Population and Family Planning in Bangladesh SWP557 A Survey of the Research Mohammad Alauddin Rashid Faruqee WORLD BANK STAFF WORKING PAPERS Number 557 _ ~~~~~~~~~~- WORLD BANK STAFF WORKING PAPERS CJ6 7 Number 557 ) Population and Family Planning in Bangladesh A Survey of the Research . - s.e g> Cl,. . T T 4,* T *;^, X Mohammad Alauddin Rashid Faruqee The World Bank Washington, D.C., U.S.A. Copyright C 1983 The International Bank for Reconste,iction and Developrment / THE WORLD 3ANT.< 1818 H Street, N.W. Washington, D.C 20433, U.S A. All rights reserved Manufactured in the United States o' America First printing February 1983 This is a working document publ shed intformnally by the World Bank. '.Co present the results of research with -he least possible delay, the typescript has not been prepared in accordance with the procedures appropnate to formal printed texts, and the WNorld Bank accepts no responrsibility 'or errors. The publication is supplied at a token chlarge to defray pazi of the cost of manufacture and distribution. The views and interpretations in .hiis doc-tment are those of the author(s) and should not be attributed to the World Bank, to ns affiliated organizations, or to any individual acting on t-heir be'-a '. Any £naps usecd have been prepared solely for the convenience of the readers, the d&Pominations used and the boundaries shown do not imply, on the part of the World Bank and its affiliates, any judgment on the legal status of any territory or any endorsement or acceptance of such boundaries. The full range of World Bank pulclications is described in the Catalog of World Bank Publications; the continuing research program of the Bank is outlined in World Bank Researclh Program- Abstracis of Current Stp!dies. Both booklets are updated annually; the most recent edition of each is available without charge from the Publicatiors Distribution UJnit of the Bank in Washington or from the European Office of the Bank, 66, avenue d'lena, 75116 Paris, France. Mohammad Alauddin is a senior leciurer at Dhaka University and a consultant to the Development ResEarch Department of the World Bank; Rashid Faruqee is an economist with the Bz nk's Western Africa Regional Office. Library of Congress Cataloging in Publication Data Alauddins Mohammad Population an-d family pl.rning i.% Banginadsh. (World Bank staff Yjorkir g papers 557) Bibliography: po 10 Bangladeshq-Population. 2 Fe-Jti1ity, HumE'-n-- Bangladesh. 3. Birth contlocl-Bangladesh. l. Yaruqes,D Rashid, 1938- 0 11 T-i-- T O Ses HB3640.6oA3A39 1983 3$04.6i09549i2 83-1238 ISBN 0O-8213-0150-0 Abstract This survey attempts to do the following: o Provide an inventory of major studies on fertility trends, profiles, and determinants, and on family planning in Bangladesh. O Analyze the results of the studies and uhderline their operational significance for improving the population program in Bangladesh and for taking new initiatives. o Provide a critique of the studies and suggest directions for future research. Acknowledgements David Pearce of the Bank's Population, Health, and Nutrition Department, then the Project Officer for Bangladesh, encouraged us to do the survey and reviewed various drafts. Emmanuel D'Silva reviewed an earlier draft of the paper and made helpful suggestions. K. C. Zachariah and Timothy King gave valuable comments on the Part I of the paper. Research on Population and Family Planning in Bangladesh: A Survey Page No. PART 1: MAIN RESULTS AND THEIR IMPLICATIONS 1 Preview of Studies 2 Subjects of Studies 3 Fertility Profile and Trends 5 Demographic and Physiological Determinants of Fertility 6 Socioeconomic Correlates of Fertility 7 Determinants of Contraceptive Behavior 13 A Critique 16 Conclusion 20 PART II: THE DETAILED FINDINGS 21 Introduction 22 Demographic Profiles and Trends 24 Fertility 24 Crude Birth Rate 24 Age-Specific Fertility Rate 24 Total Fertility Rate 27 Rural-Urban Differences 27 Regional Difference 34 Mortality 37 Crude Death Rate 37 Infant Mortality Rate 39 Sex Differences 39 Socioeconomic Differences 42 Migration 44 Migration and Fertility 52 Spatial Distribution 52 Population District 52 Population by Density by District 52 Urban-Rural Differences 54 Households: Growth and Composition 58 Page No. Direct Determinants of Fertility 61 Age at First Marriage 61 Proportion Married 65 Duration and Dissolution of Marriages 69 Fecundity of Women 71 Factors.Influencing Natural Fertility 74 Infant Mortality and Fertility 78 Socioeconomic Correlates of Fertility 80 gocial Class 80 Education 80 Occupation 84 Income 84 Landownership -87 Family Type 91 Value of Children 91 Status of Women 94 Employment and Labor Force Participation 94 Religion and Religiosity 95 Purdah 98 Swanirvar Program 98 Determinants of Contracept-Lve Behavior 100 Factors Affecting Demand for Contraceptive Services 100 Sociocultural Factors Affecting Demand for Contraceptive Se-vices 101 Factors Affecting SuppLy of Contraceptive Services 104 Matching Supply and Demand 111 Current Contraceptive 'Jse 111 Intentions to Use Contraceptives in Future 113 Disutilities of Contraception 113 Contraceptive Acceptor Characteristics 125 Differences in Family Planning Acceptance 125 Residence 125 Social Class 130 Occupation 130 Income 130 Religion 132 Education 132 Purdah 132 Rural Development and vtodernization 132 References 135 Page No. PART I: Table 1. Fertility and Family Planning Research in Bangladesh, by Subject of Investigation, 1950-81 4 Table 2. Summary of Results (Fertility) 8 Table 3. Summary of Results (Family Planning) 14 PART II: Figure 1.1 Determinants of Fertility and Contraceptive Behavior: A Conceptual Framework for the Survey 23 Table 2.1 Crude Birth Rate, Bangladesh, 1911-78 25 Table 2.2 Decomposition of the Percentage Change in the Crude Birth Rate, Bangladesh, 1961 and 1974 26 Table 2.3 Age-Specific Fertility Rates and Total Fertility Rates: National and Sub-National Surveys, 1953-1978 28 Table 2.4 Age-Specific Marital Fertility Rates and Total Marital Fertility Rates: Bangladesh, 1958-59-75 29 Table 2.5 Total Fertility Rates, Bangladesh, 1955-61 to 1979 30 Table 2.6 Children Ever Born, by Age and by Rural and Urban Residence, 1968-69 and 1975-76 31 Table 2.7 Mean Number of Children Ever Born to Ever Married Women Aged 10-49, by Current Age and Rural-Urban Residence: BFS, 1976 32 Table 2.8 Mean Number of Children Ever Born to Ever Married Women Aged 10-49, by Duration of Marriage and Rural-Urban Residence: BFS, 1976 33 Table 2.9 Children-Women Ratios, by Division and by Rural-Urban Area, 1961-1974 35 - iv Page No. Table 2.10 Mean Number of Ch:'ldren Ever Born to the Women Aged 15-45 of Chittagong Division by District 36 Table 2.11 Growth Rate of Four Bangladesh Thanas, 1976 38 Table 2.12 Crude Birth Rates; Bangladesh, 1911-78 40 Table 2.13 Crude Birth Rates: Bangladesh, 1911-79 41 Table 2o14 Infant and Child M4ortality Rates and Fetal Death Ratio for Difference Landholding Groups: Comparinganj, Bangladesh 43 Table 2.15 Lifetime Internal Migrants of Bangladesh, 1951-74 46 Table 2.16 Lifetime Net Migr.ants by District, 1951-74 47 Table 2.17 Rank Order of Dis:ricts Gaining and Losing Population, 1974 48 Table 2.18 Net Migrations Bangladesh, 1961-74 49 Table 2.19 Net Interdistrict Migration, Bangladesh, 1961-74 51 Table 2.20 Population Distribution by District: Bangladesh, 1901-74 53 Table 2.21 Population Densitg by District: Bangladesh, 1901-74 55 Table 2.22 Percentage of Urban Population by Districtg Bangladesh, 1901>74 56 Table 2.23 Population and Population Growth, by Residence, Bangladesh, 190174 57 Table 2.24 Growth of Households by Rural and Urban Areas, Bangladesh, 1960-73 59 Table 2.25 Distribution of HDuseholds by Family Composition and Average Household Size: Bangladesh, 1960 and 1973 60 Page No. Table 3.1 Proportions Ever Married by Sex and Age Group, Bangladesh, 1951, 1961 and 1974 62 Table 3.2 Mean Age at Marriage, 1974-81 63 Table 3.3 Percentage of Women Currently Married Aged 10-49, Bangladesh, 1961-75 66 Table 3.4 Percentage of Women Married, by Current Age, 1975 67 Table 3.5 Percentage Distribution of Women of Reproductive Age, by Marital Status, Bangladesh, 1951-76 68 Table 3.6 Duration of First and Current Marriage, 1975 70 Table 3.7 Distribution of Women Aged 10-49, by Duration of Marriage, BFS, 1975 72 Table 3.8 Percentage Distribution of Ever- Married Women Aged 10-49, by Fecundity, BFS, 1975 73 Table 3.9 Women Having No Live Births in the First Five Years of Marriage and Mean Number of Births in the First Five Years of Marriage, by Age at First Marriage 75 Table 3.10 Mean Number of Children Ever-Born to All Ever-Married Women, by Age at First Marriage and Current Age 76 Table 4.1 Mean Number of Children Ever-Born to Ever-Married Women Aged 10-49, by Duration of Marriage and Education of Wife, BFS, 1975 81 Table 4.2 Mean Number of Children Ever-Born to Ever-Married Women, by Current Age and Education of Wife and Husband 83 Table 4.3 Mean Number of Children Ever-Born to All Ever-Married Women by Current Age and Husband's Occupation 85 Table 4.4 Income and Fertility 86 - vi - Page No. Table 4.5 Mean Marital Age-Specific Fertility Rates and Marital Total Fertility Rates of Rural Bangladesh Women, by Husband's Landholdings 1968-70 89 Table 4.6 Total Fertility Rates of Women Aged 15-44 for Landholding Groups: Companiganj Thana, Bangladesh, 1975-76 and 1977-78 90 Table 4.7 Death Rate by Family Landholding in a Famine Year, Companiganj Thana, Noakhali District, 1975 92 Table 4.8 Fertility by Region According to Two Recent 3tudies 97 Table 5.1 Proportion of Never Married Men and Women Aged 45-49 in Census and Other Surveys, 1951-1976 102 Table 5.2 Health, MCH and Family Planning Facilities by Location 105 Table 5.3 Distribution of HoEpital and Other Facilities, by TypE's of Services 106 Table 5.4 Distribution of Heclth and Family Planning Facilities Having Doctors Trained in Sterilization 107 Table 5.5 Distribution of Doctors Trained in Sterilization, by Division 110 Table 5.6 Percentage of Current Contraceptives Used in Bangladesh, 1968-81 112 Table 5.7 Percentage CurrentLy Using Contraceptive Methods, by Method of Currently Married Women under 50, BFS 1975, and BCPS 1979, 1981 114 Table 5o8 Proportion of PeopLe Who Do Not Want More Children 115 Table 5.9 Percentage of People Who Intend to Use Family Planning in the Future 116 - vii - Page No. Table 5.10 Percentage of Women Using Modern Methods, by Time and Area, Matlab, Comilla 117 Table 5.11 Main Side Effects Leading to Discontinua- tion of Family Planning Methods 118 Table 5.12 Poststerilization Physical Complaints, Selected Studies in Bangladesh 120 Table 5.13 Sexual After Effects of Surgical Sterilization (%) 121 Table 5.14 Reason for Discontinuation of Use of Family Planning Method 122 Table 5.15 Difficulties Faced by Family Welfare Assistants to Persuade Couples to Accept Family Planning 123 Table 5.16 Reason for not Currently Using Family Planning for Currently Married, Nonpregnant Women, Bangladesh, 1979 124 Table 5.17 Current Contraceptive use by Age of Women: Bangladesh, 1968-69, 1975-76, and 1979 126 Table 5.18 Percentage Distribution of Family Planning Acceptors, by Method and Age Group, Bangladesh 127 Table 5.19 Contraceptive Use by Number of Living Children: Bangladesh, 1968/69 and 1975-76 128 Table 5.20 Percentage Distribution of Contra- ceptive Acceptors by Method and of Living Children, Bangladesh 129 Table 5.21 Rural-Urban Current Contraception in Bangladesh 131 - viii GLOSSARY BCPS Bangladesh Contraceptive Prevalence Survey (1979) BFS Bangladesh Fertility Survey (1975-76) BRSFM Bangladesh Retrospective Survey of Fertility and Mortality (1974) NIS National Impact Survey (1968-69) PGE Population Growth Estimation Project (early 1960s) Thana Administrative unit under the jurisdiction of a police station (thana) normally covering 150-175 villages and a population around 200sOOOo IBRD 15712R f-s., 501- 1,~. 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One of the poorest countries in the world, it also has one of the highest den- sities of rural population. Concern about the problem has instigated various studies by researchers in Bangladesh and outside. In the 1950s, 1960s, and early 1970s there were only a few studies; since late 1975 there has been a proliferation of studies and research projects, fostered especially by outside research grants. But, the results of these efforts are not readily avail- able. Even if results are available, the question of using them for policy and program development is hardly ever raised. In fact, policymakers and pro- gram managers generally believe, despite all the efforts, that population and family planning research in Bangladesh leaves much to be desired. No attempt has yet been made to substantiate this belief. We therefore undertook this survey with four objectives: o To prepare an inventory and provide a general critique of all studies on family planning and on fertility trends, profiles, and determinants. o To analyze and assess the results of these studies with a special focus on their operational significance for population control and family planning in Bangladesh. o To provide a critique of the design, data, methods, dissemination, and use of completed studies. o With the foregoing as background, to suggest priority areas for future operational research in Bangladesh, with a view to its coordi- nation, its requirements for resources, and its desirable phasing. - 2 - Preview of the Studies Bangladesh and Pakistan share with :ndia a common history of census-taking and vital registration up to the time of independence in 1947. Since 1947 there have been four censuses in the area that now constitutes Bangladesh: in 1951, 1961, 1974, and 1981; the first two before the independence of Bangladesh, the second two after. The census data have a number of limitations. First, the censuses suffer from undercounts ancl overcounts for different places and dates. Second, the age-reporting is rather poor in Bangladesh, and the error pattern does not seem to be consistent from one enumeration to the next. Third, the data do not make it poss ble to distinguish population changes due to migration and those due to births and deaths. Because of these limita- tions, reliable inferences cannot be drawn about demographic changes in the country as a whole or in geographic subdivisions. A good vital registration would have helped0 UJnfortunately, :he coverage of the present system of vital registration is so inadequate that no attempt is even made to tabulate the data collected0 Of the studies surveyed in this paper, only five are based on national samples: the Population Gcowth Estimation Project (PGE) in early 1960s, the National Impact Survey (4IS) conducted in 1968-69 (Pakistan Population Planning Council, 1974), the Bangladesh Retrospective Survey of Fertility and Mortality (BRSFM) in 1974 (Blacker 1975), the Bangladesh Fertility Survey (BFS), which was part of the World Fertility Survey, and Bangladesh Contraceptive Prevalence Survey (BCPS) held in 1979. The PGE data did not collect parity data for all women, so there is no internal yardstick against which to measure the results. The main limitation of the BFS data is incorrect reporting of births in the pregnancy histories0 The BRSFM data suggest a possible omission of female children from reports of children ever born0 The BCPS has, of course, a limited focus: the prevalence of contracep- tive use0 Most of the studies are based on local surveys0 The quality of these surveys is often difficult to judge, because these studies do not always record the procedures in designing and carrying out the interviews0 There are well-known problems of collecting demographic and family planning data by interview in cross-sectional surveys, either local or national. First, memory lapses often mar the accuracy of the reported events of pregnancies, births, and deaths, and age data are always suspect0 Second, there are cultural barriers to asking and eliciting responses on family planning questions0 Third, without proper supervision cf the field interviews, there is always a chance that some of the interviews can be totally or partially fake0 Even with field checks, the interviewers are often tempted to make up the answers rather than conscientiously go thrcugh the interview. This is not to suggest that all cross-sectional surveys are to be discarded. If there is careful supervision of the interviews and the interviewers schedules include carefully designed probe questions, the generated data can be reliable0 - 3 - Longitudinal data are more reliable because there is a built-in check on consistency. In this respect, the only data set that is reliable and extensively used is the Matlab data set generated from longitudinal recording of household status after the various field services provided by the Cholera Research Laboratory (recently renamed the International Center for Diarrheal Disease Research, Dacca). The Bangladesh Institute of Development Studies (BIDS) has also recently collected a longitudinal data set from four areas in the four administrative divisions of the country. Besides data collected through both male and female investigators, a participant-observation method was also used to obtain information about the study villages. No extensive analysis of the BIDS data set has been made so far. Some techniques exist to evaluate the quality of demographic data. For example, a consistency check can assess the accuracy of the reported dates of family planning use by comparing the reported fertility dates with the natural fertility schedules. The U.S. National Academy of Sciences has reviewed the demographic data in Bangladesh and concluded that most of the national demographic surveys have produced unreliable data (National Research Council, 1981). Only the data of the Cholera Research Laboratory have been praised for accuracy and reliability. Subjects of Studies In table I we list more than 300 studies and classify them by the subjects of investigation and the time they were conducted. We tried to be exhaustive, but we are sure that we have missed some studies. Demographic and population surveys got the most attention of researchers in Bangladesh, followed by studies on effectiveness and side-effects of family planning methods. Of the method-specific studies, half were on sterilization, especially vasectomy. We hope that the survey will broaden understanding on the following questions relevant to policy: o From studies already completed, what is the evidence on fertility trends and differences for various population groups in Bangladesh? What roles do socioeconomic variables, contraceptive practice, and age at marriage play in explaining those differences and trends? O What data do these studies provide about the factors that influence acceptance of family planning and its practice in rural Bangladesh? O What can be inferred from the results of these studies about the strengths and weaknesses of Bangladesh's population and family plan- ning program? We summarize here the results under four broad topics: demographic profile and trends, demographic and physiological determinants of fertility, socio- economic correlates of fertility behavior, and the determinants of contra- ceptive behavior. Table I Fertility and Family Planning Research in Bangladesh, by Subject of Investigation, 1950-81 Before Since independence, independence, Subject of investigation 1950-70 1971-81 Total Fertility levels and trends 2 12 14 Fertility and mortality 0 13 13 Demographic and population surveys 6 50 56 Correlates of fertility 3 19 22 Development, fertility, and family planning 0 10 10 Women's status, fertility, and family planning 0 12 12 Nuptiality 3 10 13 Correlates of family planning 7 21 28 Contraceptive methods 15 39 54 (effectiveness and side effects) FP Norms, values, and cultural practices 0 11 11 KAP and general studies 7 30 37 FP field workers and change agents 6 11 17 FP communication and motivation 11 12 23 Delivery of FP services 2 11 13 Methodological studies 0 4 4 - 5 - Fertility Profile and Trends Most studies reveal the persistence of high fertility patterns consistent with the noncontracepting behavior of the population (for example, Afzal 1967, Schultz 1970, Blacker 1977, Cain and DeVries-Baastiens 1976, Chowdhury and others 1970, and Sirageldin and others 1975). The results show that the crude birth rate hovered around 55-57 during the early 1960s. Since the mid-1960s it seems to have declined slightly -- from more than 45 to around 40, except in 1975, when several studies recorded a sharp drop. In analyzing data derived from two national probability sample sur- veys -- the National Impact (of Family Planning) Survey (NIS) in 1968-69 and the World Fertility Survey for Bangladesh (BFS) in 1976 -- Amin and Faruqee (1980) found clearly declining trends in fertility between 1960 to 1975. But this declining trend was discounted because the results were inconsistent and because the fertility rates estimated from retrospective surveys could have been vitiated by memory lapses. The authors also examined the trend in cumu- lative fertility per married woman and found a somewhat different picture. The children-ever-born figure, when averaged for all ages, did not signifi- cantly decline. They attributed the unusually depressed cross-sectional marital fertility rates of 1974-75 to the physical effect of a recent famine on the fecundity of poor women, such as nonagricultural laborers and landless farm workers. From the evidence, it can be concluded that no sustained trend (up or down) in fertility in Bangladesh is evident from the early 1960s to 1975. In most years the total fertility rate was between 6.8 and 7.3, and the crude birth rate between 47 and 51 per thousand in national surveys. The absence of an obvious trend does not necessarily mean that fertility was constant. In fact, fertility rates varied greatly between the years and from one survey to another. In general, national surveys give higher fertility rates than small local surveys. This variation, besides indicating differences in data quality, could be reflecting local variation because of special circumstances (such as intensive development project). In some cases, the crude birth rate has come down close to 30. From reliable data on birth registration, fer- tility in Matlab was found to be low in 1975, after the 1974 famine, but it recovered in 1976 and 1977. Several other studies (such as Amin and Faruqee 1980) record a decline in fertility around 1974-75. And the Matlab birth registration data, which are generally considered reliable, indicate that fer- tility in Matlab was low in 1975, after the 1974 famine, but the rate rose again in 1976 and 1977. The average fertility over several years may have been lower than an early year, because the years in question encompass floods, bad harvests, and wartime disruptions; but there is no indication of_lower fertility in recent normal years. The population growth rates estimated from unadjusted figures confirm this conclusion. Even the slight decline of the population growth rate (calculated from adjusted figures) is consistent with an unchanged fertility rate and a slight decline in mortality rates. - 6 - Demographic and Physiological Determinants of Fertility Early and universal marriage prevails throughout Bangladesh. A rising trend in the age at marriage has been observed in recent years (Aziz 1978, Bangladesh Fertility Survey [BFS] 1978, Rabbani and others 1979, Maloney and others 1980). The median age at marriage for women has risen significantly -- from 13.9 years in 1961 to 15.9 years in 1974. The percentage of those married by age twelve falls from more than 40 percent for the older women to 15 percent for those now 15-19 (BangLadesh Ministry of Health and Population Control 1978). A strong and fairly zonsistent negative correlation between fertility and the age at marriage has been found for both females and males in Bangladesh (Duza 1964, Afzal 1967, S:oeckel and Chowdhury 1969, Maloney and others 1980). The rising age at marriage and the increasing range of female age at first marriage will have a far-reaching demographic effect on fertility in Bangladesh. In an intercountry comparison (among 55 countries), an index of the proportion married was found to be the highest in Bangladesh (Bongaarts 1978). In 1975-76 nine of every ten girls were married during their teens. Only 5 percent of the women in the 2')-24 age group were not married (compare this with 61 percent in Sri Lanka). The proportion of currently married women aged 10-49 has found to be between 8') to 87 percent in the three censuses-- 1961, 1974, and 1980--with no differance between rural and urban areas. The 1974 census recorded a rise of seven percentage points in that proportton0 According to BFS data, the average duration of marriage among ever- married women aged 10-49 is about fifteen years0 Nearly a third of these women have remained married for twenty or more years, two-thirds for