social development program in Bangladesh, is associated with modern contraceptive use, social workers should consider how various social development efforts can be combined to address additional social problems through already established programs. Our suggestions for this are noted below.

Social work practice in Bangladesh is largely supported by donor-funded non-government organizations (NGOs). NGOs such as Brac provide services such as microfinance as well as services related to sexual and reproductive health, which is why it is possible that those who access microfinance are more likely to access contraception, because NGOs promote those services to them. The results of this study thus suggest a relationship between microfinance participation and contraceptive use, pointing to the potential benefits of developing family planning programs that could be offered in conjunction with microfinance programs, albeit more intentionally rather than on an ad hoc basis, while ensuring that women have agency over their own bodies. The possibility of combining targeted public health programs and microfinance has been recommended previously (Kim et al., 2007). This type of empowering practice partnership has the potential to further increase contraceptive use, and could be integrated fairly seamlessly into microfinance program sites, given that microfinance programs typically target women, family planning programs are also useful for poverty alleviation, and contraception is already available over the counter in Bangladesh. Such an approach would be consistent with the recommendations of others who support the feasibility of integrating women’s health, HIV/AIDS prevention, training and education programs with microfinance programs to create integrated programs that can also share staff and resources (Dunford, 2001; Hargreaves et al., 2009; Pronyk et al., 2005). This kind of approach also has the possibility of increasing uptake of other reproductive health services (Watson and Dunford, 2006), and there are already a few of these kinds of partnerships in existence that include facilitating connections with health providers (Leatherman et al., 2012).

Conclusion

Microfinance participation increases use of modern methods of contraception, indicating that microfinance participation, perhaps through increased social networks and increased access to information, informs women’s knowledge regarding contraceptive methods which, in turn, allows them to use modern versus traditional methods of contraception.

Footnotes

Acknowledgements

We would like to thank Macro International for making the Bangladesh Demographic and Health Surveys available for analysis. Our sincere gratitude to all study participants.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author biographies

Nadine Shaanta Murshid is Assistant Professor, School of Social Work University at Buffalo. Her work focuses on structural violence, institutions, and health disparities.

Gretchen E Ely is Associate Professor, School of Social Work, University at Buffalo. Her work focuses on reproductive health and abortion.

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