less. The rate of marital dissolution is low0 There also has been a marked decline in the proportion of widows0 In 1951, for example, 20 percent of the women aged 35-39 were widows, compared witi 14 percent in 1961 and 9 percent in 1971. Studies show that fewer than 10 percent of ever-married women reported an impairment in fecundity (for example the BFS reported 6 percent, the BCPS 9 percent)0 But it cannot be ascertained from the available data if they have primary or secondary sterility0 The proportion childless after five years of marriage and the mean number of births in the first five years suggest the prevalence of subfecundity among young women in the early stage of marriage0 The proportion childless after five years of marriage drops from 24 percent for those marrying between 12 and 14 to 13 percent for those marrying between 17 and 19. Conversely, the mean number of births in the first five years of marriage rises from 1.2 to 106 as the age at marriage increases from 12-14 years to 18-19 years0 The frequency and duration of breastfeeding, a behavioral factor, affects the resumption of ovulation after delivery0 Nearly all women in Bangladesh breastfeed their children0 The mean length of breastfeeding is estimated to be 19 months (for women with at least two live births) in urban - 7 - areas, 17.5 months months in rural areas. There is little or no variation in the length of breastfeeding when observed by religion, birth order, age at marriage, husband's occupation, or mother's current age. Several studies examined the effect of nutrition on menarche, amenorrhoea, and children ever born (Chowdhury and others 1977, Mosley 1977). Chowdhury and others (1977), in examining the effect of nutrition on the onset of menarche for 1,155 girls aged 10-20, found an association between malnutrition and increased age at menarche. Body weiglht was found to be highly correlated with the age at menarche. A seasonal variation was also noted. Menarche peaked in the winter months, the period of the largest annual rice harvest. Mosley (1977) examined the effect of malnutrition on biological mechanisms directly related to fertility: reproductive life-span, postpartum amenorrhoea, fecundability, and pregnancy outcome. He conducted a cross- sectional survey of 2,048 breastfeeding women in rural Bangladesh in 1975 to explore factors affecting the duration of postpartum amenorrhoea. Information on menstrual status, infant supplementation, socioeconomic status, and anothropometric measurements was collected from lactating women with infants aged 13-21 months. The median length of amenorrhoea was observed to be more than eighteen months. There was a higher probability of being amenorrhoic for older women and for poorer women. Maternal malnutrition slightly extended the duration of amenorrhoea. The argument that high mortality is partly a cause of high fertility in Bangladesh is not consistently supported by the findings. Chowdhury and others (1976) found no support for the argument. But Chowdhury, Khan, and Chen (1978), using longitudinal data from a sample of women in Matlab Thana, reported a positive relation between the number of children ever born and the number of child deaths. Maloney and others (1980) tested the hypothesis that high infant mortality would result in the desire for a large number of children as replacement insurance. But the data failed to justify the motiva- tion for replacement, a subject deserving further study. Socioeconomic Correlates of Fertility The factors most often studied in relation to Bangladesh fertility are region, employment, social class, family structure, migration status, rural-urban background, occupation, and family income. Other factors considered include purdah, religion, lactation, landownership, infant mortality, the status of women, and such broader phenomena as rural development and modernity. Some of the findings on the socioeconomic differences in fertility are reviewed here (see table 2) and areas not yet explored are indicated. Most studies find little difference between rural and urban fertility. Controlling for the duration of marriage, Ahmed (1979) found that urban fertility is higher than rural. Better medical facilities, better hous- ing and sanitation, and better health and nutrition in urban areas were the explanations given for the higher urban fertility. - 8 - Table 2 Summa7y of Results Empirical Evidence on the Effect of Selected Socioeconomic Factors on Fertility in Bangladesh Selected Direction of characteristics relationship Studies Age at marriage Negative Duza 1964, Afzal 1967, Khan and Bean 1967, Maloney and others 1980 Positive Stoeckel and Choudhury 1969, Haque 1966 Farming and related Positive Chowdhury and Aziz 1974, occupation Ahmed and Mallick 1978, Maloney and others 1980 White collar Negative BFS 1975-76, Ahmed and occupation Mallick 1978, Chowdhury and Aziz 1974 Income Positive Samad and others 1974, Maloney and others 1980, Stoeckel and Chowdhury 1979 Socioeconomic class Inverse U-shape Chowdhury 1977 Positive BFS 1975-76 Cain 1977 Negative Stoeckel and Chowdhury 1969, Khan 1977, Maloney and others 1980 Landholding Positive Samad and others 1974, BFS 1975-76, Akbar and Halim 1978, Arthur and McNicoll 1978, Stoeckel and Chowdhury 1979, Alam and others 1980, Chen and others 1980, Maloney and others 1980 Mixed Latif and Chovzdhury 1977 - 9 - Table 2 (continued) Summary of Results Selected Direction of characteristics relationship Studies Negative Stoeckel and Chowdhury 1969 No relationship Cain and Baastiens 1976 Education Negative Amin and Faruqee 1980, Chowdhury 1977, Khan 1977 Positive Blacker 1975, Maloney and others 1980 Inverse U-shape Chowdhury 1977 Muslim religion Positive Obaidullah 1966, Chowdhury 1971, Samad and others 1974, Chowdhury 1975, BFS 1975-76, Maloney and others 1980, Blacker 1975, Stoeckel and Chowdhury 1969 Observance of purdah Positive Maloney and others 1980 Urban residence Positive Ahmed 1979 No relationship Amin and Faruqee 1980 Family type: Nuclear Positive Stoeckel and Chowdhury 1969 Joint Negative Samad and others 1974 Working status Negative Ahmed 1979 Little or no Chowdhury 1978 relationship Mixed Chowdhury 1974 Infant and child death Positive Chowdhury, Khan and Chen 1978 Negative Chowdhury and others 1976 - 10 - Table 2 (continued) Summary of Results Selected Direction of characteristics relationship Studies Infant and child mortality No relationship Chowdhury and others 1976, as a replacement factor Maloney and others 1980 Swanirvar program Negative Cited in Government of Bangladesh 1976 Membership in Co-operative Negative Stoeckel and Chowdhury 1969 Society Membership in Rural Negative External Evaluation Unit of Mothers' Club Planning Commission 1976 Concentrated development Negative External Evaluation Unit of activities (activities Planning Commission, 1979 by the Ministries of Health and Population Control, Education, Agriculture, Social Welfare, LGRD, etc.) Postpartum amenorrhea Negative Chen and others 1974 BFS 1975-76 Family Planning Practice Negative Stoeckel and Chowdhury 1973 Phillips and others 1981 - 11 - Fertility estimates for Bangladesh by region are scarce, and the few attempts to determine different fertility showed no pattern. Using unadjusted 1974 census data, Chen and Chaudhury (1975) found no significant difference in fertility (measured by child-women ratios) by districts. Further investiga- tion of the estimates of those ratios for four divisions (Dacca, Khulna, Chittagong, and Rajshashi) revealed some variation. According to 1974 census data, Chittagong has the lowest child-woman ratio, Rajshahi the highest. The National Research Council (1981)--having analyzed 1974 BRSFM and 1974 census data of average parity by age and geographic region--found differences by division and the ranks consistent, but the parity levels recorded by BRSFM and by the census are not very consistent. Their analysis confirms Chen and Chaudhury's findings (1975) that fertility is highest in Rajshahi, closely followed by Khulna; it is somewhat lower in Dacca, and lowest in Chittagong. Chaudhury (1977), in analyzing data from the Bangladesh Retrospective Survey of Fertility and Mortality (BRSFM), showed a real difference in fer- tility between districts in the Chittagong Division. Similarly, Samad (1976) reported differences in growth rates from his study of four rural thanas. Neither Chowdhury nor Samad explained variations in fertility by division, district, and thana; investigations of regional factors associated with the variation in fertility would be useful. A study by Khan and others (1977) on migration and fertility found that fertility is higher among the natives than among the rural migrants to Chittagong City. This is the only major study on the relations between fertility and migration, and further studies are needed to confirm this difference. Most studies on the differences in fertility by social class have shown that fertility is comparatively lower at the high and low ends of social scale than at the middle. Data from the BRSFM showed that the richest and the poorest segments of the sample population have lower fertility than the middle and lower-middle class (Choudhury 1977). Maloney and others (1980) found similar evidence that the rural poor are less fertile than the rural middle class. But Stoeckel and Choudhury (1969) give opposing evidence on fertility by social class: with data drawn from fifteen villages in Comilla Kotwali Thana, they found that fertility is higher in low-status groups than In high- status groups. Several studies have found positive correlations between fertility and the size of landholding (Arthur and McNicoll 1978, Chen and others 1976, Akbar and Halim 1977, Samad and others 1974). Other results show mixed evidence. For example Latif and Chowdhury (1977) found that the relation was positive for a northern village (Thakurgaon in Dinajpur), but insignificant for a southern village (Mithakhali in Barisal). And in the Comilla Kotwali thana, the size of landholding was found to be negatively related to fertility (Stoeckel and Choudhury 1969). But in another study conducted ten years later, a positive relation was found (Stoeckel and Chowdhury 1979). The most recent study (Alam and others 1980) indicates that the relation is positive. Because of the conflicting findings, the ability to generalize is limited, and further empirical work is needed to resolve the conflicts. - 12 - The effect of occupational differences on fertility in Bangladesh is another frequent subject of investigation. According to the Bangladesh Fertility Survey (1978)9 women whose husbands are in white-collar occupations tend to have lower-than-average fertility0 Ahmed and Mallick (1978)D using data from four villages in rural thanas of Chittagong district, reported the highest fertility for the wives of the farmers and laborers and lower fer- tility for women whose husbands were in service-related occupations. Similar patterns were reported in the study of some villages of Matlab Thana (Chowdhury and Aziz 1974). The linited data on income have hindered analysis of a large nuniber of empirical work on the relation between income and fertil- ity. Studies by Samad and others '1974) and Maloney and others (1980) show no consistent relation between fertility and incomeo In the latter case a posi- tive relation between the two variables was found. The value given to children, especially sons, has a significant bear- ing on fertility (Ahmed 1972, Repe:to 1972, Cain 1977a, Salahuddin, cited in Javillonar and others 1979). Sirageldin, using recent preliminary data, con- cluded that share-cropping is an important economic motive for some families to have several children. Families with many working-age male children have grounds to claim land for share-cripping. That fathers benefit from many children because they, and especially the sons, contribute to household pro- duction is strongly supported by data (Cain 1977a)0 Khuda (1977) and Rahman (1978) provide further data to support the hypothesis that parental dependency has its roots in the productive utility of children and the need for old-age support0 Fertility appears to differ by religion (Obaidullah 1966, Choudhury 1971, Samad and others 1974, Chowdhury 1977, Bangladesh Fertility Survey 1978, Maloney and others 1980)0 These studies show fertility to be higher for Muslims than for Hindus, not controlling for other variables0 Maloney and others (1980) also reports higher frequency of coitus for Muslims. An earlier study of fifteen villages of Comilla Kotwali thana reported similar findings (Stoeckel and Chowdhury 1969). An inverse (bivariate) relation between women's education and fertility is shown by the Bangladesh 1974 census report and the Bangladesh Fertility Survey0 The study by An'in and Faruqee (1980) confirms the negative effect of a couple's education on children ever born with no differences in the effect of the husband's and wife's education. The BRSFM data showed a different relation between fertility and education: women who have a primary education tend to bear more children than those who have no education0 Chowdhury (1977) reported an inverted U-shaped relation between fertility and education for both sexes in Chittegong Division0 Ahmed (1979), using the BFS data, shows that education has no effect on fertility. The fertility of work- ing mothers in urban and rural areas is found lower than that of nonworking mothers, and the inverse relation holds even after controlling for educational level0 - 13 - Determinants of Contraceptive Behavior Socioeconomic variables--such as religion, education, occupation, social class, and urban-rural background--are very important in explaining the knowledge and practice of contraception in Bangladesh villages (for example, Alauddin 1979, Mia 1978, Bangladesh Fertility Survey 1978 and National Institute of Research and Training 1981) (see table 3). A higher proportion of urban women than rural women have used or cur- rently use contraception (BFS 1978). Contraceptive patterns seem to correspond with the fertility patterns of different classes--women of higher social status have used contraceptive methods more than those of the lower status (Sorcar 1976). But other studies have found contrary patterns of con- traceptive use by social class. Khan and Choldin (1965), with data from five villages of Comilla, report that lower-class, landless laborers propor- tionately outnumber others in the use of family planning. Such conflicting evidence makes it impossible to discern the influence of social status on con- traception. Controlling for occupation, education, and landholding, Stoeckel and Choudhury (1973) found that occupational status alone is consistently related to the knowledge and practice of contraception: those in business and skilled occupations have used contraception in larger proportions than those in other occupational groups. In addition, women of higher income were shown to be more likely to be using or to have used contraception than those of low income (Bangladesh 1979); the positive relation between income and contracep- tion does not hold for sterilization (Ratcliffe and others 1968, Ali and others 1977, Bangladesh Association for Voluntary Sterilization 1978). The relation between education and contraceptive use in Bangladesh has been shown to be consistently positive (Alauddin 1979, Choudhury 1977 and 1980). The recently published BCPS report (NIPORT 1981) has found that only about a sixth of women (15.8 percent) have ever used an effective method of contraception. The survey finds that the proportion ever using increases steadily with age, up to age 35, and then declines. The ever-use rate is sig- nificantly higher among women with primary or more education than among women with no education. The pattern in the ever-use rate is similar for husband's educational level. The survey also finds that a larger proportion of the urban than rural residents has ever used any method. When religion is controlled for, the proportion ever using any method among Hindus is substantially higher than that for Muslims. The BCPS found a current-use rate of 11 percent by ever married women. The current-use rate also increases with age up to 35, then declines. The socioeconomic correlates of the current-use rate give a picture similar to that for ever use of contraceptives. A few studies examined the hypothesis that joint efforts in rural development and population planning programs--rather than population programs alone-- would be more effective in increasing contraceptive use and reducing fertility in Bangladesh (Alauddin 1979, Huda 1980, Bangladesh 1979, Mia - 14 - Table 3 Summsry of Results Empirical Evidence on the Effect of Selected Socioeconomic Factors on Knowledge and Use of Contraception in Bangladesh Selected Direction of characteristics relationship Studies Urban residence Positive Pakistan Population Planning Council 1974 , BFS 1975-76, Rahim 19799 NIPORT 1981D MIS 1981 in progress Social class Posit:ve Sorcar 1977 Inverse, Khan and Cholding 1965, specially with Ali and others 19779 sterilization Khan 1980 Occupation: Day laborers Posit-Lve with Ratcliffe and others 1968, vasectomy Ali and others 1977, BAVS 1978 Business and skilled Positive Stoeckel and Chowdhury 1973, work Sorcar 1976, 1977 Income PositLve External Evaluation Unit of Planning Commission 1979 Hindu religion Pos'ttve Stoeckel and Chowdhury 1973, BFS 1975-76 Purdah Negative Maloney and others 1980 Education Positive Alauddin 1979, Chowdhury 1977, 1978 No relationship Khan and Choldin 1965 Landholding Positive Stoeckel and Chowdhury 1973, Alauddin 1979 Trained workers Positive Quddus 1979, Phillips and others 1981 - 15 - Table 3 (continued) Summary of Results Selected Direction of characteristics relationship Studies Family type: Nuclear Robert and others 1964 Participation by Positive Sanders and others 1976 community leaders Involvement of local Positive Hamid and others 1976 influentials such as Swanirvar workers, Gram Sarkers Income-generating Positive Alauddin and Sorcar 1981a, activities 1981b Participation of Women in Positive Alauddin and Sorcar 1981b, Social Organization, such Planning Commission 1976, as Mothers' Club, MCH and Marum 1981 Nutrition Training group, Handicrafts Intensity of services and Positive Alauddin and Sorcar 1981b, frequency of contacts Quddus 1979, Alauddin 1979, Phillips and others 1981 Membership in Women's Positive Mia 1978, External Evaluation Cooperative Society Unit 1979 Membership (for males) Positive Schuman 1967 in Cooperative Society Access to means of Positive Alauddin 1979 Transportation - 16 - 1978) The evidence is inconclusivE, but it shows in general that the combined programs have the desired cLemographic effects. By adopting a pretest-posttest design for control and experimental groups in an evaluation of family planning programs in village development projects, Sanders and others (1976) reported higher rates of contraceptive acceptanceo The success in this case is attributed to the involvement of village leaders and the wider participation by villagers in planni-ng and implementing village health and family planning. A Critique Most of the studies looked at here used a local sample, often very small. Tne few national surveys of fertility and family planning produced some inconsis- tent results, because they used recall, for example, to collect information on previous pregnancies and birth. Few attempts have been made to produce con- sistent demographic estimates by using such techniques as the Chandra Shekar-Deming method0 The interrelation of demographic and economic condi- tions with subsequent reproductive behavior could not be satisfactorily studied because of the lack of longitudinal data0 Moreover, reliable data on many critical variables (such as income) have not been collected0 Few studies used a multivariate framework0 Although the simple cross-tabulations in these studies help, they do not provide a clear picture of the direct and indirect effects of policy variables on fertility0 For example, the preliminary results of the descriptive study on fertility determinants by the Bangladesh Institute of Development Studies (BIDS) show that postponement of marriage and a shift in the percentage of ever-married women were important in lowering fertility among some women0 But it cannot be determined from the analysis how much the age at marriage contributes to a decline in fertility, independent of female education0 Nor can the way that age at marriage is influenced by other factors be ascertained0 Some of these factors could be relevant for policy0 Generally speaking, the few multi- variate studies did not include many policy-relevant economic variables0 For example, the ways that access to services influence household behavior is rarely analyzed. Fertility levels continue to be high in Bangladesh; they are, how- ever, not uniform between regions end among geographical localities0 As to trends, a clear picture of fertility for the country is hard to draw0 The last census and a few surveys indicate (though inconclusively) a beginning of a slight reduction in fertility0 Some studies found small differences in fertility by socioeconomic characteristics; others, however, found almost no significant differences, except those caused by differences in marriage patterns0 Although we are still far off from a clear understanding of whether demand or supply factors determine changes in Bangladesh fertility, we have begun to have localized evidence fr7om Matlab that vigorous contraceptive ser- vice can initiate a fertility change in a poor rural traditional population0 Because an unmet demand for efficient contraception in rural areas of - 17 - Bangladesh, these areas can be served by an intensive field program (Phillips and others 1981). Greater understanding will perhaps come from analyzing the role of intermediate variables of fertility--such variables as fecundity, lactation, child mortality, and age at marriage. In addition, such other factors, as health, nutrition, and mortality could be suggested as possible explanations of fertility differences in Bangladesh. Conclusions Fertility in Bangladesh seems to be high for all socioeconomic groups. There is some evidence that the highest and lowest income groups have lower fertil- ity than the middle groups. This evidence is consistent with the hypothesis that the lower fertility for the higher socioeconomic groups is the result of fertility regulation, that for the lower groups the result of physical limita- tions on their fertility. This picture implies that socioeconomic development will raise the fertility of the lowest income groups. On the other hand, as more middle-income groups reach the highest level, their fertility will fall. The resulting fertility rate will therefore depend on the relative size and movement of these groups. Selective interventions in development lead to a more favorable fer- tility outcome than what will follow naturally from development. The results of some studies indicate thatVthe demand for children represents the demand for economic security. In this regard, land reform leading to a more equitable distribution of land and giving economic security to more people may reduce fertility. On the other hand, except for very large land owners, the land-owning class generally has a higher fertility rate than the landless. With a redistribution or land, the positive effect of land-owning on fertility may increase fertility. The question in that case is how to reinforce families feelings of security through land reform or other measures--and at the same time curb the forces that produce a positive effect of land reform on fertility. Access to the labor market and higher wage income may have a posi- tive effect because children, especially male children, may be considered a means to more wage income. In Bangladesh, children begin their economically useful lives very early. Rahman (1978) reports that more than 60 percent of boys and 93 percent of girls enter the household labor force by age 10, and almost every boy and every girl by age 12. This picture will change if there is compulsory primary education, or if there are openings of outside employment generated by rural industries, trade, and development projects. The status of women, which is low in Bangladesh, has significant bearing on fertility behavior. The few studies that have been carried out in Bangladesh on the subject suggest that decision-making power, participation in the formal setor, and education status are positively associated with the use of contraceptives and inversely related to fertility. Rural development - 18 - projects, if focused on women, will create employment and income for women, increase their acceptance of family planning, and eventually decrease their fertility. Education is not a strong determinant of fertility in Bangladesh. Although lower fertility is associa:ed with higher education after a threshold, the results do not suppo--t a policy of investing in more education to regulate fertility. The most important findings are that postpartum amenorrhoea seems to be a significant determinant of fertility and that socioeconomic forces influencing thLs variable will have a considerable effect on fertility. Postpartum amenorrhea depends on the frequency and duration of breast feeding, a behavioral factor. Nearly all mothers breastfeed their children in Bangladesh and the mean length of breast feeding (about 19 months) varies very little0 But there is some evidence that in Bangladesh older women and women of lower socioeconomic status have higher probability of being amenorrheic. In addition, maternal malnutrition extends amenorrhea slightly0 All these imply that wit'l socioeconomic development and improvement of levels of living amenorrhea will decrease in future, unless other effective means of fertility control are introduced and accepted0 Evidence on relations between infant mortality and fertility is ambigous. No statistically signifizant difference in birth intervals between women who had experienced at least Dne child death and those who had not0 This implies that at moderately hig'h fertility and mortality, there is no evidence that child deaths generate strong desire to replace children in Bangladesh0 But there is some convincing evidence of a positive relation between high fertility and high mortality, which work through biological rather than behavioral effects in raral Bangladesh0 With a reduction in infant mortality in the future, two effects are expected: fertility would be reduced, and survivorship, a central element of net reproduction, would be improved0 Age at marriage also is critical; so, programs that delay marriage will have an effect on fertility0 The results on family planning are much less ambiguous0 Substantial increases in contraceptive use are possible through extended services of better quality0 Trained workers produce better results than untrained workers (Quddus 1979; Phillips and others 1981). Access to services has led to more acceptance than lack of services0 Nothing earth-shaking, kuit several directions for family planning programs seem to be indidated by these results0 First, the integration of family planning activities with health services is desirable0 Needed even more is the integration of family planning with rural development activities, especially those that boost family incomeo The evidence is clear that concen- trated rural development programs for income generation (such as in Swanirvar) produce consistent use of contraceptives0 Second, an intensive program of in- formation, education, and communication is highly desirable because of the misinformation and ignorance still persisting about contraceptive use0 Third and most important, the supply side of the delivery system must be improved0 - 19 - Specific steps that some studies suggest in this regard include: o Extending family planning services (say, by adding such services in health centers where they are not available). o Adequate preparatory training and occasional refresher training of field workers. The lack of training of field workers seems to con- tribute partly to dropouts and inefficient management of side-effects and post adoption complications. O Gearing follow-up services to the efficient management of side- effects. o Improving the supervision of family planning workers. O Keeping and using records by the field-workers. The evidence is ambiguous or weak on the following questions, which future research should address: o Tiow does the recent fertility of some socioeconomic groups compare with their earlier fertility? o Do deteriorating economic and living conditions give fertility- raising forces an edge over fertility-depressing forces? If so, what are the mechanisms? o Is there emerging area or regional difference in fertility--a differ- ence that could be the results of differences in crops, wages, prices, land tenure, and flood conditions? What is the effect of these differences for households? For example, does the higher fertility of some regions (or some households) stem more from bio- logical mechanisms--such as shorter postpartum sterility, greater fecundity, or less fetal wastage--than from the demand for labor by larger farmers? o What is the relative contribution of demand factors and supply factors to low rate of family planning acceptance? Is the regional variation in family planning acceptance rates explained by the availability of services? O Is it possible, in the absence of a field experiment, to draw lessons from existing projects and program about family planning alone, about family planning combined with maternal-and-child-health services, and about family planning combined with income-generating programs? O What factors are associated with workers' performance? What kinds of training help most? o What is the relative efficacy and contribution of voluntary agencies and the government family planning programs to fertility regulation? -20 - o What is the demographic impact of specific development projects and programs evaluated longitudinally? O What socioeconomic factors explain--and what are the demographic effects of--the recent rise in the age at marriage and the duration of marriage? Rather than propose broad areas of investigation, program administrators and policymakers should come up with quelstions they would like to have answered. This would, to some extent, ensure the use of the research findings and im- prove the operational strategy of the program. Too many organizations and institutions-, at times without resea-ch capability, are doing population research in Bangladesh. Donor agencLes have in many instances encouraged segmented research in the agencies under their patronage. The result is duplication of research and waste of scarce resources. A central agency should be created to promote, coordinate, and regulate research0 Its function would be to point out to researchers and funding agencies whether the proposed study is an addition or duplication or is consistent with the research policy of the country0 PART If THE DETAILED FINDINGS - 22 - INTRODIJCTION A conceptual model of determinants of fertility and contraceptive behavior forms the basis of this survey and is outlined in figure Li0I The direct determinants of fertility are assumed to work primarily through biological factors, variations in exposure factors, and deliberate fertility control. The intermediate variables are influenced by household, cultural, and socio- economic characteristics. The direct determinants are, in turn, influenced by other variableso The socioeconomic factors related to fertility generally are residence, religion, edcuation, social class, and female labor force par- ticipation. These variables affect fertility through intermediate (direct) determinants: fertility norms and beliefs, attitudes to family planning, ex- posure variables, fertility control variables and biological variables. The conceptual framework shows the fertility control, or contraception variable, as an exogenous factor influencing fertility0 As indicated in the figure, socioeconomic variables affect fertility control0 The next section provides a snapshot of the right-hand side of the framework--fertility, its profile, trends, and differences0 Section 3 discusses evidence on direct determinants of fertility. Section 4 presents the evidence of the effects of the socioeconomic variables on fertility, in the form of household characteristics or community characteristics. Section 5 presents evidence on the levels, trends, and determinants of contraceptive behavior. Figure 1.1 Determinants of Fertility and Contraceptive Behavior: A Conceptual Framework for the Survey - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Exposure Factors COMMUNITY CHARACTERISTICS Age at Marriage Vital Fertility, Mortality, , Proportions Marrying Literacy, etc Duration of Marriage Cultural Religion, Beliefs and -- - - Fertility Norms L Frequency of Practices, Norms and and Belief Intercourse Pressures, etc . Infrastructural Roads and Transpor- tation, Development Programs, Urbaniza- tion and Urban Ser- -l vices, Health and EP , Services, Major Trades Knowledge and Fertility and Occupation, etc - - -- Attitude About - Control Factors Family Planning Contraception I Induced l__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ A b o rtio n . _ _ _ie l l ~~~~~~~~~~~~~~~~~~~~~~~~~~~F * BBiological l Factors HOUSEHOLD CHARACTERISTICS - Lactation Size, Income, Occupation, Education, Fecundity- Land Holdings, Participation of …( {Nutrition, Women and Children, Family Size Health), Norms, etc. Infant Mortality World Bank-24419 24 - 20 DEMOGRAPHEC PROFILES AND TRENDS 7ertility Crude Birth Rate There are three distince patterns in the crude birth rate (CBR) in Bangladesh (table 201)0 First, during the first half of the 1900s, the CBR was consistently around 50 per 1,OCO population. Second, it fluctuated between 57 and 55 during the early 1960Os Third, since the midhd1960s the CBR seems to have declined slightly -- to around 45 per 1DOOOD except in 1975 when a very high drop in the CBR was recorded by Cholero Research Laboratory (CRL). There had been bad harvests in 1972-73 and damaging floods and a famine in the summer of 19740 But the CRL data cannot be taken as representative of Bangladesh, despite the good quality of the longitudinal data. Recent data (collected in 1981) drawn from a large number of villages exposed to intensive development irterventions demonstrate a sharp drop in CBRs to around mid-30 (Alauddin anc Surcar 1981a, 1981b, 1981c; Mia and other 1981)0 These villages are not, however, claimed to be representative. Both the CDS and CRL data show that fertility was lowest in 1975 and then rebounded. Hong (1980) examired whether fertility in 1975 was affected by the famine in 1974 and whether it suggests a future trend. She decomposed percentage changes in the CBR into the contributions of age structure, marital structure and marital fertility for 1961-1974 and found that the CBR declined only 3 percent, from 52 per 1000 to 50.5 (table 2.2). The decline can be attributed mostly to the change in marital structure, especially in the 15-19 age group; the unfavorable changes in age structure reduced the contribution of changes in marital fertility0 Age-Specific Fertility Rate The age-specific fertility rates (ASFR) do not lead to any conclusion about declining fertility in Bangladesh0 In table 2.3 are five major data sets from national and regional surveys0 Compared with all other data sources for any year, the BFS data show the lowest marital fertility level for the 15-19 age group This might be because of changes in marital structure and in fertility levels among married women aged 15-19 (see table 2.4). - 25 - Table 2.1: Crude Birth Rate, Bangladesh, 1911-79 Mia & Census 1 PGE 2 NIS 3 CRL 4 BRSFM 5 BFS 6 CDS 7 BRAC 8 Others 1911 53.8 1921 52.9 1931 50.4 1941 52.7 1951 49.4 1962 57.0 1962-65 53.0 1963 55.0 1966-67 47.1 1967-68 42.0 45.4 1968-69 46.6 1969-70 45.3 1970-71 53.5 1971-72 44.5 1972-73 41.8 1973-74 45.6 1974 47.4 42.9 48.0 1975 29.4 46.9 37.7 1976 43.3 41.2 1977 46.4 64.1 1978 43.8 1979 32.6 1980 40.4 1981 35 Sources: 1. Bangladesh Bureau of Statistics (1978), p. 95. 2. Pakistan Institute of Development Economics (1968), vol. 1, p. 48; vol. II, p. 91. 3. Pakistan Population Council (1974), p. 102. 4. Curlin and others (1976), table 1; D'Souza and Khan (1980), p. 20. 5. Population Bureau and Census Commission (1979), p. 3. 6. World Bank (1979), p. 2. 7. Alam and others (1980), pp. 1, 11. 8. BRAC, 1980. 9. Mia and others (1981) forthcoming. - 26 - Table 2.2: Decomposition of the Percentage Change in the Crude Birth Rate, Bangladesh, 1961 and 1974 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total Age structure 18403 8306 75.9 10.8 0o5 802 09 173.4 Marital structure 226.4 43.7 1.7 12.8 15.6 13.4 3.3 226.8 Marital fertility 2.0 14.1 108.2 10.6 604 40.2 12.2 46.6 Total 44.2 25.8 185o8 8.7 75.5 45.3 7.9 10000 (The CBR declined 3 percent from 52.0 to 50.5) Source: Hong (1980) , po 21. The data on women and currently married women in 1961 are from the Pakistan Office of the Cen:sus Commissioner (1962)o The ASFRs for 1961 are from the PGE 1962-65. The data on women in 1974 are from Bangladesh Bureau of Statistics (1977), po 93. Marital Structture and ASFRs for 1974 from the BR3FMo Note: This technique decomposes a gross change in the CBR into the sum of age-specific components. One set of these components shows changes due to changes in age-spectfic birth rates; and a third set show changes due to change in marital status. See Retherford and Cho (1978) for details. This lecomposition is based on proportions of women currently married0 - 27 - Total Fertility Rate The total fertility rate, the average number of children born to a woman surviving through her reproductive years, probably averages 6.8 to 7.3 over the fifteen years before 1974 (NRC 1980). There is no firm evidence of any significant trend in fertility decline up to 1975, but the rising age at marriage may push fertility downward. According to table 2.5, fertility estimates for Bangladesh vary substantially with the method of data collection and analysis used to obtain them. Thus the exact fertility in Bangladesh could not be estimated because of the weakness of data. It can be concluded that no sustained trend (up or down) in fertility in Bangladesh is evident from the early 1960s to the mid-1970s. In most years the total fertility rate remained within the range of 6.8 to 7.3; the crude birth rate, between 47 and 51 per 1,000. The trend of sharp fertility declines indicated by fertility history surveys are mutually inconsistent and can be discounted. Other than the fertility downswings in response to national disasters or political upheavals, the data suggest that there has been no systematic decline in fertility in Bangladesh. Rural-urban Differences In contrast to developed countries, there is no marked rural-urban differences in fertility in Bangladesh either in the mean number of children ever born or in the completed family size. Major national-level surveys (NIS, 1969; BRSFM 1974, and BFS 1975) confirm such observations (see table 2.6). There has been no change in rural-urban differences over time. The mean number of children ever born to ever married women by their current age shows that except for the youngest (16-19), all rural women have had slightly higher fertility than urban women (table 2.7). But after standardizing the data by duration of marriage (table 2.8), the difference reverses: the mean parity becomes lower for the rural than for the urban women married for less than 20 years. The magnitude of this reversal is not great. There is no difference in fertility between rural and urban women married for 20 or more years. But urban younger women married for less than 20 years tend to have higher fertility than their rural sisters. The magni- tude of difference in fertility for urban women is still higher for those who have been married for 20 years. There are several explanations for higher fertility of younger urban women. First, they are likely to have no adolescent sterility or subfecundity as the rural ones do. Second, better health, nutrition, and medical facili- ties in urban areas might contribute to the higher fertility in urban areas. Rural migrants in urban centers are likely to enjoy better food and nutrition 28 - Table 2.3: Age-Specific Fertility Rates and Total Fertility Rates: National and Sub-national Surveys, 1953-1978 National Survey Sub-national Survey PGE 1 BRSFM2 BFS DSEP CDS5 BIDS6 1963 1964 1965 1974 1975 1953- 1957- 1961- 1975- 1977- 56 60 62 76 78 1978 ASFR 15-19 267.5 276.9 264.7 198.3 109.O 292 305 234 159.5 194.8 14841 20-24 373.8 355.1 346.6 337.3 288.6 372 301 337 274.4 277.8 262.0 25-29 373.8 343.8 364.4 310.9 291o1 337 250 280 272.4 285.7 275.4 30-34 308.3 219.8 249.2 261.5 1.50.2 246 206 258 184.6 227.0 256.6 35-39 167o2 158.7 123o6 197.0 :84.8 152 123 161 123.8 110.4 132.9 40-44 55.6 60.4 49.8 95.4 3.07.4 70 48 34 70.0 58o9 075.9 45-49 17.4 13.7 1541 13.5 34.7 - 17 18 064.5 TER 7o82 7414 7.07 7.07 6.34 7.25 6.25 6.61 5.42 5.77 6o08 Sources: 1 U.S. Bureau of Census pO 56; Chandrasekaran-Deming Formulao Using Longitudinal Registration data provides much lower ASFRs. 2. Population Bureau anid Census Commission po 4. 3. Schultz and Da Vanzo po 17 (for 1953-56, 15-44 years; for 1957- 69, 10-49 years). 4. Afzal, po 74. 5. Alam , et al. po 14. 6. BIDS Draft Report 1I81, po 57. - 29 - Table 2.4: Age-Specific Marital Fertility Rates and Total Marital Fertility Rates: Bangladesh, 1959-75 National Survey Sub-national Survey NIS 1 BFS 2 COMILLA 3 CRL 4 MATLAB 5 1960- 1964- 1966- 1967- 1975- 1958- 1963- 1964- 1966- 61 65 67 69 76 59 64 65 67 '74 '76 '75 ASFR 10-14 - - - - 19.5 193 135 131 141 158.6 139 71.4 15-19 255.1 258.7 238.6 265.2 168.2 283 280 301 248 281.2 277 260.5 20-24 351.6 356.0 309.4 355.2 319.6 333 299 298 279 335.8 378 357.0 25-29 348.2 331.2 265.3 280.4 316.1 300 268 267 242 336.7 302 312.8 30-34 248.3 243.1 215.5 245.2 275.9 253 242 245 199 269.8 283 261.8 35-39 183.3 154.7 142.8 161.7 219.2 219 149 157 267 183.8 143 199.2 40-44 67.9 63.5 47.5 49.8 136.3 198 73 82 62 68.0 50 102.7 45-49 10.4 10.6 8.1 6.3 48.9 - - - - 22.9 11 90.9 TMFR 7.50 7.09 6.14 6.82 7.42 7.93 6.56 6.75 6.78 8.28 7.92 7.92 a. Calculated by applying the 1966-68 rate for women 45-49 to earlier periods. Sources: 1. Pakistan Population Planning Council p. 107. 2. Calculations based on data from the Bangladesh Fertility Survey, Ministry of Health and Population Control. The rates are calculated by dividing the ASFRs by the proportions currently married found in p. 49 of the Report. 3. Stoeckel and Chowdhury, p. 14. 4. Ruzicka and Chowdhury, 1978a p. 10, 1978b p. 9. 5. Ruzicka and Chowdhury, 1978b. p. 9. - 30 - 'Cable 205: Total Fertility Rate, Bangladesh, 1955-61 to 1979 Year Rate Data sources 1955-61 6.03 Afzal (1967) 1958-59 7.51 Stoeckel and Choudhury (Comilla) 1960-62 7.58 Sirageldin, et al. (NIS) 1961 7.30 World Banks, 1979 1963 6478 U.S. Bureau of Census (PGE) 7082 East Pakistan Family Planning Board 1963-64 6.23 Stoeckel and Shoudhury 1963-65 7.02 Sirageldin, et al. 1963-65 6.30 PGE 7.40* 1964 6016 U.S. Bureau of Census 1964-65 6.40 Stoeckel and Choudhury 6.50 U.S. Bureau of Census 1965 5.79 U.S. Bureau of Census 1966-67 5.54 Stoeckel and Choudhury 1966-68 5.84 Sirageldin, et al. 1967-69 6.28 Sirageldin, et al. 1974 7.00 World Bank 1974 4o80 BRSFM 7.20** 1975 7.42 BFS 5090*** 1976 6.08 1978 6.24 Hossain, et al. 1979 4.94 Bangladesh Rural Advancement Committee 6.19 BCPS * Adjusted for missed events. ** Adjusted for life-time fertility. *** Marital fertility rates. - 31 - Table 2.6: Children Ever Born, by Age and By Rural and Urban Residence, 1968-69 and 1975-76 NSI, 1968-69 BFS, 1975-76 Age group Rural Urban Rural IJrban 10 - 14 .03 .00 .08 .18 15 - 19 .909 1.00 .89 1.01 20 - 24 2.52 2.59 2.53 2.49 25 - 29 4.28 4.18 4.37 4.12 30 - 34 5.60 6.02 5.91 5.70 35 - 39 6.40 6.57 6.83 7.35 40 - 44 6.47 7.80 7.60 7.40 45 - 49 6.57 7.47 7.20 7.20 All ages 4.01 4.31 3.96 3.88 Sources: National Impact Survey, 1968; World Fertility Survey for Bangladesh, 1975. - 32 - Table 2.7: Mean Number of Childran Ever Born to Ever Married Women Aged 10-49 , By Current Age and Rural-Urban Residenze: BFS, 1976 Rural Urban Current age (N=5,024) (N=1,489) 10-19 0.62 Oo78 20-29 3.13 2.91 30-39 6.05 5.85 40-49 6.94 6.74 Observed mean 3.96 3.86 Standardized mean* 3.96 3o82 Source: Ahmed (1979). * The standard population is the deighted BFS national sample of ever married women aged 10-49. The aeights were 0.347 for urban residence and 1194 for rural residence. - 33 - Table 2.8: Mean Number of Children Ever Born to Ever Married Women Aged 10-49, By Duration of Marriage and Rural-Urban Residence: BFS, 1976 Rural Urban Years of marriage (N=5,024) (N=1,489) 10 1.11 1.47 10-19 4.07 4.31 20+ 6.84 6.84 Observed mean 3.96 3.86 Standardized mean* 3.93 4.14 Source: Ahmen (1970a). * The standard population is the weighted BFS sample of ever married women aged 10-49 by duration of marriage. - 34 - than their place of origin; this mipht weaken the fertility depressant factors of adolescent sterility, subfecundity, and lactational amenorrhea among the migrants. Third, the pattern of breast-feeding and lactation could also con- tribute to higher urban fertility. There is empirical evidence that the mean length of breast-feeding is lower for urban women than for rural women (BFS, 1978)o This, as well as their better nutritional status may shorten the dura- tion of lactational amenorrhea for urban women. There Is a contradiction, however. The current use rates of contraception among the urban women are about three times greater for all ages and for all family sizes than the rural women, yet the fertility is higher among the urban women0 Does this mean family planning has no effect on fertility? Or, do only the high parity couples use family planning methods? The age and parity of contraceptive users are in the expected direc- tion0 Older women use contraception to prevent additional births for they have already achieved large family0 The younger women use contraception to keep their family size small; the demographic contribution of contraception by the latter group is far more greater than the former0 It is also expected that the younger cohorts will have nore progressive attitudes to family size limitation than the older cohorts of women0 While there is a need and scope for a much higher contraceptive prevalence in the urban areas, the question nevertheless remains about why the rural contraceptive prevalence is so much lower than urban even though the level of fertility is not markedly different0 It merits examination if dif- ferent access to family planning inForration and services along with socio- economic variables contribute to higher contraceptive practice in the urban than in the rural area0 It also merits examination if there is a different level of contraceptive need between rural and urban women, given the variation in their biological factors, such a.3 fecundity, lactational amenorrhea, and ovulation0 Regional Differences Fertility and mortality estimates for Bangladesh by region are very scarce0 Using unadjusted 1974 censas cata, Chen and Chaudhury (1975) tried to determine differential fertility by examining modified child-women ratios (children under five divided by the female population aged ten and above) according to districts0 The modified ratios ranged from 0051 to 059, but without any clear pattern0 Rabbani and others (1979) also estimated the ratio (unmodified for the four divisions of Bangladesh) by rural and urban areas (table 2.9). There are variations in the ratios by division--Chittagong has the lowest, Rajshahi the highest, according to 1974 census data0 The ratio is higher in rural areas than urban areas, but the urban ratio drops markedly from 854 in 1961 to 756 in 1974. Chowdhury (1977), however, reported differences in fertility in Chittagong Division0 Using the BRSFM data he reported that the average number of children ever born to women aged 14-45 is highest in Noakhali district, - 35 - Table 2.9 Children-Women Ratios, by Division and by Rural-Urban Area, 1961-1974 All areas Rural Urban Division 1961 1974 191 1974 1961 1974 Dacca 870 843 870 855 866 759 Chittagong 830 822 830 826 830 769 Khulna 891 859 893 868 824 748 Rajshahi 887 885 887 893 880 731 Bangladesh 867 851 868 859 854 756 Source: Rabbani and others (1979). -~ 36 - Table 2010 Mean Number of Children Ever Born to the Women Aged 15-45 of Chittagong T)iv:sion by District District Children ever born Sylhet 3.68 Comilla 3.69 Noakhali 3.98 Chittagong 3.95 Chittagong Hill Tracts 3.41 Source: Chowdhury (1977). - 37 - closely followed by Chittagong, and lowest in the Chittagong Hill tracts (table 2.10). The lower fertility in the Chittagong Hill Tracts might be associated with the sociocultural characteristics and ethnic background of the population of the district. Most of the people there are of tribal origin and of Buddhist faith. Similarly Samad (1976) found differences in growth rates from his study of four rural thanas: Sherpur had the highest growth rate (3.3 percent), Gopalpur the lowest (2.2 percent (table 2.11). Three of the thanas have higher growth rates than the rational average, estimated to be 2.5 percent by the Planning Commission. Chowdhury (1977), Samad (2976), and Rabbani and others (1979) did not explain the variations they found in fertility--by division, by district, and by thana, respectively. Mere knowledge of the existence of regional differences in fertility does not have much value for policymaking. The policy-relevant question is: What factors--singly or jointly in some combination explain the differences in fertility? Agriculture development? Education? Urbanization? Health and family planning efforts and services? Or what? With the increased use of irrigation and chemical fertilizers in the past decade, high-yielding, fertilizer-responsive rice varieties have been re- placing traditional varieties, particularly in the districts along the western borders: Dinajpur, Rajshahi, Kishtia, and Jessore. These areas recorded relatively high growth rates in the 1961-74 intercensal period (Arthur and McNicoll, 1978). Future studies should try to link differences in population growth in these areas to new activities in agriculture. MORTALITY Crude Death Rate (CDR) In the past three or four decades, death rates have been halved from above 40 per 1,000 to about 20 in Bangladesh. Recent data indicate a drop in death rates to between 10-15 per 1,000 in some regions of the country. Various factors have contributed to this decline: better transport and communication systems for government relief during famines, improvements in - 38 - Table 2.11: Growth Rate of Four Bangladesh Thanas, 1976 Thana Growth rate (percent) Sherpur, Bogra 3.3 Jhikaragacha, Jessore 2.7 Rangunia, Chittagong 2.7 Gopalpur, Tangail 2.2 Source: Samad (1976). - 39 - public health, treatment of epidemic diseases, and reduced virulence of some diseases. Among the causes of death, the most important declines have prob- ably been in the incidence of smallpox, cholera, and malaria - the first now eliminated, the others substantially controlled. Despite these improvements, mortality for the country is still high by contemporary standards among devel- oping countries. The planning commission estimates the CDR at 17 per 1,000 in 1973. Other estimates of the CDR are shown in table 2.12. The CRL data reveals a possible trend, reinforced by the complemen- tarity between the CRL and CDS data. The BRAC data is also similar to the CRL and CDS data. Although the national data do not match well with the CRL data or with CDS data for 1975, it is reasonable to assume that the CDR of 19 for Bangladesh in the mid-1970s might be higher than it would have been without the 1974 famine and that the current national CDR is less than 19 per 1,000 a conclusion supported by other subregional data. Infant Mortality Rate A decline of the infant mortality rate (IMR) has been reported in several studies (Stoeckel and and Choudhury, 1973; Schultz, 1970; Sirageluddin and others 1975b). According to the DSEP, the PGE, and Matlab data, the IMR ranged between 150-176 from the early 1950s to the mid-1960s. But the NIS data show a much lower IMR than either the Matlab or PGE data for similar time periods. The reason might be that the NIS data was only for currently married women, not that child deaths were underenumerated by the NIS. In general the CRL, CDS, and BRAC data show a slightly lower infant mortality than that estimated for the whole country. The impact of natural diseasters and political events on the IMR, as with the CDR, is clearer in the CRTL longitudinal data: the IMR rose from 129 in 1973 to 192 in 1975. The BFS estimate of the IMR also reflects the impact of famine (table 2.13). Sex Differences Evidence is conclusive that in one rural area of Bangladesh, female mortality is higher than male mortality from shortly after birth through the childbearing ages (D'Souza and Chen 1980). Male mortality exceeds female mor- tality in the neonatal period, but this difference is reversed in the postnatal period. The most marked differences are for children aged 1-4, for whom female mortality exceeds male mortality by 50 percent. According to a World Bank review, the shorter life expectancy in Bangladesh is typical of South Asia, including India. Chen and others (1981) examined the behavioral antecedents of higher female than male mortality shortly after birth through childbearing ages in Matlab thana, a rural area of Bangladesh. They postulated that the low life expectancy for female children reflects male-biased health and nutrition- related behavior. They found malnutrition to be substantially higher among - 40 - Table 2.12: Crude Birth Rates: Bangladesh, 1911-81 Census 1 PGE 2 CRL 3 BRSFM L BFS 5 CDS 6 BRAC 7 Mia and others 1921 47.3 1931 41.7 1941 37.8 1951 40.7 1961 29.7 1962 20.0 1962-65 20.0 1963 19.0 1966-67 15.0 1967-68 16.6 1968-69 1500 1966-70 14.9 1970-71 14.8 1971-72 21.4 1972-73 16.2 1973-74 14.2 1974 19.4 16.5 19.8 1975 20.8 19o0 24.0 1976 14.8 19.4 1977 13.6 14.7 1978 13.7 1979 11.24 /a 14.60 7- 1981 10 /a For Chior. 7TW For Manikganj Sources: 10 Bangladesh Bureau of Sta:istics, 1978, po 95. 2. Pakistan Institute of Development Economics, Vol. 1, p0 84; Vol0 II, po 91o 3. For 1966/67-1973/74, Curlin, et al., Table-1; for 1974-779 D'Souza and Khan, po 20. 4. Population Bureau and Census Commission, po 5. 5. Ministry of Health and Population Control0 6. Alam and others, pp. 1, LI. 7o BRAC, po 17. 8. Mia and others (in progress)0 - 41 - Table 2.13: Infant Mortality Rates : Bangladesh, 1952-81 Mosehuddin DSEP1 COMILLA2 NIS3 PGE4 CRL5 BRSFM6 BFS7 CDS8 BRAC9 & others'0 1952 173 1953 172 1954 167 1955 156 1956 156 1957 158 1958 150 1958-59 176 1959 155 1960 156 1961 140.4 1961-62 150 153.3a 1962 124.9 128.3b 1963 126.0 1963-64 148 1964 118.9 1964-65 156 176a 19 19.4 131b 1965 120.6 1966 121.0 1966-67 139 110.7 1967 116.6 1967-68 125.4 1968-69 123.8 1969-70 127.5 1970-71 131.3 1971-72 146.6 1972-73 127.5 1973 129.0 1974 137.9 153 1975 191.8 150 139.7 1976 102.9 121.0 1977 113.7 104.4 1978 115.2 1979 122 1981 122 a. males b. females Source: 1. National Research Council, p. 59; Obaidullah, part 2, chapter 2. 2. Stoeckel and Chowdhury, p. 24. 3. Pakistan Population Planning Council, p. 130. 4. National Research Council, p. 57. 5. Curlin, et al., Table 4. 6. Population Bureau and Census Commission, p. 5. 7. World Fertility Survey, p. 9. 8. Alam, et al., p. 11. 9. BRAC, p. 17. 10. Moslehuddin et al, p. 3. - 42 - female children than among male children0 In-depth dietary surveys showed males consuming more calories and proteins than females at all ages, even when nutrient requirements due to varying body weight, pregnancy, lactation, and activity are considered. While infection rates are similar for the sexes, the use of health services at free treatment clinics showed a marked male preference0 Socioeconomic Differences Using data from the Matlab area, a few studies have focused on mortality differences by socioeconomic statuso D'Souza and ot'hers (1980) examined socioeconomic differences in mortality; Chowdhury and Aziz (1974) correlated occupation with morta]il:y differences; Becker (1978) studied the relation between the season of deai:h and socioeconomic status0 Since independence in 1971, Bangladesh has had two severe crises: one the war of liberation, the other the 1974 famineo Death rates were higher in these periods, particularly among poorer groups (Chen and Choudhury 1977). The crude death rate among lardless families was three times that of families with three or more acres of land (McCord 1976 and 1980). D'Souza and others (1980) showed a clear inverse relation between mortality and socioeconomic status in Matlab, an inverse relation that per- sists for all the age groups consLiered: 1-4, 5=14, 15-44, and 45+ years0 The parameters used to assess sociDeconomic status--years of education of the head of household and others in the household, occupation, area of dwelling, ownership of cows--all demonstrated higher mortality rate for che lower social classes0 The findings confirm the results of the 1974 BFS and the 1974 BRSF with mortality differences by socioeconomic status0 Using the BFS data in a multivariate analysis, Mitra (1979) has also shown an inverse relation between child mortality and socioeconomic characteristics--parents' education, father's occupation, and economic status0 Child mortality also differs by socioeconomic status0 The BRSFM (IJK 1977) and BFS data (Huda 1980) show that in all age groups the higher the education of the wife or husband, the lower the child mortality0 The differences are much greater by women's education0 Using the CDS data, Alam and others (1980) show differences in infant and child mortality by size of landholdings (table 2.14). Infant and child death rates declined between 1975-1976 and 1977-1978 for all landowner - 43 - Table 2.14: Infant and Child Mortality Rates and Fetal Death Ratio for Different Landholding Groups: Companiganj, Bangladesh Land per family Infant mortality Child mortality Fetal death (acre) rates (a) rates (b) ratios 1975-76 1977-78 1975-76 1977-78 1975-78 None 156.1 142.2 80.9 23.4 132.0 0.01-1.00 114.9 98.6 48.9 17.4 149.8 1.01-3.00 117.9 80.2 31.0 19.7 137.6 3.01 + 140.0 125.0 23.3 9.7 171.6 (a) Infant mortality rates (less than a year) per 1,000 live births. (b) Child mortality rates (1-4 year) per 1,000 population. Source: Alam and others (1980), pp. 8 and 18. 44 groups. The landless have substantially higher infant and child mortality rates; but the IMR among the rural rich also is exceptionally high. An earlier enquiry (Huffman 1976) based solely on infant mortality data in the Matlab area did not show significant differences by socioeconomic classes. It is argued that because infants are breastfed in all social classes, socio- economic differences might play a smaller role in infant mortality. But her arguments are not tenable on the grounds that the lower class people cannot use modern treatment facilities and have less access to preventive medicine. Hence infant mortality is expected to be higher in this group, an assumption supported by most studies in this area. According to the CDS data, fetal death ratios do not vary by a family's land ownership; in fact they are slightly higher for families with larger landholdings. The families with the largest landholdings have the highest fetal wastage -- a fact related to their higher fertility. The BRSFM data show that Ln all age groups urban residents have lower child death rates than rural residents0 Children of women who live in brick houses had higher chance of survival than children whose mothers live in mud houses. According to the BFS data the urban-rural difference in child mortality disappears when the mother's education and the father's occupation are controlled. Infant and child mortality go down as the education of both the husband and wife increase. In other studies child mortality has declined as maternal literacy increase (S½loan 1971). The child mortality differences by religion are small and not consistent by age group. Kabir (1977) reported a higher IMR for rural areas than Eor urban areas, although the difference is small. Males have a higher death rate than females0 Neonatal mortality accounts for nearly half the infan: deaths0 Huda (1980) used the BFS data. to examine differences in aggregate child mortality by community variables0 The variables are transport, educa- tion, urbanization, agricultural m3dernization, and medical and health facilities0 Communities with greater agricultural modernization, better access to medical and health facilities, and superior transport facilities have lower child mortality0 MIGRATION Migration, the movement of people from one place to another, is of great social and demographic significance, but it has not been researched much in Bangladesh. In this survey, we could identify only six studies on migration0 Khan (1974) estimated net migration for Bangladesh fcr 1901-61 by using data on birth place, age distribution of the population, displaced persons, and religion. According to his estimates Bangladesh was losing population through net emigration, except during 1901-11, when Bangladesh gained 1,740,000 persons through net immigration0 The net emigration was 1,060,000 in 1901-1921, around 6,000,000 in 1921-31 and 1931-41, 19 million in 1941-51, and 1l1 million in 1951-6L. - 45 - The most important source of emigration from Bangladesh was the Hindu population. During 1901-1961 the Muslims in Bangladesh increased 114.8 per- cent, the Hindus decreased by 2.3 percent. The proportion of Hindus in the total population fell from 33.2 percent in 1901 to 22 percent in 1951 and to 18.5 percent in 1961. Net emigration from Bangladesh during 1941-51 and 1951-61 was important in holding down the rate of population growth. During 1941-51 net emigration was 1.9 million, the natural increase 3.3 million; during 1951-61, 11.5 percent of the natural increase of 9.9 million population was depleted through net emigration. No estimate of net emigration from Bangladesh is available since the 1961 census. But it is agreed that the net emigration since 1961 is about 1.5 million persons a decade, which reduces the recent rate of population growth 0.2 percentage points a year (Khan 1973). The question about place of birth on the census schedule enabled us to classify the enumerated population in two groups: lifetime migrants, or persons enumerated in a place different from the place of birth; nonmigrants, or persons enumerated in their place of birth (table 2.15). The percentage of lifetime migrants in the population (restricted to persons born in Bangladesh) increased from 2.31 in 1951 to 3.53 in 1961 and then stabilized at 3.44 percent in 1974. Data on the net internal migration for each district for the census years 1951, 1961, and 1974 show that of the nineteen districts in the country, ten recorded a net gain in 1974 (table 2.16). Dacca district shows the highest increase in the lifetime migrants and Comilla shows the greatest decline (table 2.17). Rangpur district had the highest increase in 1961, but it ranked sixth in in-migrants in 1974. Noakhali district ranked first among districts losing population both in 1951 and 1961, but was second in 1974 after Comilla district. Using 1961 and 1974 census data, Krishnan and Rowe (1978) studied interdistrict and interdivisional migration. Of the divisions, Rajshahi has received the most migrants, and Chittagong has lost the most (table 2.18). The net migration rate was 5.7 percent for Rajshahi division and -3.9 percent for Chittagong. The net flow is from east to west, and it would seem that women migrate more than men. - 46 - Table 2.15: Life-time Internal Migrants of Bangladesh, 1951-74 Lifetime Percentage of total Year Migrarts population 1951 950207 2.31 1961 1,711,1L03 3.53 1974 2,431,L,31 3044 Source: Data for 1951 and 1961 are from Census of Pakistan 19619 vol, 2, East Pakistan, table 8 ppo 11-:.16 to 1LI37; those for 1974 are from the 1974 Census, table 9. - 47 - Table 2.16: Lifetime Net Migrants by District, 1951-74 Net In-migrants District 1951 1961 1974 Dinajpur +20,470 + 75,381 +132,409 Rangpur +86,473 +141,655 + 62,029 Cogra + 647 - 11,577 - 16,488 Rajshahi +38,182 + 66,651 + 60,887 Pabna -37,500 - 70,615 - 99,166 Kushtia + 1,608 + 4,475 + 19,199 Jessore +20,385 +114,927 + 40,321 Khulna +37,666 + 74,042 +227,225 Bakerganj +10,964 - 51,140 - 14,478 Patuakhali n.a. n.a. n.a. Mymensingh -29,755 -122,739 -111,250 Tangail n.a. n.a. - 96,870 Dacca -57,402 + 50,846 +578,654 Faridpur -13,331 - 63,213 -253,777 Sylhet +58,492 + 96,813 +130,675 Comilla -76,933 -189,985 -358,045 Noakhali -95,045 -202,507 -261,226 Chittagong +20,608 + 50,513 + 90,849 Chittagong +14,471 + 36,473 + 52,592 Hill Tracts n.a. n.a. n.a. n.a. Not available. Source: Same as for table 2.15. - 48 - Table 2.17: Rank Order of Districts Gaining and Losing Populations 1974 Districts gaining Districts losing Rank population population 1 Dacca Comilla 2 Khulna Noakhali 3 Dlnajput Faridpur 4 Sylhet Patuakhali 5 Clhittagong liymensingh 6 Rangpur Pabna 7 Rajshahi Tangail 8 Chittagong Bogra Hill Tracts 9 Jessore Bakerganj 10 Kushtia - 49 - Table 2.18: Net Migration, Bangladesh, 1961-74 Net migration Rate (percentage of 1961 population Division (thousands) Total Male Female Rajshahi 671 +5.7 4.7 6.6 Khulna 41 + .4 -0.5 1.3 Dacca -187 -1.2 -0.6 -1.9 Chittagong -528 -3.9 -3.1 -6.1 Source: Computed by the authors from 1974 census data of Bangladesh, Bulletin 2, Census Publication No. 26, Census Commission Ministry of Home Affairs, Dacca, 1975. 50 - Table 2.19 presents the data on net migration by districts for 1961-74. As noted in the discussion of migration by division, the western districts are net receivers. Dacca and Chittagong districts, because they include two large cities, are also receivers. But all the other districts have lost more people than they gair.ed during the intercensal period. The sex difference in net migration might also be noted from the same table. The BIDS (1981), with data drawn from the regions of Bangladesh, estimated that 4.7 percent of the residents were absent from the household the night before the census0 The percentage of residents absent that night was highest in Companigonj (7.8 percent:, in Chittagong Division and lowest in Khetlal (2.6 percent) in Rajshahi Division. As expected, men were more mobile than women. Characteristics of interna: migration may be elicited from census data, but the determinants of migration are better tapped through surveys0 Two such studies for Bangladesh, by Stoeckel and others (1972a) and Chaudhury and Curlin (1975), examine the dynamics of rural out-migration from data col- lected on 4,040 out-migrants for 111 villages in Matlab Thana0 Stoeckel and others (1972a) focus their attention on selectivity, destination, and reasons underlying movement0 The following broad conclusions were derived by the authors: o Out-migration selects (a) the youthful part of the age structure, (b) males employed in the "servant," "mill and office," "business," and "self-employed " categories, and (c) members of the smallest and largest households0 o "Occupational opportunities" are said to be the cause of out- migration by most men; most women move out as dependents or as wives0 o Men move to urban areas in greater proportion than women but women move in greater proportion to rural areas0 The reasons for these differences are the urban selectivity of males for occupations nad the rural selectivity of females for marriage0 o Under the most conservative assumptions, the urban population of Bangladesh would have groun al: least 10 percent in 1969 from rural out-migration alone0 - 51 - Table 2.19: Net Interdistrict Migration, Bangladesh, 1961-74 Net migration Rate (percentage of 1961 population) District (thousands) Total Male Female Dinajpur 167 9.8 7.2 12.5 Rangpur 110 2.9 1.9 3.8 Gogra 18 1.1 0.4 1.4 Rajshahi 316 11.2 10.4 8.6 Pabna 61 3.1 3.5 2.7 Kushtia 245 21.0 19.3 22.9 Jessore 248 11.3 9.4 11.4 Khulna 115 4.7 3.7 5.7 Patuakhali -180 -15.1 -15.6 -14.2 Bakerganj -386 -12.5 -12.5 -12.5 M1ymensingh -410 -12.9 -12.4 -13.5 Tangail 447 8.8 11.1 6.2 Dacca - 13 - 0.9 - 0.3 - 1.5 Faridpur -211 - 3.8 - 5.0 - 2.5 Sylhet -148 - 4.2 - 4.8 - 3.6 Comitla -352 - 8.0 - 6.6 - 9.5 Noakhali -116 - 4.9 - 3.5 - 6.4 Chittagong 122 4.0 36.9 2.6 Chittagong Hill Tracts - 33 -8.5 -12.3 - 4.0 Source: Same as for table 2.18. - 52 Chaudhury and Curlin (1975) have extended their analysis from 1968-69 (reported by Stoeckel and others 1972a) to 1972-73 through all the intermedi- ary time points. The selectivity by age, sex, and education retains the pattern noted by Stoeckel and other. The authors have tried to highlight the implications of this highly selective mlgration on urban growth, on the delivery of social services in urban areas, and on regional development in Bangladesh. McCord and others (1980) found an association of our-migration with poverty and reported 15 percent net out-migration among the landless in 1975 and 1976. There was a significant s.hift in landownership: the proportion of the population with a family holding more than three acres of land rose from 17 percent to 21 percent between 1975 and 1978 in Companiganj. The 1971 war of liberation displaced, at least temporarily, a tenth of the population. Besides this, migration has been sporadic, with a large net exodus at the time of Partition in 1947; but on the average it has little impact on population growth. Migration and Fertility Khan (1977) found that desired and actual fertility are higher among the natives than the rural migrants to Chittagong city0 The desired family size and actual fertility for migrants are 3.79 and 4.0, those of urban natives, 4.78 and 4.96. The age at marriage for the migrants' wives is also higher than that of the urban natives; the average ages are 17o6 and 14 years, respectively0 This is the only stucly that looked at fertility in relation to migration0 Further studies are needed to confirm such differences0 SPATIAIL DISTRIBUTION Population by District Dacca has had the largest population in Bangladesh since 1974. Other than Dacca and Mymensingh, which havTe twice the average population per dis- trict, and the Chittagong Hill Tracts, which have less than the average population per district, population size differences among districts are not great0 There has been little change in the last 70 years in population dis- tribution by district0 Excluding the Chittagong Hill Tracts, the difference between the largest and the smallesi: districts was 4.5 times in 1901, and 501 times in 1974 (table 2.20). Population Density by District Dacca and Comilla have the highest density; the Chittagong Hill Tracts have the lowest0 Mymensingh has one of the largest populations, but it still has a low density0 Dacca has a population density more than twice the national average0 But all four districts (Dacca, Mymensingh, Tangail, - 53 - Table 2.20: Population Distribution by District: Bangladesh, 1901-74 (thousands) District 1901 1911 1921 1931 1941 1951 1961 1974 Dacca 2617 2929 3172 3449 4224 4073 5096 8293 Mymensingh 3922 4531 4842 5135 6030 4558 5532 8056 Tangail - - - - - - - Faridpur 1781 1958 2030 2163 2650 2710 3179 4322 Chittagong 1353 1508 1611 1797 2153 2309 2983 4647 Chittagong 125 154 173 213 247 288 383 541 Hill Tracts Noakhali 1143 1303 1473 1707 2217 2274 2383 3443 Comilla 2139 2455 2696 3056 38600 3792 4389 6195 Sylhet 2031 2241 2298 2466 2832 3059 3940 5067 Rajshahi 1902 2000 2028 1993 2198 2205 2811 4545 Rangpur 2202 2434 2555 2646 2924 2916 3796 5799 Dinajpur 1126 1168 1220 1236 1336 1355 1710 2737 Bogra 884 1017 1083 1122 1260 1278 1574 2375 Pabna 1418 1425 1385 1438 1696 1584 1959 2996 Khulna 1268 1380 1472 1629 1944 2076 2449 3843 Jessore 1647 1597 1590 1552 1695 1703 2190 3542 Kushtia 885 842 783 808 920 984 1166 2005 Barisal 2845 2613 2844 3194 3811 2636 2068 4183 Patuakhali - - - - - 1006 1194 1596 Bangladesh 28928 31555 Note: From 1901-1974 Patuakhali and Tangail were included under Bakerganj and Mymensingh district, respectively. Source: Bangladesh Bureau of Statistics (1979), p. 48. - 54 - Faridpur) that comprise the Dacca Dtvision have higher density figures than the national average. Tangail's growth has been particularly noticeable since 1961. The low density in the Chittagong Hill Tracts, Sylhet, and Khulna is partly explained by the hills and forests in these districts; the high density of Dacca, by its being the center o0: political, educational, and commercial activity (table 2.21). Urban-rural Differences Urban-rural differences by districts are significant. Dacca, the capital city, is the most urban district, with more than 30 percent urban in 1974. In contrast, Noakhali has only a 1.6 percent urban population. Although only 2.4 percent were urbar in 1901, 9 percent were by 1974 (table 2.22)0 The rural rate of population growth is much slower than the urban rate0 There has been a significant increase in the percentage of the urban population since 1921, and the urbarnization rate was particularly high between 1961-74 (table 2.23). Dacca, Chittagong, and Khulna are the most urban and most rapidly urbanizing districts0 Because these three districts comprised 217 percent of the total population by 1974, they will substatially affect urban population growth in Bangladesh0 The Bangladesh population under fifteen has constituted more than 45 percent of the total population since the 1960s. The proportion of population over sixty is very small0 The propcrtion of the older and younger age groups declined slightly between 1911 and 1941, after which this proportion in- creased0 Because the Bangladesh population is very young, rapid population growth is inevitable in the future0 Compared with the major regions of the world, Bangladesh has an unusally high dependency ratio0 That ratio fluctuated only a little between 1911 and 1951. By 1961 the dependency situation had grown worse, with the 1961 age structure showing the highest dependency ratio since 19110 Although the dependency ratio has since declined, the 1974 ratio still is very high: 97 percent0 Developed countries have dependency ratios of around 50 percent, other developing countries around 80 percent0 The survey data suggest an even gloomier picture than the census data0 Since the nineteenth century, sex ratios have systematically indi- cated that there are more men than women0 The higher mortality of females and the possibly higher underreporting of females are the main reasons for the high male sex ratio in the population (Rukunuddin 1967, Visaria 1963). - 55 - Table 2.21; Population Density by District: Bangladesh, 1901-74 Area in District sq. miles 1901 1911 1921 1931 1941 1951 1961 1974 including Dacca 2880 953 1069 1157 1258 1541 1492 1909 2879 Mymensingh 5064 630 727 777 824 968 917 1093 1590 Tangail 1309 - - - - - 943 1143 1690 Faridpur 2669 689 758 786 837 1026 1051 1311 1619 Chittagong 2786 527 587 637 699 838 902 1139 1668 Chittagong Hill Tracts 5089 25 31 35 43 49 57 75 106 Noakhali 2033 715 816 922 1068 1388 1424 1468 1694 Comilla 2592 845 970 1065 1208 1525 1500 1794 2390 Sylhet 4783 416 459 471 505 580 628 737 1059 Rajshahi 3653 523 550 558 548 604 608 788 1244 Rangpur 3701 595 658 601 715 790 792 1130 1567 Dinajpur 2609 444 461 481 587 527 544 659 1049 Bogra 1501 599 689 734 761 855 868 1075 1583 Pabna 1906 776 780 759 788 929 869 1157 1572 Khulna 4630 264 287 306 339 404 432 600 830 Jessore 2584 633 614 611 596 651 656 877 1371 Kushtia 1342 646 614 517 489 671 647 882 1494 Barisal 2792 615 647 704 791 943 1031 1176 1498 Patuakhali 1675 - - - - - 680 732 947 Bangladesh 55598 534 583 614 656 776 761 922 1374 Note: From 1901 to 1941 Patuakhali was included under Barisal District and Tangail was included under Mymensingh District. Source: Bangladesh Bureau of Statistics (1979), p. 57 - 56 - Table 2.22: Percentage of Urban Population by District: Bangladesh, 1901-74 District 1901 1911 1921 1931 1941 1951 1961 1974 Dacca 4.34 4066 8.05 8068 6.58 10O09 14.79 31.18 Mymensingh 2.68 2069 2.62 2.72 3.32 3.51 3.91 5.59 Tangail - - - - - 1.79 1.69 5.24 Faridpur 2.5 1q55 2.26 2.11 2.11 2.14 2.48 2.86 Chittagong 1.85 2.1S 2.45 3.22 4.55 11.78 12.50 21.88 Chittagong Hill Tracts - - 2.54 - - - 5.97 10.18 Noakhali 0.61 0.53 0.54 1.40 1.08 1.06 1.42 1.59 Comilla 2.32 2.35 2.33 2.41 3.24 3.09 3.17 4.24 Sylhet - - - 1.65 2.20 2.52 2.03 2.76 Rajshahi - 2.09 2.21 2.66 3.88 3.85 4.27 5.78 Dinajpur 0o83 0.88 [o05 1.08 2.18 5.68 4.21 4.42 Rangpur 1.35 1.50 1199 2.54 3.23 4.39 4.19 4.81 Bogra 0.13 1.32 1i52 1.74 2.14 2.82 2.98 3.70 Pabna 2.88 3007 3.23 3.73 4.34 4.36 5010 7.61 Khulna 191 2.12 2.21 2.15 3.39 2.84 7oO6 18.21 Jessore 1.16 1o19 -22 1o25 2q08 2.17 3o42 5.42 Kushtia 5.69 - - 6.68 - 4.52 5.40 8.32 Barisal 2.00 2.01 2.28 2.27 4.08 4.63 3.49 3.92 Patuakhali - - - - 0.99 1l00 2.52 Bangladesh 2.43 2.54 2.64 3.03 3.36 4.34 5.19 9.13 Total urban population (thousands) 702 807 878 1076 1537 1820 2641 6977 a. Included in Mymensingh District from 1091 to 1941. b. Before 1931 Sylhet was a part of undivided Assam in India and separate data on Sylhet were not kept. c. Adjusted figures0 Source: Bangladesh Bureau of Statistics (1978)9 po 82-1979 ppo 73 and 47. - 57 - Table 2.23: Population and Population Growth, by Residence, Bangladesh, 1901-74 Population (thousands) Intercensal growth rates (percent) Year Urban Rural Urban Rural 1901 702 28,226 1.39 0.86 1911 807 30,748 0.84 0.52 1921 878 32,376 2.03 0.90 1931 1,076 35,428 3.57 1.33 1941 1,537 40,460 1.69 -.09 1951 1,822 40,112 3.72 1.84 1961 2,641 48,200 3.66 2.32 1974 6,274 65,205 a. Unadjusted census statistics, due to the unavailability of adjusted sta- tistics by urban and rural. Source: Calculated by the authors from Bangladesh Bureau of Statistics, 1978, p. 82. - 58 - HOUSEHOLDS: G3ROWTH AND COMPOSITION The number of households increased 32 percent during 1960=73; the increase of urban households was five times higher than that of rural households. The share of rural households declined frorn 95 percent in 1960 to about 92 percent in 1973; that of urban households Increased from 5 percent to 8 percent (table 2.24). The rate of household increases did not keep pace with the population growth. The population increased about 41 percent during 1961-74, the number of households only 32 percent0 The UoN. definition of households is used in Bangladesh: "A collection of persons Living and eating in one mess with their dependents, relatives, servants, and lodgers who normally reside together." Table 2.25 shows the change in household composition between 1960 and 1973. Consistent statistics in the two time periods are the urban and rural differences: more couples with or without children and with or without parents are in rural than in urban areas0 In contrast, the one-person family is more prevalent in urban than in rural areas, as are households that include other relatives or nonrelatives0 This seems to suggest that most rural-to- urban migration is by individuals, not by families0 The average number of persons per household increased from 5.4 in 1961 to 5.9 in 1974. The rate of change in household size is the same for both rural and urban areas0 Higher life expectancy resulting from lower mortality may have contributed to this increase0 Urban areas had 02 more persons per household than rural areas in both periods0 This household size difference by residence may support the fact that rural-to-urban migrants may reside with relatives or nonrelatives. - 59 - Table 24: Growth of Households by Rural and Urban Areas, Bangladesh 1960-73 1960 1973 Percentage Area Number of Number of Change, households Percent households Percent 1960-73 Rural 9,132,057 95.09 11,610,230 91.59 27.13 Urban 470,795 4.90 1,065,353 8.40 126.28 Bangladesh 9,602,852 100.00 12,675,583 100.00 31.49 Source: Adapted from Rafiqul Huda Chaudhury (undated). "Families, Households and Housing Needs in Bangladesh." Dacca: BIDS. - 60 - Table 2.25: Distribution of Households by Family Composition and Average Household Size: Bangladesh, 1960 and 1973 Composition of 1960 1973 households Urban Rural Total Urban Rural Total One person only 9o1 4A3 4.6 5.5 2o8 3.0 Husband and wife only 4.8 5S1 500 7.9 805 8.5 Husband and wife with own children 28.9 3302 32.9 76.5 83.3 82.7 Husband and wife with or without children but with parents 22.5 30.7 30.3 2.5 4.1 4.0 Households comprising other relatives 20.1 19.8 19.8 4.5 1l0 1.3 Households comprising nonrelatives 12.9 7.0 7A3 3o2 .3 05 All households Percent 10000 10O0 10000 100l 0 10000 100oO Total number 471 99112 9,603 1,055 11,592 12,646 (thousands) Average household size 5.6 5.4 5.4 601 5.9 5.9 Sources: Bangladesh Bureau of Statistics, 1979, po 108; East Pakistan Bureau of Statistics, po 28. - 61 - DIRECT DETERMINANTS OF FERTILITY In this chapter we survey the evidence on direct determinants of fertility in studies using Bangladesh data, such as age of entering into sexual unions, proportion married, duration of marriage, and frequency of intercourse, as well as sterility, subfecundity, and lactational infecundability. Deliberate fertility control, such as contraception and abortion, are other important determinants of fertility. These determinants of fertility are called intermediate variables by Davis and Blake (1956) and proximate determinants by Bongaarts (1978). As our analytical model shows, the primary characteristics of these variables are their direct influence on fertility. Socioeconomic statusi cultural practices, fertility norms and beliefs, and environmental variables affect fertility indirectly through these determinants. This chapter is exclusively devoted to the survey of studies that have analyzed exposure and natural fertility rather than deliberate fertility control. The evidence of deliberate fertility control, its differences and determinants, are analyzed in section 4. Age at First Marriage Most men and women in Bangladesh marry. On the average men marry eight years later than women. Data from the population censuses of 1951, 1961, and 1974 show the proportions ever married by age and sex, together with singulate mean age at first marriage (table 3.1). 1/ The mean age at first marriage for males increased half a year during 1951-61 and a year during 1961-64. That for females declined slightly, from 14.4 yearss in 1951 to 13.9 in 1961, and then rose to 15.9 by 1974. Besides censuses, the data from two other nationwide demographic surveys - the BRSFM (IJ.K., 1977) and the BFS (1978) -- and other sample sur- veys with limited coverage support the evidence of rising trend in age at marriage for females. All the studies with smaller sample sizes reported a higher mean age at marriage than the nationally representative surveys and censuses, except the BRSFM. The CRL studies, which are generally based on better data, reported a mean age at marriage that is slightly higher than the present legal age -- 16 for girls. Reports on vital events, including age at marriage, were collected by specially appointed local registrars under close and well-organized supervision. Rapport with the population was promoted by the health activities of programs. 1/ Singulate mean age at marriage (SMAM) is calculated from proportions of those single in each age group recorded by a census. Neither a period nor a cohort measures, it should be interpreted with caution. - 62 - Table 301: Proportions Ever Married by Sex and Age Group, Bangaldesh, 1951, 1961, and 1974 Males Females Age group 1951 1961 1974 1951 1961 1973 10-14 o0207 o0223 o0068 o2631 o3261 .0952 15-19 .1611 o1224 o0766 o8870 o9771 o7552 20-24 o5373 o5029 o3994 o9698 o9866 o9676 25-29 o8491 .8270 o7752 o9885 o9948 o9913 30-34 o9448 o9472 o9483 o9953 o9958 o9944 35-39 o9738 o9739 .9783 o9976 o9976 o9957 40-44 o9805 oS895 .9850 o9976 o9985 o9955 45-49 o9872 SC918 .9890 o9979 o9989 .9967 Singulate mean age at marriage 22.4 22.9 2309 14A4 13.9 15.9 1/ Singulate mean age at marriage (SMAM) is calculated from proportions of those single in each age group recorded by a censuso Neither a period nor a cohort measures, it should be interpreted with cautiono - 63 - Table 3.2: Mean Age at Marriage, 1974-81 Mean age at marriage Year Data source Males Females Age difference 1974 BRSFM 1/ 24.9 16.5 8.4 CRL 2/ 24.6 17.0 7.6 1975 BFS 3/ 24.0 16.0 8.0 CRL 4/ 24.9 16.5 8.4 1976 CRL 5/ 24.4 16.7 7.7 1977 CRL 6/ 25.6 17.1 7.5 1978 Ahmed and Mallick 7/ n.a. 16.3 n.a. 1978 Cain 8/ n.a. 16.0 n.a. 1981 Alauddin and others 9/ n.a. 16.0 n.a. Source: 1. Bangladesh Bureau of statistics, 79, p. 92. 2. Ruzicka and Chowdhury, 1978d, p. 20. 3. Ministry of Health and Population Planning, p. 14. 4. Ruzicka and Chowdhury (1978c), p. 14. 5. Ruzicka and Chowdhury (1978d), p. 15. 6. Samad and others, p. 29. 7. Ahmed and Mallick (1978). 8. Cain, (1978). 9. Alauddin and others (1981c). - 64 Adjustments by marriage cohort and by current age further affirm that the mean age at marriage is steadily rising0 The mean age at m.arriage for women who married in 1947 was 11.4 years; by 1962 it had risen to 12.3 years and by 1972 14.3 years. The women marrying during 1975 and early 1976 were about 15 at the time of their marriage (BFS 1978). The median age at marriage for women aged 30 or more is about 12.5 but rises to 13.2, 13.5, and 1500 for those 25-29, 20-249 and 15-19o Education has a substantial effect on the age at marriage in Bangladesh. Green and others (1972) found the age at marriage to be signifi- cantly correlated with the woman's education. The BFS (1978) reported a positive association between education and age at first marriage. The mean age at marriage for women with no education was 12.8 years, with primary education 13.6 years, and with higher esducation 14o7 years. A similar association between education and age at marriage has been reported for other developing countries. A wife's rather than a husband's education appears to have a greater effect on marriage in Bangladesh0 Child residence is a stror.ger differentiating variable than current residences, due to regular rural-urban migration0 For the same educations, the urban age at marriage is higher thgn the rural age--for Muslims and non-Muslims (Shahidullah 1979)o Such differences may be due to greater oppor- tunities for work and education in urban areas0 A recent study of all married women in four villages in Chittagong district (Ahmed and Mallick 1978) reported mean ages at marriage from 15.07 to 17o41, or much higher than the nat:onal average reported in several studies0 One possible reason for this higher-than-average age at marriage for women in these villages is their literacy, which ranges from 39 to 61 percent--three to five times the national literacy rate for women0 The literacy rates for men in these villages are also higher ':han the national average0 Aziz (1978) reported a rif3ing age at first marriage in the Matlab area and noted, too, that rising l-teracy among younger women might be a con- tributing factor0 He corroborated this speculation with the findings of a study by Islam and others (1979)o They showed that 4o6 percent of the women 45 and over from the same area were literate, 16 percent of those 25-44, 30 percent of those 14-24, and 32 perzent at those 10-14. The data show that women are attending school in increaslng proportions and that this might have a bearing on the age at marriage0 The religious differences in the age at first marriage were not significant, though non-Muslims tend to have a slightly higher age at marriage in all age groups0 The difference may be due to the higher education of non- Muslimso Nor does occupation seem to make much difference in the age at first marriages but the tenant farmer's wives have the lowest average at marriageo Using CRL census data for Matlab thana, Aziz (1978) reported that the rising age of menarche seems to be an important fact in delaying marriage0 The median age of menarche was found to be 1508 for Muslims ard 16 for Hindus0 Only a few girls reached menarche by age 13, a fifth by age 14. - 65 - Delayed menarcheal age is mainly attributable to poor nutrition (Chowdhury and others 1977). Because the onset of menarche often triggers marriage, it is speculated that the apparent recent increase in the age at marriage reflects the delayed menarche of girls who experienced the food crisis of the early 1970s. Aziz (1978) further observed that due to economic hardship, the parents of boys have lost the traditional interest in marrying them to prepubertal daughter-in-law. Instead, they prefer a postpubertal daughter-in- law who can add to the labor pool for household activities. Aziz's observation seems to be in conflict with Amin's (1970) findings. He reported a slightly higher age at first marriage for higher socioeconomic status than for lower. An apparent paradox: economic stress and social opportunity in edu- cation seem to be affecting the age at marriage in Bangladesh. Education on the one hand, and the impoverished conditions of malnutrition leading to late menarche and the in-law's preference for a postpubertal daughter-in-law on the other, are reported to have association with rising age at marriage (Alauddin, 1980a). For policy recommendations, further research should try to identify what determines the age at first marriage. Proportion Married The proportion of currently married women aged 10-49 stayed between 80 and 87 percent during 1961-75, with little difference between rural and urban areas (table 3.3). The 1974 census registered a seven percentage point rise in the proportion of women currently married between 1961 and 1974. The decline from 87 percent in 1974 to 82 percent in 1975 is perhaps the result of the famine in 1974. According to the BFS (1978), nine of ten girls were married during their teens (Table 3.4). Only 5 percent of the women in age group 20-24 were not married, compared with 61 percent in Sri Lanka. Shahidullah (1979) estimated a very high index of proportion married for Bangladesh: so did Bongaarts (1978). In a crosscultural comparison, he found that the proportion of women was highest in Bangladesh. The proportions of women currently married, ever married, and never married show that almost all the women in Bangladesh are married by 25 (table 3.5). A desirable change in teen age marriage, is observed, however. Three of ten women aged 10-14 were never married in 1961, one of ten in 1974. Nine of ten women aged 15-19 were married in 1961, seven of ten in 1974. 66 - Table 3.3: Percentage of Women Currently Married Aged 10-49, Bangladiesh, 1961--75 Source Rural TJrban 1961 Census 80 79 1974 Census 87 86 1975 BFS 82 82 - 67 - Table 3.4: Percentage of Women Married, by Current Age, 1975 Age Percentage ever-married 12 7 13 14 14 25 15 47 16 60 17 76 18 85 19 90 20 93 Source: Bangladesh Fertility Survey, 1975. 68 - Table 3.5° Percentage Distribution of Women of Reproductive Age, by Marital Statusg ?angladesh, 1951-74 Age Never married Ever married Currently married 1951 1961 1974 951 1961 1974 1951 1961 1974 10-14 73.69 67.39 90.48 26o3 32.6 9.52 25o42 31.75 8.54 15-19 11.30 8.29 24.48 88.7 91.7 75.52 46.12 89.48 71.76 20-24 3.02 1.34 3.24 97.0 98.7 96.76 93.38 95o60 92.98 25-29 1015 0O52 0.87 09.9 99.5 99o13 92.12 94.75 95.20 30-34 0.24 024 043 99.8 99.8 99.57 79.32 84o66 89.85 40-44 0.24 0015 045 (9.8 99.8 99.5 66.01 71.55 81.38 45-49 0.21 0011 033 99.8 99.9 99.67 60.46 61.31 75.12 Total 17.2 12.5 24.6 8208 87.5 75.4 72.5 78.4 69.3 Women aged 10-49 2,050 19586 5,273 99882 114135 16D081 8D650 99969 14D863 (thousands) Source: Pakistan Office of the Census Commissioner, no date a, p. 4-2; no date e.p. 4-5; Bangladesh Bureau of Statistics, 1977. po 93 - 69 - There is a notable change in the proportion of never-married women aged 15-19. The proportion of never-married females at age 15-19 rose from 7 percent in 1961 to 26 in 1975 for rural area and from 27 percent in 1961 to 41 percent in 1975 for urban area (Shahidullah 1979). The BRSFM data show the proportion of never-married women in this age group to be 32 percent in 1973- 74 (Rabbani and others 1979). The rate of increase in the proportion of never-married rural women aged 15-19 was five times faster than that of never- married urban women in the same age group. Even so, the proportion of ever- married women aged 15-19 in Bangladesh is the highest in the subcontinent and ten times higher than that in Sri Lanka. This reduction in the proportion of ever-married women at younger ages is largely offset by the almost universal marriage of women by age 25. Such changes in marital status, as pointed out by Hong (1980), influence fertility only to a very small extent, if at all. With early and universal marriage, even with a reduction in marital fertility the transition in fertility is somewhat slower. The transition can nevertheless be faster if there is an accompanying delay in age at marriage, as was the experience in Eastern and Central Europe. Western Europe, in contrast, had a quicker fertility transition in age-specific fertility rates through late marriage and widespread celibacy. In several developing countries where fertility declined during the last two decades, the delayed age at marriage contributed to the decline (Ujang 1980). Duration and Dissolution of Marriages According to BFS data, most women aged 10-49--89 percent rural and 87 percent urban--were in marital union. Table 3.6 shows the mean and standard deviation of the duration of marriages for first and current marriages and for urban and rural women aged 10-49. The mean duration of marriages, both first and current, is one year less for urban women than for rural women. As ex- pected, the duration is slightly shorter for current marriage than for first marriage. Table 3.7 shows the distribution of the BFS sample of women aged 10- 49. Two demographic phenomena seem to have been important during 1951-74 (see table 3.5): the rise in age at first marriage has led to a decline in the proportion currently married under age 20, and the proportions currently married after age 25 have increased substantially. The result has been a marked reduction in the proportion of widows, from 20 percent of the women aged 35-39 in 1951 to 14 percent in 1961 and 9 percent in 1974. - 70 - Table 3.6 Duration of First and Current Marriage, 1975 Rural Urban Mean Stanclard Mean Standard duration deviation N duration deviation N First marriage 15046 10,75 5023 14014 10024 1,4R9 Current marriage 13063 10,06 5,023 12064 9080 1D489 Source: Bangladesh Fertility Survey, 19750 - 71 - According to the BFS, 21.5 percent of ever-married women had their first marriage and: 9.9 percent by the death of the husband, 10.5 percent by divorce, and 1.1 percent by separation. Though urban marriages appear to be slightly more stable, the differences in the rates of marriage dissolution between rural and urban are not marked (Shahidullah 1979). Marked differences in the dissolution of marriage exist by educaton and religion. Twenty-four percent of women with no formal education had their first marriage dissolved, compared with 12.1 percent of women with primary level education and 9 percent of women with higher than primary education. Almost twice (23.2 percent) as many Muslim first marriages had been dissolved as that of Hindu first marriages (13.1 percent). The effects of dissolution are mitigated by remarriage. Young, uneducated, Muslem women show a greater propensity to remarry than other women. The rates of remarriage are higher for men because they are less affected by age of remarriage, and because they remarry sooner than women (Ruzicka and Chowdhury 1978d, Samad and others 1979). Infertility and subfertility are the important causes of divorce in rural and urban Bangladesh. Arthur and McNicoll's (1977) observation that "if the children do not arrive, divorce is a real possibility" is validated by empirical evidence provided by Ruzicka and Chowdhury (1978), who found the divorce rate higher among couples unable to have children. Fecundity of Women Along with exposure factors, a couple's fertility depends on their fecundity and reproductive behavior. As seen in the distribution of women by their fecundity and exposure status in Table 3.8, most (80 percent) ever- married women aged 10-49, rural and urban, claimed to be fecund--either exposed or pregnant. A woman who considered herself physically able to bear children was considered fecund. About 8 percent of the women reported to have a fecundity impairment, because of either biological reasons or steriliza- tion. Stoeckel and others (1972) found a lower proportion of fecund women--70 percent. The proportion fecund is relatively low in age group 10-14 and rises abruptly in the 15-19 age group. If fecundity is specified under conditions of current menstruation, the proportion of fecund women becomes still lower. An analysis of the menstrual status of eligible women by five quarterly prevalence surveys conducted in 1975-76 revealed that the proportion of cur- rently menstruating women never exceeded 40 percent (Rahman and others 1979). The coital frequency at the time of ovulaton (in the middle of a woman's menstrual cycle) has been shown to have a strong direct relation to fecundability. But research on the frequency of coitus seems to have been taboo in Bangladesh. In our survey, we found only one study (Maloney - 72 Table 3.7: Distribution of Women Aged 1049, By Duration of Marriage, 1BFS, 1975 Duration (years) Percentage of women 10 34.9 10-19 32.8 20 or more 32.2 Total 100l0 N = 6,515 Source: Ahmed (1979). - 73 - Table 3.8 Percentage Distribution of Ever-Married Women Aged 10-49, by Fecundity, BFS: 1975. Rural Urban Fecundity (N=5,023) (N=1,489) Pregnant 11.1 11.0 Widowed, divorced, or separated 11.3 12.9 Married, living with husband, and husband or wife sterilized for contraceptive purpose 0.6 2.4 Married, living with husband, and has self- reported fecundity impairment 6.2 5.6 M1arried, living with husband and fecund 70.8 68.1 - 74 - and others 1980) of the frequency of coitus per week. The reported frequency was about 2.5 times per week on the* average. Little is known about the determinants of coital frequency, which include sexual drive, voluntary abstinence to avoid conception, social customs prohibiting intercourse, and involuntary abstinence due to illness, impotence, or temporary separation0 Factors Influencing Natural Fertil:.ty Besides exposure, a number of physiological factors influence natural fertility. Subfecundity, primary and secondary sterility, and the frequency and duration of maternal breastfeeding are the main physiological factors that affect natural fertility. According to the BFS (19783), only 6 percent of women reported a fecundity impairment. But it was not found whether they had primary or secondary sterilityo Subfecundity, adolescent sterility, and secondary sterility can be exterpolated from the data in table 3.9o The proportion childless after five years of marriage drops from 90 percent for those marrying before the age of 10 to 14 percent for those marrying between 15 and 19. Conversely the mean number of births in the first five years rises from 001 to 105 when age at marriage changes from under 10 to 15-17. The net effect of the opposing influences Df early marriage and adolescent sterility can be seen in table 3.10 Up to age 15, the age at marriage has no effect on cumulative birth cohort fertility0 For instance, in the current age group 20O 24, the mean number of births remains at about 2.7 for the women marrying between 10-14. Secondary sterility, measured from the age at last pregnancy termination, increases very slowly below age 35 but increases rapidly after age 40. Maternal Breastfeedingo The delay in the resumption of ovulation after delivery depends on the frequency and duration of breastfeeding, a behavioral factor; it overlaps with another behavioral factor, the delay in resumption of sexual intercourse after delivery, which also is naturally determined0 Nearly all women breastfeed their children (BFS)0 The mean length of breastfeeding is estimated at 19o0 months for women with at least two live births; women in urban areas report 17o5 months, women in rural areas 19o2 months0 Little or no variation in the length of breastfeeding is observed by the mother's current age, age at marr:Iage, birth order, religion, or husband's occupation0 Chen and others (1974b) used data drawn from 209 married and pre- sumably fecund women (between the ages of 13 and 44) who were followed up for two complete calendar years with biweekly interviews and monthly pregnancy tests0 They reported lactational amenorrhoea to be the prime factor respon- sible for prolonged birth intervals: it accounted for 45 percent of the length - 75 - Table 3.9 Women Having No Live Births in the First Five Years of Marriage and Mean Number of Births in the First Five Years of Marriage, by Age at First Marriage Percentage with no live- Means number of live Age at first births in the first birth in first five marriage five years of marriage years of marriage 10 90 0.1 10-11 46 0.7 12-14 24 1.2 15-17 14 1.5 18-19 13 1.6 20+ 23 1.2 All 40 1.0 76 - Table 310: Mean Number of Children Ever-Born to All Ever-Married Women, By Age at First Marriage and Current Age Current age 10 10-11 12=14 15-17 18+ All 15 ol o 2 - 0O1 15-19 101 101 10 005 0.3 0.8 20-24 2.6 2.8 2.7 19 0.8 2.4 25-29 4.1 4.5 4.5 3.7 2.2 4.2 30-34 5.5 6.2 5.8 5.2 4.4 5.7 35-39 6.6 6.7 7.0 6.4 501 6.7 40-44 7.0 6.9 7.3 7.2 6.3 7.1 45-49 6.5 6.8 6.8 7.3 6.3 6.7 All 4.7 4.5 3.9 3.1 2.6 4.0 N 1,029 1D187 2,976 1,096 228 6D515 Source: BFS (1978)D Table 64, po h50 - 77 - of birth intervals. Postpartum sterility played a significant role in regulating fertility in an essentially noncontracepting population. The study also revealed a seasonal pattern of births. This might be due to a seasonal trend in fecundability. The highest conception rates were found in the coolest months of the year. Supporting the proposition of seasonal variation in lactational amenorrhoea, Huffman and others (1978) reported a higher probability of resuming menstruation during September-December. This season corresponds to the largest annual harvest of rice, suggesting that a nutritional factor could be operating through an increased availability of staple food. But the data of the same study suggested that maternal nutrition is unlikely to shorten postpartum amenorrhoea significantly. The average duration of amenorrhoea differed by less than one month for well-nourished women. Other factors-- such as changes in infant feeding supplementation or decreased suckling due to preoccupation of mothers in harvest--may determine the return of menstruation during this season. By studying a group of 200 breast-feeding women with children aged 17-25 months and following them for 1-1/2 years or until the mothers conceived, Huffman an others (1980) reported a seasonal trend in suckling time--the women tend to reduce the frequency of suckling during the harvest season. Total suckling time was inversely associated with socioeconomic status and with infant nutritional status. No association was found between the nutritional status of the mother and the mean suckling time. According to this study, the median duration of breastfeeding was 30 months. More than 75 percent of the women whose most recently born children were living has been breastfeeding at 2-1/2 years postpartum. Several studies examined the effect of nutrition on menarche, amenorrhoea, and children ever born. Chowdhury and others (1977) examined the effect of nutrition on menarche with a group of 1,155 girls aged 10-20. The study found an association between malnutrition and increased age at menarche. Body weight was found to be highly correlated with the age of menarche. A seasonal variation was also noted: menarche was highest in the winter months, which correspond to the largest annual rice harvest. Mosley (1977) has examined the effect of malnutrition on biological mechanisms directly related to fertility: fecundability the reproductive life-span, postpartum amenorrhoea, and pregnancy outcome. A cross-sectional survey of 2,048 breastfeeding women in rural Bangladesh was conducted in 1975 to explore factors affecting the duration of postpartum amenorrhoea. Information on menstrual status, infant supplementation, socioeconomic status, and anthropometric measurements was collected from lactating women with infants 13-21 months of age. The median length of amenorrhoea was observed to be over 18 months. There was a higher probability of being amenorrheic for older women and for those of lower socioeconomic status. Maternal malnutrition extended amenorrhoea slightly. Using the BFS data, Chowdhury (1979) found a significant relationship between nutrition and children ever born. When controlled for age, however, - 78 - the relation disappeared. In another study of the effect of age on postpartum amenorrhoea, Chowdhury (1978) found the age of women to be positively related to length of postpartum amenorrhoea and waiting time for conceptiono But when the effect of age is eliminated9 parity is negatively related to the length of both amenorrhoea and menstruating intervals. Sirageldin and his coauthors (1975a) explained that the fertility decline recorded in the National Impact Survey in 1968-1969 was "largely biological." Their argument was based on "reduced infant and child mortality9" which prolongs lactation, and thus extends amenorrhoea, to increase the interval between births. Chowdhury and others (1S76) provided further evidence. The median birth interval for Bangladesh women whose children died during infancy is 24.1 months. The corresponding interval for women whose children did not die is 37.2 months0 Thus a difference of 13.1 months is attributable to the biological effects of infant death, interruption of lactation9 and earlier onset of postpartum ovulation and susceptibility to conception0 Chen and others (1974b) express caution, however, about the ex- pectation of a fertility decline following declines in infant mortality. "The interaction of maternal nutrition and child feeding practices with the duration of lactational amenorrhoea suggests that a nutritional program could possibly shorten the duration of lactational amenorrhoea by 50 percent or more. If this were to occur, it would shorten the average live birth rate unless some other means of fertility control were introduced and accepted (po 37) 1 Infant Mortality and Fertility Scrimshaw (1978) provides an excellent overview of the relations between infant mortality and fertility0 As she points out: "The prevailing assumption is that high fertility is a necessary biological and behavioral response to high mortality0 This E.ssumption is manifested in the theory of demographic transition9 which states in the simplest form that mortality decline is eventually followed by fertility decline; in the child replacement hypothesis, which states that parents try to replace children who die; in the child survival hypothesis9 which states that couples aim to produce enough children to ensure the survival of some intended number to adulthood; and in the argument that couples will not reduce their fertility until they are convinced infant mortality levels have dropped (po 383)." In an attempt to examine the relations between infant mortality and fertility, Chowdhury and others (1q76) analyzed birth intervals for Pakistan and Bangladesh according to previous child deaths9 excluding child deaths just before the birth intervals examined0 They found no statistically significant difference in birth intervals between women who had experienced at least one child death and those who had not0 They concluded that with moderately high fertility and mortality9 "there is no evidence that child deaths generate a desire to replace children (po 258)." They provide evidence9 however9 that the positive relation between high fertility and high mortality might work through biological rather than behavioral effects in rural Bangladesh and that the biological effects are much more powerful than the behavioral0 Other - 79 - studies support the evidence that women with an infant or fetal death would conceive again soon, possibly perpetuating a series of unsuccessful pregnan- cies. Behavioral effects, on the other hand, cause a difference of only 3.1 months at most. By using longitudinal data drawn from 5,263 women of Matlab thana, Chowdhury, Khan, and Chen (1978) demonstrated a positive relation between the number of children ever born and the number of child deaths. The relation is not conclusive, however, because the method used to examine the influence of mortality on fertility does not exclude the possibility that fertility in- fluenced mortality. Other studies do not find high mortality partly responsible for high fertility in Bangladesh. Maloney and others (1980) tested the hypothesis that those who have experienced death of children will want a large number of children as "replacement insurance." The data they collected does not support the hypothesis. The percentage of respondents who desire no more children increases with the number of child deaths. The majority of men with two or more sons desire no more children. The majority of men and women with one live daughter desire no more daughters. Chowdhury and others (1976) also estimated the effect on fertility, if any, of low or no infant mortality. They show keeping all other factors constant, that an elimination of all infant deaths would lengthen the average birth interval from 35.6 months to 37.2 months. This is equivalent to reducing fertility 4 percent, a modest effect. The reduced mortality of infants would have a dual effect: fertility would be reduced, and survivorship, a central element of net reproduction, would be improved. 83 - SOCIOECONOMIC CORRELATES OF FERTILITY The main factors studied in relatior to Bangladesh fertility are social class, region, employment, family structure9, migration status, rural-urban background, occupation, education, znd income. Other factors considered include purdah, religion, lactation, land ownership, infant mortality, the status of women, and such broader phenomena as rural development and modernity. These factors were studied in varying frequency, using different sample sizes drawn from different areas, and following different methods. Social Class Studies in this area suggest that fertility tends to be comparatively low at the high and low ends of the socioeconomic scale. Using the BRSFM data, Chowdhury (1977) reported tha: the richest and the poorest have lower fertility compared with the middle and lowJer middle classes0 M4aloney and others (1980) found that the rural 3oor generally are less fertile than the rural middle class0 They also found that rural families with such titles as Chaudhury, Bepari, Mandal, and MuLla (suggesting that they belong to the higher social class) tend to have htgher fertility than urban families having such titles0 The BFS (1978) reportad that families who own such household items as radio or boat (indicators 3f status in Bangladeshi society) tend to have higher fertility than those who do not0 Tne BIDS (1981) data seem to corroborate those of the BFSo According to the BIDS data on total number of children ever-born alive to ever-married women of all ages, the poor and the laboring class generally have lower fertility and the subsistent, middle- income, and rich farmers in general, especially the land-rich class have higher fertility than average0 The different fertility reported by Stoeckel and Choudhury (1969) is inconsistent with the above findings0 With data from fifteen villages in Comilla Kotwali thana they found that fertility is higher in low-status groups than in high-status groups0 Such differences might, however, be due to their categorizing people into only two broad classes, high and low0 Cain (1977) reported a weak positive relation between class and female fertility, but a stronger positive relation between class and male fertility. Such relations exist, le suggests, because of class differences in polygamy, divorce, and remarriage0 Economic class differences in postpartum amenorrhoea could also explain sucl a positive relation between economic class and fertility0 The period of temporary sterility due to postpartum amenorrhoea is shorter for the more wealthy0 Education In most countries, women's education has shown a consistent inverse relation with fertility0 But in Bangladesh the inverse relation is not con- clusive0 The 1974 census of Banglaidesh reported that women with no schooling had on the average 3.9 live births, those with primary education 3.4 live - 81 - Table 4.1: Mean Number of Children Ever Born to Ever-married Women Aged 10-49, by Duration of Marriage and Education of Wife; BFS, 1975 Education of Wife Duration of marriage and Secondary current place of residence Uneducated Primary or more 10 Rural 1.11 1.15 0.94 Urban 1.48 1.57 1.35 10-19 Rural 4.05 4.15 3.92 Urban 4.32 4.50 3.88 20+ Rural 6.87 6.81 6.83 Urban 6.71 7.33 6.66 Observed mean Rural 4.16 3.35 2.13 Urban 4.15 4.00 2.65 Standardized* Rural 3.93 3.96 3.82 Urban 4.10 4.39 3.89 Source: Ahmed (1979). * The standard population is the BFS national sample of ever-married women aged 10-49. 82 - births, and those with secondary or higher education 2.6 live births. These figures are standardized neither for age nor for duration of marriage0 The BFS reported that women with no schooling have on the average 4.2 live births, those with primary education 304 live births, and those with secondary or higher education 2.4 live births. These differences turn out to be negligible when duration of marriage is controlled. After the data are standardized for duration of marriage, women with primary education are found to have the highest mean parity, women with secondary or higher education the lowest0 Women with more than primary education, both rural and urban, nave smaller families at all ages up to forty-five years0 The effect of primary or Eecondary education of husbands is not as significant as that of wives in lowering the average fertility. In fact, women whose husbands have primary or secondary education have the highest fertility0 Husband's education is inversely related to fertility only at higher levels than secondary (table 4o2). The report on the 1974 BRSFM showed that women who have primary education tend to bear more children than those who have no education0 The report also showed that the education of husbands tends to be positively associated with the average fertility of their wives0 The study by Maloney and cthers (1980) shows that fertility does not decline with primary education; it increases. The number of children ever born increases with schooling up to class 9 or 10 for males, and class 6 or 8 for females, and this holds true more or less in all age groups0 Most prob- ably, those with no schooling and the lowest fertility are the rural poor; those with primary education are not of the economically depressed groups and could be rural middle class0 Choudhury (1977) reported an inverted U-shaped relation of fertility to education for both sexes in Chittagong Division0 The average number of children born to women aged 15-49 i.s 3.72 for women with no formal schooling, 4.01 for those having 1-5 years of schooling and 3.85 for those with 6-10 years of schooling0 Primary education of women seems not to contribute to lower fertility, while secondary ecducation does0 Drawing data from a cross°-section of women of Dacca City, Choudhury (1977) reported an inverse relation between education of the wife and fertil- ity, measured by children ever bornr This relation holds true for every age group and also when allowance is mcde for the effect of duration of marriage, age at marriage, labor force status, husband's income, and exposure to mass mediao The study alo shows a weak but inverse relation between the husband's education and fertility across almost all age groups0 Interestingly, at every age, female education depresses fertility more than male education increases fertility. In a study of different fertility among the Chittagong Municipality population by migration status, Khan (1977) found an inverse relation between education and fertility among migrants and nonmigrants0 In one of the earliest studies with a rural samp'e from Comilla, Stoeckel and Choudhury - 83 - Table 4.2: Mean Number of Children Ever Born to Ever-married Women, by Current Age and Education of Wife and Husband Current age Education 20 20-24 25-34 35-44 45+ Total Wife's All Wives 0.7 2.4 4.8 6.9 6.7 4.0 No Schooling 0.7 2.5 4.9 6.9 6.7 4.2 Primary 0.7 2.6 4.7 7.1 6.9 3.4 Higher 0.6 1.9 3.8 6.6 7.6 2.4 Husband's All Husbands 0.7 2.4 4.8 6.9 6.8 4.0 No Schooling 0.7 2.3 4.9 6.8 6.7 4.0 Primary 0.7 2.6 4.9 7.2 6.8 4.0 Secondary 0.7 2.7 4.7 7.2 7.2 3.8 Higher 0.7 1.9 4.4 6.6 6.3 2.8 Source: Bangladesh Fertility Survey. First Country Report, 1975. Dacca: Bangladesh Ministry of Health and Population Control, p. 67 and 70. 84 - (1969) also found an inverse relation between education and a woman's age at first marriage. The government of Eangladesh aims to make primary education universal during the 1980s but this may not have much immediate effect on fertility. As the number of youth proceeding to middle and high school grows , this increase in numbers with higher education is likely to dampen fertilityo Occupation According to the BFS (1978), women whose husbands are in white-collar occupations tend to have lower-than-average fertility0 The main difference appears to be between the population in agricultural and nonagricultural sec- tors, the former group showing higher fertility. In the agricultural sector, there is little difference between sharecroppers and landowning farmers, and landless laborers have the lowest fertility (table 4o3). BIDS (1981) also reported that fertility was lowest for the landless and marginal farmers0 Maloney and others (1980) found that cultivators and artisans have the highest fertility because they have the highest dependence on God and purdah. Rural professionals and religious leaders have less frequent coitus but higher fertility. Persons in modern and in urban occupations have the most frequent coitus, but have less pardah, less dependence on God, more contraceptive use, and lower fertility. Ahmed and Mallick (1978), reported the highest fertility among the wives of farmers and laborers, the neirt highest among wives of businessmen0 Lower fertility was reported for women whose husband's occupation is service° related0 Similar findings were reported by Choudhury and Aziz (1974)o Using data from 101 villages of Matlab thanE.D they reported the highest fertility for the farmers and the lowest for service and factory workers0 The latter occupational group live away from their family for most of the year, which might partly explain their lower fertilityo Income Samad and others (1974) reported from a census of four unions in Nowabgong thana of Dacca district a significant correlation between income and the ratio of children to womeno The quality of data, the authors acknowledge, is not satisfactory and the relation is not controlled for different occupa- tions. Maloney and others (1980) reported similar results0 Table 4.4 shows - 85 - Table 4.3: Mean Number of Children Ever-born to All Ever-married Women by Current Age and Husband's Occupation Husband's Current age of wife occupation 20 20-24 25-34 35-44 45+ All ages White collar 0.8 2.4 4.7 6.6 6.5 3.8 Cultivator- 0.7 2.6 5.0 6.1 6.9 4.3 landowner Cultivator- 0.8 2.8 5.2 7.3 7.5 4.4 Other Landless 0.7 2.2 4.8 7.1 7.1 3.7 laborers Source: Bangladesh (1978), p. 20. 86 - Table 4.4: Income and Fertility Mean number of children ever born Annual income (taka in 1977 Aged Aged Aged Aged prices) under 24 25-35 35°45 45 and over 2,000 2.4 3.0 4.5 505 2 0003D999 201 3.4 5.3 6.4 4,000-5D999 1o8 3.5 5.4 7.2 6,000 and more 3.6 3.7 5.9 7.8 Source: Adapted from Maloney and otlhers (1980). - 87 - that the women of the highest income group have the highest number of children ever born. This is true for all age groups. Despite the possible relation between income and age, completed fertility (those aged 45 and above) for the poorest is 5.5 children ever born, rising for the highest income to 7.8. This clear tendency has also been noted in the BFS (1978): landless laborers have the lowest fertility, and those with some visible assets in the households have higher fertility. About the desire for no children, Maloney and others (1980) found that the economically better off rural people more frequently say they have enough children: of those with high income, about half in the age group 24-35 desire no more. Note, however, that the desire to have no more children is not necessarily reflected in behavior. But it may be of interest to see if there are any changes in desired family size over time because of the rural development programs (which tend to affect the better-off first). Stoeckel and Chowdhury (1979) reported that the total fertility rate (TFR) of women whose families are producers is slightly higher than that of women those families are nonproducers; the largest difference, 10 percent, occurs between women whose families are producers or nonproducers of rice. Landownership Discussion of the relation between landownership and fertility in Bangladesh can appropriately begin with the observation by Arthur and McNicoll (1978): For the relatively affluent landowners, there has prob- ably been no diminution in the advantages of a large family. Maintenance of wealth and status depends chiefly on power relations within the local community, and more recently also derives from taking advantage of new urban opportunities and from playing a "brokerage" role with respect to rural government services. Subdivision of land among children poses little threat: family holdings can be augmented through marriage and by purchase or foreclosure of mortgages, and other occupational outlet are increasingly available. For middle peasants, say those with between one and three hectares, one would expect family size to have a more important economic impact. Children provide labour from an early age, and sons give some assurance of status and security in old it age. Empirical evidence drawn from studies that analyzed the relation of size of holdings to fertility generally confirm the above observation. Maloney and others (1978) reported that even after controlling for age of the women, those who have more land have more children. Of those who have completed their fertility, persons having five to ten acres of land have an average of 8.5 children, compared wth 7.0 for the sample, 6.7 for the - 88 landless, and 6.3 for those with 1/2 to 1 acre, many of whom struggle for existence. The same authors found the kind of land tenure to be related to fertility. Those who both own and lease out land have the most children across all ages. Chen and others (1976) also noted a positive correlation between fertility and landholding. Similarly, Akbar and Malim (1977) found that bigger landowners or more well-to-do villagers tend to have bigger family size0 Samad and others (1974)1, drawing data from a census of 129 villages of a rural thana, reported a significant correlation between family size and landholding0 The analyses of BFS data reported that landless laborers have the lowest fertility (Ministry of Population Control 1978, Sohail 1979)o Latif and Chowdhury (1977) reported mixed results for a simple three- variable model relating size of landholding to marital duration and fertility (defined by children ever born)0 The size of holding was found to be signifi- cantly and positively related to fertiity in a northern Bangladesh village (Thakurgaon in Dinajpur)1, but no such relation was found in a southern village (Mithakhali in Barisal)0 The small po?ulation and the small number of control variables limit the ability to generalize from these findingso An analysis of the 1968-69 "National Impact Survey" data by Cain and Baastiens (1976) showed almost no difference in fertility between families with adequate and inadequate living conditions and with and without agricul- tural land0 Stoeckel and Choudhury (1969) found the size of landholdings to be negatively related to fertility in the Comilla Kotwali thana; but a later study (Stoeckel and Choudhury 1973) found smaller family size and greater approval and knowledge of contraception among those with small landholdings0 But in another study ten years later, Stoeckel and Choudhury (1979) reported that fertility rates of Bangladeshi women are related to their husband's landholdings0 In all age groupsD, with the exception of women 15-195, women whose husbands have no land have low^yer fertility than women whose husbands have some land, no matter the amount (table 4.5). Although differences in the TFR are quite small between women whose husband's own 20o2.9 acres, the TFR shows a direct relation with landholding with a difference of more than 13 percent separating women whose husbands have no land from women w^hose husbands have the most land0 The most recent study (Alam and others 1980) showed a positive rela- tionship of landholding to fertility0 Table 4.6 shows that the total fertil- ity rate of the landless was lowest in both l975-76 and 1977-780 BIDS (1981) with still more recent data reported a bell-shaped pattern of t.he relation between fertility and landholding. Fertility (children ever born) is the highest for the subsistence and middle-class farmers1, the lowest for landless and marginal farmers0 The fertility of rich farmers1, although nigher than the average, is lower than that of subsistence and middle-class farmers0 Landholding is also found to be related to age at marriage and mor- tality (Cain 1978)o Data from an intensive study of one small rural locality indicates that with increasing landholdings there is a slight lfncrease in age at marriage for females and a slight decrease for males. But the difference - 89 - Table 4.5: Mean Marital Age-Specific Fertility Rates and Marital Total Fertility Rates of Rural Bangladesh Women, by Husband's Landholdings, 1968-70 Mean Fertility Rate by Landholding Age of women No 1 1-1.9 2-2.9 3+ (years) land acre acres acres acres 15-19 .206 .187 .184 .167 .193 20-24 .311 .324 .328. .240 .267 25-29 .322 .326 .372 .338 .336 30-34 .269 .283 .286 .324 .308 40-44 .079 .87 .095 .087 .095 45-59 .021 .025 .021 .018 .012 Total 1.368 1.415 1.468 1.478 1.538 N = 3,654 8,655 3,895 1,671 1,814 Source: Stoeckel and Chowdhury (1979). 90 - Table 4.6: Total Fertility Ratas of Women Aged 15-44 for Landholding Groups. Companiganj Thana, Bangladesh, 1975-76 and 1977-78 Land per family Total fertility rate Percentages increase from (acres) T-77 FT M7-f-f8-- 1975-76 to 1977-78 No land 5.2 5.3 1.8 0O01-1o00 5o2 5.5 4.2 1.01-3.00 5.4 5.7 7.0 3.01+ 6.4 7.1 10.7 Source: Alam and others (1980). - 91 - is only one year. Cain also reported that the child mortality rate for the poor is nearly twice the rate for the well-off. Infant mortality, however, shows comparatively little class difference. McCord (1976), giving figures from a famine year, shows death rates in landless families three to four times higher than those in families with more than 1.2 hectares (table 4.7). He commented that overall there is a dual mortality process in Bangladesh: lower risks for those who are well-off, much higher risks for those at the margin; with more impoverishment, this second type of mortality could become more dominant. Most of the studies suggest that landholding is positively related to fertility; one or two, however, contradict this. Resolution of the conflict- ing findings awaits further empirical work with a nationally representative sample. As has been pointed out, the studies reviewed either have small sam- ples or cover only a small area, factors that limit the ability to generalize from these findings. Family Type Research data on the relation between family structure and fertility are scarce. In our survey we came across only a few studies that considered family type as a relevant variable, and their findings are not consistent. Stoeckel and Choudhury (1969) used data from fifteen villages of Comilla Kotwali thana to examine a hypothesis about the relation between female marital fertility and family type: they found higher fertility in single families than in joint families. But Samad and others (1974) found a higher child-women ratio in joint families. In a postoperative study of tubal ligation acceptors in Dacca, Robert and others (1964) found more acceptors from nuclear families than from joint families: 65 percent of female sterilization acceptors are from nuclear families, compared with 34 percent from joint families. Value of Children The value of children, especially sons, has become a topic of research for better understanding in relation to human fertility. Empirical findings confirm that the value of children--and the importance of having both sons and daughters to make a family complete--have a significant bearing on fertility behavior. Salahuddin (cited in Javillonar and others 1979) observes: "Girls are made fully conscious that unlike their brothers who are assets to the family, they are only liabilities." Most studies confirm such a preference for male children, true even for the profesional elite, the urban middle class, and the rural population (Ahmed 1972). Repetto (1972) reports on the relation between the son-preference and fertility in North India, Morocco, and Bangladesh. The most persuasive evidence comes from the study by Cain (1977), who showed that higher fertility, particularly having more sons, 9 2 Table 4.7: Death Rate by Family Landholding in a Famine Yea-- Companiganj Thana, Woakhali District, 1975 Death rate of children Size of landholding Crude death rate aged 1-4 (hectares) (per 15000) (per 1OO0) 0 35.8 86.5 Less than 002 2804 48.2 0.2-1o2 21.5 49ol More than 1o2 12.2 17.5 Source: McCord (1976)o - 93 - is rational. Presenting data from a "typical" agricultural village in Bangladesh, he showed that male children are net producers by age 12, compen- sate for their total consumption by age 15, and compensate for a sister's total consumption by age 22. With the same set of data he further claimed that fathers benefited from many children because children, especially sons, contribute to household production and alleviate the substantial economic risks confronting households. Surviving sons are needed to inherit land and to maintain control of land in times of crisis. Large landowning families receive more benefits from their sons because the parental household controls the sons' contributions for a longer period. Khuda (1977) and Rahman (1978) provide further empirical data in support of the hypothesis that parental dependency has its root in the produc- tive utility of children and in the need for old-age support. From an inten- sive study of a village in Bangladesh, Khuda reported that the productivity of both boys and girls at ages 10-12 is almost equal to that of adults. Drawing data from the field research area of the Cholera Research Laboratory at Matlab, Rahman reported that children begin their economically useful lives as early as age 6. About 29 percent of boys and 78 percent of girls by age 8, more than 60 percent of boys and 93 percent of girls by age 10, and almost every boy and every girl by age 12 enter the household labor force. Rahman (1978) presented further evidence that 96 percent of the women expect financial help from their grown-up children. Help from children is the principal means of support in old-age for most women, the only means for three-quarters of them. Almost all women expect to live with their children, even after their children's marriage, and almost all of them want to. Rich parents have, on the average, more living sons (2.8) than poor parents (1.8). They also enjoy greater old-age support than the poor (Cain 1977). Rich parents have a smaller proportion of sons living away than the poor. The mean age of sons leaving the families of their parents is much higher for the most wealthy group than for the poorest. Among the large land- owners, more than 80 percent of the sons live with their parents; when they leave, their mean age is 28.5. Among the landless, 65 percent of the sons live with heir parents; when they leave, they do so at an earlier age (22.3 years). The hypothesis that sons receive preferential care and attention is supported in the comparative death rates of male and female children in a study of the impact of the Bangladesh civil war (1971) on births and deaths in a rural area of Bangladesh by Curlin and others (1976). In Matlab thana of Comilla district during the 1971 war, the Cholera Research Laboratory reported death rates for females aged 1-4 almost twice as high as those of males of the same age. Having analyzed the BFS data, Huda (1980) reported that female children show roughly a 10 percent higher mortality rate than males and the sex difference in mortality remains unchanged even after controlling for the socioeconomic status of the family. The other evidence of preferential treatment toward a son is the different investment in a son for education. Latif and Chowdhury (1977) found that most families educate their sons rather than their daughters because boys are more of an economic asset to the family. -94 - Status of Women In Bangladesh, the social structure relegates women to a lower status. Without education and confTined to a domestic role, women remain under the support, protection, and control of an adult male all her life--first her father, then her husband, finally her son (Ellickson 1976, citad in Javillonar and others 1979)0 Husband-wife age differences of almost ten years at marriage also place women in subordinate position relative to meno And the system of purdah regulates many aspects of women's everyday life, including mobility. Though the system offers women little access to opportunities, it confers on them status as a protec:ed group. The joint-family structure usually permits a smooth transition for a woman through the stages of her life, and it provides continued security after her husband's death0 But it does not give her freedom and authority0 In such a social structure, women can gain some authority and status through increasing age and childbearing0 Changes in this situation (such as a weakening of purdah) are recent and are yet to be remarkably felt. The contributions of Bangladeshi women, especially rural women, as food producers and processors and as home-industry workers are significant0 But the contributions are largely invisible, unrecognized, and considered as part of their housework roles (Alangir 1977)o Even those who work outside the household setting acquire a work role as an addition to housework, not as a substitute0 Policymakers, scientists, and politicians concerned with high rates of population growth increasingly recognize that the status of women has significant bearing on fertility behavior0 Unfortunately, we could identify only two empirical studies directly concerned with this issue: one looked into the relation between the status of women and fertility, the other between purdah and fertility. In the first, a study of female status and fertility behavior in a metropolitan urban area of Bangladesh, Chaudhury (1978b) con- firmed the hypotheses that decision-making power, employment status, and educational status are positively associated with the use of contraceptives and inversely related to fertility0 Employment and Labor Force Participation Evidence from the BFS data suggest that the working status of a wife is inversely related to fertility for both rural and urban women, even if duration of marriage is controlled0 The standardized mean parity for rural working women was 3.8 in 1975-76. The standardized mean parity for urban non- working women is 4.2; that for urban working women 3.8 (Ahmed 1979)o The analysis further revealed thaat fertility varies with work status at all levels of education, but not in the same directiono Ahmed (1979) con- cluded that working women, whether in rural or urban areas, whether uneducated or highly educated, whether rich cr poor, have lower fertility than their nonworking counterparts, if the duration of marriage is controlled0 - 95 - In another study conducted by Chaudhury (1978b), work experience was found to have little or no effect on fertility of currently married women living with their husbands in Dacca. The finding is striking: fertility varies with work status, particularly at lower levels of education, but there is little or no variation in fertility by work status at the higher levels. The mean parity of women with higher than primary education is 2.4, and the variance in fertility for this group may be small to begin with. As such, it would be surprising if variation is found for higher educated women by their work status. Chaudhury (1974) found an inverse relation between labor force par- ticipation in agricultural activities and fertility and a positive but nonsignificant relationship between female labor force participation in non- agricultural activities and fertility. These data suggest that female labor force participation in the traditional sector may contribute to lowering fertility. Labor force participation in agriculture is confined to poorer women. It is plausible to argue that women's socioeconomic status, not women's employment in agriculture, is the key variable linked to their lower fertility. Female participation in domestic work is positively related to fertility. No clear conclusion can be drawn from the findings. The positive but nonsignificant relation between employment in nonagricultural activities and fertility, for example, is inconsistent with theoretical expectation. Further studies are needed. Religion and Religiosity Several studies provide empirical evidence that frequency of coitus and fertility differ by religion. According to Maloney and others (1980), Muslims have coitus slightly more frequently than Hindus. Obaidullah (1966) reported that the Muslims had about 26 percent higher fertility than Hindus in rural Bangladesh during 1961-62. Stoeckel and Choudhury (1969) collected data from fifteen villages of Comilla Kotwali thana and reported similar findings. Taking the child-women ratio of women ever married as an index of fertility, Chaudhury (1971) concluded that Muslims have higher fertility than Hindus. He suggested that the higher fertility of Muslims might be due to (1) the higher proportion of Muslim women with a longer conjugal life than Hindus, (2) the higher infant mortality among Muslims than among Hindus, (3) the less favorable attitudes of Muslims toward family planning, and (4) less ritual abstinence observed by Muslims. But the difference in fertility between Muslims and non-Muslims is found to be small when the duration of marriage is controlled, and this holds true for rural and urban areas (Ahmed 1979). Nor do the data show that higher infant mortality causes higher fertility among the Muslims. The BRSFM (U.K. 1977), conducted only two years before the BFS, reported that the Muslims have lower infant and child mortality than Hindus. From a census of 129 villages of Nowabganj thana, about 20 miles from Dacca city, Chowdhury (1975) found that Muslims have a higher CWR than non- - 96 - Muslims. He found a gross fertility rate of 243 for Muslims, 233 for Hindus, and 152 for Christians--and a total fertility rate (per 1,000 women) of 7,025 for Muslims, 6,810 for Hindus, and Z.,885 for Christians. Fertility differences betwEen Muslim and non-'Muslim women are observed both in the BFS (1978) and the BRSFM (UoK. 1977). Tne BRSFM reported fertility of about 0.4 children higher for Muslims than for Hindus. The BFS (1978) showed that in every age group Mtuslims have higher ferti:ity than non- Muslimso On completion of fertility, Muslim women (aged 45 and above) have 609 children, Hindu women have 601o This is similar to the data reported by Maloney and others (1980) (table 4.6;). The Muslims averaged 5.2 births, the Hindus 4.8. The difference holds for all age groups and both sexes0 Muslim women in their twenties and thirties are a little more fertile ;han Hindu women0 In addition, the former seem to bear more children in tneir later years0 Hindus are more frequently educated at higher levels, marry late, and practice contraception more frequently than Mtuslims0 Among those aged forty and more who have almost completed their fertility, Muslim women have had 7.0 children, Hindu women 6040 Among mEn, the difference between Muslims and Hindus is even greater0 Muslim men past forty-five have had an average of 7.6 children, Hindu men 6030 More older Muslim men take younger wives0 According to Ruzicka and Chowdhury (1978), as the groom's age increases, the age differ- ence between the couple rises dramaticallyo It reaches, on the average, about twenty years when the husband is over thirty-five. Another way of looking at lertility by religion is to estimate religious differences in the population growth rate0 In Bangladesh, however, it is difficult to measure population growth rateso The reliability of census data is questionable; a nationwide vital registration system is absent; many do not know their age; women tend tc, be underenumerated; and recurring events, such as flood, famine, and migratior, might have dramatic local effects0 Hill (1979) made an intercensal study of population growth in Bangladesh for 1951-61 and 1961-74. During 1951-61 Muslims increased 2.4 percent, caste Hindus 005 percent, and scheduled caste Hindus decreased by 0.4 percento Migration is likely to have influenced this pattern0 Hill estimated that some 10 to 15 percent of the Hindus must have emigrated duTing 1951-61, another substantial percentage during 1961i740 Waile emigration of non° Muslims from Bangladesh may now have slowed, Muslims will increase as a proportion of the population because of their higher birth rates0 Muslims ranked higher than Hindus on religiosity measured by seven- teen items in the study by Maloney and others (1980). Religiosity was found to be associated with higher average fertilityo The completed fertility of those forty-five and above is correlated with prayer, pilgrimage, having a religious preceptor, and dependence on god. Tney found that dependence on god is related to fertility behavioro Those wMho depend on god have more children, and this is true for all age groups and both sexes0 Those who depend on god have an average of 5.3 children ever born; those who do not, 3.7. W^hen age is controlled and those aged forty-five and above are considered, Dhe difference between the two groups persists: fcr the males, it is 7.3 children and 7.0; for females, 7.2 children and 5.6. Ali (1976) reported that people with - 97 - Table 4.8: Fertility by Religion According to Two Recent Studies BFS 1978 a/ Maloney and others 1980 Current age Muslim Non-Muslim r4uslim Hindu 20-24 2.5 2.3 2.6 2.1 25-34 4.9 4.5 3.5 3.2 35-44 6.9 6.8 505 5.1 45 + 6.0 6.1 7.4 6.3 a/ Data collected in 1975. b/ Data collected in 1978. 98 - higher religious values are nonadoptors of family planning, express a desire for more children and have them. Irt addition, the use of modern contracep- tives is associated with several measures of religiosity, such as sexual abstinence on holy days, and negative advice to others on matte'fs of family planning (Maloney and others 1980). Other studies (Mia 1968, 1978) show that modernizing experiences impose modiiications on religiosity and religious values which, in turn, affect ferti:.ity norms and practices. Purdah Maloney and others (1980) examined the extent of purdah, its dif- ferent practice by religion, and its impact on fertilityo They found that men claimed more adherence to purdah than did women. Muslim men claimed more purdah than did Hindu men. Muslim women claimed more than did Hindu womeno Those not practicing purdah have noi:iceably fewer children than those prac- ticing. This holds for all age groups and both sexes0 For men and women aged forty-five and above, no purdah is associated with the lowest fertility, some purdah with intermediate, and strict purdah with higher fertility0 "Purdah is clearly a part of the bundle of proi'ertility traits prevailing over most of Bangladesh" (Maloney and others, po 94). They also reported a consistent association between the adherence to purdah and desired fertility. Those not practicing purdah more often want no additional children; those practicing some purdah are intermediate; those practicing strict purdah often want more children0 Maloney and others (1980) also found purdah to be negatively cor- related with ever-use of modern contraceptive methods (r = -05), the highest correlated of the variables of religiosity0 It also is negatively correlated (r = -019) with ever use of all kinds of contraception combined0 Education is negatively re:ated to observance of purdah and to fer- tility (Maloney and others 1980)o Wlith the increase of literacy and education, the practice of purdah is likely to decrease and have the desired influence on fertility norms0 There is evidence that literacy of females is increasing, especially young girls0 Of females currently aged forty-five and over, only 4.6 percent are literate; those 25-44, 16 percent; those 15-24, 30 percent; and those 10-14, 32 percent0 These data suggest that higher proportions of younger women are attending school and beconing literate (Islam and others 1979)o A similar trend is observed for the nation as a whole across rural and urban areas0 According to the 1974 census, the highest literacy rates are among women aged 15-19, the lowest among women aged thirty-five and over0 Swanirvar Program Hamid (1980) evaluated the effect of the Swanirvar program on fer- tility in a village in which the ever age marital rate of population growth weas estimated at 2.8 percent during 1961 and 1974. The rate came down to 2.0 - 99 - percent during 1974 and 1977, assuming that the 1974 census and the village survey data are reliable. In another village, the growth of population has come down from 2.8 percent in 1977 to 1.1 percent in 1980. The wives of landless laborers were found to be very conscious about big families. A large number of women (200) accepted sterilization during 1977-80. Factors con- tributing to the success of population control in Naldanga are: a denoted Swanirvar worker, a women's cooperative society, the support of the Union Parisal (local council) Chairman for family planning, and incentive for sterilization (Tk. 80 and a saree). Disincentives--threats of not giving rations, loans, or wheat under food for works if they do not accept sterilization--were also used to boost sterilization acceptance. - 100 - DETERMINANTS OF CONTRACEPTIVE BEHAVIOR Freedman and Berelson (1976), in their review of family planning programs, maintain that the supply and demand of contraceptives are the t.o key com- ponents of any programs for changin:g fertility Tpn this chapter, we review the findings about supply and demand i'n Bangladesh. After the discussion of demand and supply, we examine evideice on how well demand matches supply in the current use of contraception and in the intention to use contraception0 The characteristics of contraceptlve acceptors and differences in use are presented. Factors Affecting Demand for Contraceptive Services There are many claims about the influence of geophysical and sociocultural factors on the fertility of Banglad3shi women. But few empirical studies examine the relation of religious and sociocultural norms, values, and customs with fertility norms, which in turn affect the need and the demand for smaller families. Here the evidence on factors influencing fertility norms and the demand for contraception are groupel into, o Geophysical factors, such as floods, cyclones, and seasonal variations in employment0 o Sociocultural factors, sucn as social norms, values, and religious practices0 Geophysical conditions. In a disaster-prone area like that of Bangladesh, which has frequent floods and cyclones, a large family with more adult males stands a better chance of safeguarding the life and property of all members of the family (Alamgir 1977) and of avoiding distress, the sale of assets, and recourse to high-interest consumption loan (Cain 1978)o Seasonal variations in employment opportunities may also favor high fertility0 Aiamgir (1977) makes such a hypothesis and argues that for families that deperd on sales of labor power, an extra earning member can smooth the fluctuation, in earning0 Further, if the contract labor is cn family basis or share of produced output large family size will imply a greater control over wage goods0 Arthur and McNicoll (1978) also hypothesized that the motivation for high fertility in rural Bangladesh lies in the uncertainty and insecurity caused by the dependence on nature and its variation and to the economic relationships in villages. - 101 - Sociocultural Factors Affecting Demand for Contraceptive Services The sociocultural factors affecting demand for contraceptive services include norms about marriage, age at marriage, timing of first pregnancy, women's role and status in the family, and desired family size. Norms about Marriage. A commonly held belief, both in Islam and in Hinduism is that marriage is a religious duty. One should marry to procreate and to continue the family line (Mia 1978; Maloney and others 1980). Such religious obligations contribute to early marriage and high nuptiality, both among Muslims and Hindus in Bangladesh. Table 5.1 shows the proportions of men and women aged 45--49 reported never married and confirms that hardly any one is single by age 49, Age at Marriage. Religious belief promotes early marriage of girls for both Hindus and Muslims. Evidence suggest the prevalence, though eroding, of a belief that girls should be married before their first menstruation (Mia 1978). An anthropological study reveals the belief that, if a girl's menstruation begins at her parents' home, the men of the family cannot go to heaven for seven generations (Maloney and others 1980). Girls are married off to avoid any possibility of premarital relations and of socially undesirable marriages of the girl's choosing. In urban areas, however, marriage through mutual understanding is gaining increasing social acceptance. As for boys, parents want to get them married at an early age for three reasons: marriage is a religious duty to be fulfilled as soon as possible; a boy is more likely to commit a sexual offence or fall in love with a girl if his marriage is delayed after puberty; getting a boy married helps increase his commitment to family responsibility. The findings of several studies presented in chapter IV provide evidence that most Bangladeshi girls marry around the age of puberty or shortly after. For example, the BFS (1978) showed that 15 percent of the ever-married women were under 10 when they were married, 34 percent under 11, and 80 percent under 14. Similarly, Maloney and others (1980) showed that 44 percent of the females were married by age 13, 58 percent by age 14. Women's Role. In recent years a number of authors and researchers (Abdullah 1974, Sattar 1975, Sattar 1977, Kabir and others 1977, Chaudhury and Ahmed 1980) have written extensively on the role and status of women in Bangladesh. Most of them stress the effect of religious traditions, which they argue serve to constrain and confine women, for women traditionally are not associated with the power structure of the religion. Maloney and his co-authors (1980) examined the practice of purdah and its association with fertility. They found that men favored adherence to purdah more than women. Muslim men favored purdah more than Hindu men. Muslim women favored it more than Hindu women. Those not practicing purdah have noticeably fewer children than those practicing. This holds for both sexes and for all age groups. Among men and women aged 45 and above, the practice of 'no purdah' is associated with the lowest fertility, 'some purdah' -- 102 - Table 501 Proportion of Never Married Men and Women Age 45-49 in Census and Other Surveys 1951-1976 1951 1961 1961-62 1965 1974 1974 1975 Census Census D,So (Rural) PGE Census BRSFM BFS Male 02 Oo1 00 0.2 03 03 000 Female 1.3 0O8 0.0 07 1l1 0Q8 lol Source: Adapted from Bangladesh (1978)o - 103 - with intermediate fertility, and 'strict purdah' with higher fertility. Maloney and his co-authors also reported a consistent association between the adherence to purdah and desired fertility: those not practicing more often want no additional children, those sometimes practicing purdah are inter- mediate, and those practicing strict purdah more often want more children. They also found purdah to be negatively correlated with ever-use of modern contraceptive methods (r = -0.5), the highest correlated variable among all the religiosity variables. Education is negatively related to the observance of purdah and, in turn, to fertility. With the increase of literacy and education, the practice of purdah is likely to decrease and have the desired influence on fertility norms. Norms about Fertility. No religion prescribes a requisite number of children as a religious duty. But certain religious injunctions seem to favor large family size, polygamy, divorce, and remarriage, all of which have profertility influences. If a woman delays or fails pregnancy after marriage, she faces a threat of divorce (Arthur and McNicoll 1977; Mia 1977). Delays in pregnancy after marriage are suspected as indications of sterility, and sterility, viewed seriously by the elder members of the family, is believed to be a curse. Thus, the appearance of the first child shortly after marriage (pref- erably at the second year for most people) is necessary to prove that the bride is not sterile and to establish her rights as a mother in the family. Most Bangladeshis regard two boys and one girl as the ideal family size (Sorcar 1977). More recent studies, however, give the total number of desired children as 2.4 (Maloney and others 1980). Earlier studies (Langsten and Chakrovorty 1978, Rahman 1978, Osteria and others 1978) reported four to five children as the desired family size -- the wife's desired family size tends to be lower than the husband's. Khan and others (1975) also reported slightly more than three children as the desired family size. The BFS (1975) estimate of desired family size of 4.1, on the average, is the highest of all the studies cited. The motivation for large family is largely explained by the economic value of children. It has been demonstrated that parental dependency on children is universal in Bangladesh (Rahman 1978). Ninety-six percent of the respondents expect to have financial assistance from their grown children, and 94 percent of the children over 12 were employed and helping the parents regularly. Desired family size is also affected by sex preference -- most families want at least one or two sons in the family. Eighty-eight percent of the women continue to produce children to have a boy in the family, even after the desired family size is attained (Rahman 1978). Other studies (Sorcar 1977, Cain 1978) also demonstrated economic motives behind the choice of large families. Khuda (1978) reaffirms the economic value of children, especially of sons, with empirical evidence from a village in Comilla. Achieving the desired number of sons has a direct bearing on the use of contraception. Even for towns and cities, where the value of sons is likely to be less than in villages, Chaudhury (1979) reported 20 percentage points higher contraception among women who have achieved their desired number of sons than among those who have not. The preference for boys is further 104 reinforced by their economic support of the parents through early participation in the labor market. vven when the parents own large landholdings that should give enough support at their old age, they would consider male children a necessity t3 ensure the maintenance of land and property. Preference for boys over girls is thus rooted partly in religious inscriptions and partly in socioeconomic conditions. Factors Affecting Supply of Contraceptive Services The infrastructural network of health and family planning facilities is comprehensive: 3,363 health, MCH, and family planning facilities operated in 1978. Table 5.2 shows the distribution of the different facilities by rural- urban location. This table does not include several major medical institutions, such as Medical College Hospital and the Suhrawardi Hospital0 Most facilities seem to be in rural areas, which has been broad,y defined to mean areas other than cities, districts and subdivisional headquarters. But according to the census definition, many thana headquarters hav°nog thana health complexes would be urban0 1/ Thus the favorable distribution of health facilities shown for rural area should be noted with caution0 Not all facilities shown in table 5.2 provide family planning services0 More than half of the facilities provide only health services, about a fifth only family planning, an6 a fourth both family planning and health services (table 5.3). But the data seem to suffer from internal inconsistency0 For example, there Is inconsistency in the number of health and family planning facilities as shown in table 5.2 and 5.3. Not all infrastructural facilities that offer either only family planning or both health and family 3lanning services have doctors trained in sterilization0 The lowest proportion of infrastructural facilities are in rural areas (rural health centers aid dispensaries) with doctors trained in sterilization (table 5.4). Even with so few infrastructure facilities in rural areas, most sterilization cliants are from rural areaso Sixty-three percent of the rural dispensaries have no doctors0 Of the 236 dispensaries having doctors trained in sterilization, only 54 provided sterilization services0 Many of these hospitals do not nave autoclave machirnes, which are essential for sterilizations; some hospitals and clinics do not have vasectomy sets, tubectomy sets, and other required instruments0 In April 1981., there 1/ The Census Commission has defined an urban area as that whIch includes: municipality, civil lines, cantonment and any contiguous collection of houses inhabited by not less tian 5,000 persons0 In additIon, areas irrespective of population size have been treated as urban areas if they meet the following conditons: Ereas having town committees: concentration of population in a continuous collection of houses where the community maintains public utilities, suc.h as roads, street lights, water supply and sanitary arrangements; and centers having a population characterized by high literacy0 - 105 - Table 5.2 Health, MCH, and Family Planning Facilities by Location Location Facility Rural Urban Total District hospital 13 13 Subdivisional hospital - 41 41 Other hospital 149 103 252 MCW/MCH center 23 40 63 THC/Thana health complex 356 - 356 FP subcenter 625 53 678 Dispensary 1,303 93 1,396 Outpatient facility 450 114 564 Total 2,906 457 3,363 Source: Bangladesh Ministry of Health and Population Control (1978). 106 - Table 5A3 Distribution of Hospital and Other Facilities , by Types of Services Services offered Only Type of hospital Only Family No Health Planning Both Services Total District hospital - -12 12 Subdivisional hospital 21 - 18 o 39 Other hospitals of health division 25 - 6 -31 Thana health complex 11 - 174 3 188 Rural health center 33 ° 12 2 47 Dispensary 1,217 ° 144 -1,361 Family Planning Center - 571 o 571 Maternity and child welfare center - 63 63 Other hospitals, health centers of govt., or semi govto organi- zations 256 ° 103 18377 Hospitals of voluntary organization 29 3 97 o 129 Outdoor facility 134 14 131 ° 279 Total 1,726 588 760 23 3,O79 Source: Bangladesh Ministry of Health and Population Control (1978)o - 107 - Table 5.4 Distribution of Health and Family Planning Facilities Having Doctors Trained in Sterilization Facility Number Percentage District hospital 12 92 Subdivisional hospital 37 95 Thana health complex 135 72 Rural health center 23 49 Dispensaries 236 17 108 - were 713 doctors trained in sterilization. Rajshahi Division has the highest number of doctors, followed by Khulha (table 5.5). The use of the health and L"amily planning facilities is very low. Roughly 42 percent of the population received services from the rural centers in 1977, 8 percent from urban centers. Of the visitors to these facilities, 96 percent received health care servlices and only 4 percent family planning services (Ministry of Health and Population Control 1978b)o Besides the infrastructural facilities for health and family services1, such outreach workers as family welfare assistants, family welfare visitors1, dais1, and traditional birth attendants deliver services to clients at home. Roughly 13,500 family welfare assistants in rural areas distribute conventional contraceptives and do notivational work. There are 4,500 family planning assistants, 2,722 family welfare volunteers, 13,500 dais, and about 671,000 traditional birth attendants. Despite the many workers engaged in contraceptive distribution and motivation in rural areas1, their rezruitment of new clients and promotion of motivation for family planning have been poor0 Several studies have iden- tified inadequacies in the service zelivery system as responsible for this low performance0 Poor knowledge of methods and the low social status of some village workers account for their limited success in motivational work. The recruit- ment of dais in the contraceptive distribution and motivation aid not improve service delivery0 The dais are elderly women and nearly three of four are either widowed, divorced, or separated; most are illiterate0 INT7o dais in every five did not know when a woman should start taking pills in relation to her last menstrual period1, four in five did not know what to dc if a woman forgets to take pills for five consecutive days, and half could not explain the anticipated side effects (Rahman and others 1978)o According to an evaluation study, most family welfare assistants were deficient in recruiting clients for accepting contraceptives and in performing some key tasks specified in their job description (Khan 1978)o The inadequate performance of field-workers is attributed to a large number of factors: their low acceptability, their poor knowledge of the contraceptives1, their lack of proper supervision, their lack of training, and their inadequate knowledge of their job descriptions0 The marital status and educational level of field-workers also affects their acceptability0 The Evaluation Unit of the Planning Commission (1977) observed that married family welfare assistants were more accepted in the community than the unmarried ones0 Nearly 70 percent of them are married, 14 percent are divorced, separated, or widowed0 Another evaluation study reported that 98 percent of those in training were unmarried0 It is plausible that field-workers with ages lower than their clients find it difficult to carry on motivational work with relatively elderly couples (the mean age of vasectomy acceptors is 44 years1, tubectomy acceptors 30 years1, IUD acceptors 26 years1, and pill acceptors 28 years)o - 109 - The performance of field workers depends on their training, More than a quarter of the family welfare visitors in the field reported that their training was inadequate, particularly in maternal and child care (Quddus 1979). Three-quarters of them mentioned the need for refresher training (Evaluaton UJnit 1978). Other studies also point candidly to the poor training of field-workers and recommend better training both initial and refresher (Mabud 1976, Khan 1978, Osteria and others 1979, Mia and others 1974, Quddus 1979). Some studies (such as Amin and Karim 1970) point out the poor record- keeping by workers and suggest the need for training workers in this area. Recent studies (Khan 1978, Osteria 1979) also reported that many field-workers had difficulty filling in registration cards and keeping records of clients and stock. Nor did many of them maintain contact with other organizations: only a third of the family planning assistants appear to have maintained regular contact with Union Parisad, the key local admnistrative institution (Khan 1978). Thus, field-workers engaged in contraceptive distribution and motivation need training in some of the vital activities entrusted to them. Research to evaluate the performance of field workers generally suggest that most of them are not performing satisfactorily: in motivating and recruiting clients (Khan 2978), in the frequency of client contacts (Quddus 1979, Mannan 1976), or in the frequency of visits to villages (Allauddin 1979). Miannan's study found that 52 percent of the respondents said no one had visited them during the week of an intensive information and service delivery campaign. Quddus (1979) reported that 57 percent of the eligible couples were never visited by the family welfare assistants of the area. Moreover, both studies reported that not all those who make visits or contact clients talk about family planning. 110 m rable 505 Distribution of Doctors Trained in Sterilization, by Division Division Doctors trained in sterilization Dacca 171 Chittagong 125 Khulna 177 Rajshani 240 Total 713 Source Bangladesh Ministry of Health and Population Control (1981). - ill - To integrate population with agriculture, field-workers of other Ministries have been involved in family-planning promotional activities. Mia and others (1979) evaluated how agricultural extension workers perform as educators in population. They found that the agricultural worker is not widely known by farmers; of farmers aware of them, only a small proportion acknowledged that extension workers discussed family planning with them. Despite the low level of client contacts, visits by family planning workers were found to be an important predictor of contraception (Alauddin 1979). Villages where family planning workers visited at least once a month have high contraceptive use; those with no visits or less than one visit a month, have lower than average contraceptive use. This suggests that field- workers can affect people's decision about contraception, a potential that is not being fully realized. Supervison of family welfare assistants by family planning assistants was almost nonexistent (External Evaluation Unit, Planning Commission, 1978). A large proportion of FPAs did not visit the field once a week to supervise FWAs, as prescribed by their job description. An evaluatin by Mabud (1976) confirmed that leadership and supervisory support were extremely poor in the field where they were needed most. There has been practically no scientific investigation to assess the training needs of the field-workers. Matching Supply and Demand The current contraceptive prevalence rate is one important measure of how well supply and demand are matched. Another is the intention for contraception. Current Contraceptive Use Table 5.6 shows the percentage of current users reported in different studies between 1968-81. Examination of data presented in the table shows that the current rate varied from 3.6 percent to 19.4 percent during 1968-1976 and 7.3 percent to 46 percent during 1977-81. Despite major variations in the methodological approaches, data obtained by different studies show a steady increase with some fluctuation. Yet the rate of current contraceptive use is still low, at best around 19 percent. Several studies conducted in 1978-79 give lower-bound estimates of current use rates between 9.4 percent and 10 percent (Khan and others 1975, Osteria and others 1978, Langsten and Chakrovorty 1978, Rahman 1979). Two studies--Baybasthapana Sangsad (1975) and Proggani consultant (1979)--report much higher estimates of current rates in Bangladesh. Both studies reported a current use rate of 23 percent. The former studied a semiurban population, the latter sampled couples of two rural areas of Bangladesh, but they are suspected of overestimation. Other studies (Obaidullah 1980, Hamid 1980, MIS 112 - 'rable 5.6 Percentage of Current Zontraceptive Use in Bangladesh 1968=81 Percentage of current users Authors 1968 1975-76 1977 1978 1979 1980 1981 Serageldin and others 1975a 3.15 External Evaluation 1976 1904 Khan and others 1977 15.0 Osteria and others 1978 7.4 9.4 BFS 1978 7.7 Quddus 1979 1C044 Proggani Consultants 1979 23.0 Baybasthapana Sangsad 1975 23.0 Osteria and others 1979 36.0 Niport, CPS 1979 12.7 Obaidullah 1980 18o0 16.6 lOoO 12.3 External Evaluation Units Draft Report, 1980 7o3 Hamid 1980 35.0 MIS 1980 16.89 Akbar 1980 19.0 BIDS 1981 9.3 Khuda 1981 1405 Sohail 1981 4505 MIS, CPS 1981 1806 Alauddin and Sorcar 1981 4600 Alauddin and Sorcar 1981b 40.0 Alauddin and others 1981c 32.0 Phillips and others 1981 3100 - 113 - 1980, Sohail 1981, and Alauddin and Soccar 1981a, 1981b, that report high rates of current contraceptive use) (18 to 46 percent) apply to special projects. Of the studies, only the BFS (1978) had a nationally representative sample. Intentions to Use Contraceptives in Future Most studies reveal that many people, particularly those who have achieved their desired family size, do not want any more children. But families not wanting more children do not always take precautions to prevent pregnancy. Data in table 5.8 and 5.9 show the large discrepancy between the proportion of people wanting no more children and the proportion intending to use some method of contraception. Part of the discrepancy can be explained by cultural norms and values and the influence of situational, variables discussed later in this chapter. The proportion of people who expressed a desire to use some method of contraception in the future varies from 9 to 49 percent and may seem encour- aging. But allowances must be made for the effects of some situational variables on the would-be acceptors for discrepancy between their attitude and their behavior. Disutilities of Contraception Several situational variables inhibiting on the use of family planning have been identified: the side effects or disutility leading to disuse or withdrawal, the anxiety about the outcomes of a method, the fear of social disapproval, and the availability of suitable methods and services. Langsten and Chakrovorty (1978) have shown that despite abundant supply of contraceptives at the doorsteps of the target population, the continuation rate gradually declines (table 5.10). Evaluating the gradual decline in the rate of acceptance following a program of intensive distribution, Khan and others (1977) identified two kinds of problem responsible for the failure of the program to achieve the desired rate of continuation: o Intrinsic factors related to the methods, such as side effects that lead to a high dropout rate. o Program deficiencies, such as male distribution and the lack of followup services and treatment facilities. 114 - Table 5.7 Percentage Currently Using Contraceptive Methods, By Method of Currently Married Woman under 50D BFS 1975 and BCPS 1979, 1981 Method BFS, 1975 BCPS 1979 1981 Oral pill 2.7 3.6 3.5 Condom 07 105 106 IUD Oo5 Oo2 O4 Tubectomy 03 2.4 4.0 Vasectomy 05 02 04 Injection 02 0.4 Vaginal method 0-1 Oo3 Abstinence 1o1 008 1i2 Rhythm (safe period) 10 2.2 3.9 Withdrawal 06 02 108 Other 0.3 06 0.7 Current Use Rate 7.7 12.7 1806 - 115 - Table 5.8 Proportion of People Who Do Not Want More Children Percentage who do not desire more children Author Year Rural Urban Sergeldin 1975 55.0 61.0 BFS 1975 63.5 72.4 Osteria and others 1978 34.0 - Akbar 1980 55.0 - 116 Table 5.9 Percentage of People Who Intend Tc Use Family Planning in the future Author Percentage intending Year to use Serageldin and others 1975 15.0 BFS 1975 18.7 Osteria and others 1978 49.3 Khan and others 1977 3507 Langsten and Chakraborty 1978 35o8 Quddus 1979 14.4 Rahman 1979 45.0 Akbar 1980 1900 > * Might try injection if it had ro side-effects. - 117 - Table 5.10 Percentage of Women Using Modern Methods, by Time and Area, Matlab, Comilla Base line, After After Area 1975 three months twelve months Experimental area 1.7 18.7 15.6 Control area 2.7 3.8 3.9 Source: Langsten and Chakrovorty (1978). ° 118 - Table 5.11 Main Side effects Leading to Discontinuation of Family IPlanning Methods Byabasthapana Sangsad Sorcar (1977) Akbar Quddus (1979) (1975) (1978) Lack of knowledge 100 Side effects 45.40 31.00 Side effects 62.3 Method disadvantage 4.0 UnavailEible 3.36 ° Lack of Supply 3o28 Husbands' objection 500 Religious Objection of groun(d 2o10 17000 husbands 3o28 Unreliable 14014 - 119 - It appears that side effects are the main cause for discontinuing family planning. Quddus (1979) reported that 62.3 percent of contraceptive acceptors discontinued a method because of side effects. Osteria and others (1978) reported that a decline in the use of the pill from 17.1 percent to 8.7 percent between 1975 and 1977 was due to side effects. Rahman and others (1979) found that 87 percent of the initial users withdrew from using the pills because of side effects, 13 percent for other reasons, such as husband's objection or rumors about bad consequences. Most other authors (Baybasthapana Sangsad 1975, Sorcar 1977) reported similar findings. In most studies of rural Bangladesh, the continuation rate, a valid measure of the use-effectiveness of oral contraceptives, was found to be less than 50 percent at twelve months (Chowdhury and Chowdhury 1978). One of the early studies on IUD retention reported that 60 percent of all IUD users experienced side effects; expulsion was reported in 46.5 percent of cases (Croley and others 1968). Jelly and condoms are disliked by many couples because of their bothersome use and diminished sexual enjoyment. Despite widespread knowledge of sterilization as a contraceptive method, the acceptance rate is lower than for other contraceptive methods. About 6 males per 1,000 and 4 females per 1,000 used sterilization as a contraceptive method in 1977. But Ali and others (1978) provide evidence that sterilization was being increasingly adopted after 1972. Since 1977, the demand for female sterilization has been increasing, that of male sterilization declining, even though male sterilization is the focus of publicity campaigns. Some studies report postoperative health problems and sexual impotency as the main concerns of the clients before their acceptance of sterilization (Bhatia and others 1979, Quddus and others 1969, Huda and others 1968). But most studies suggest that about 60 percent of the sterilized clients in Bangladesh have reported no compaints after sterilization (table 5.12). Most sterilized people report an improvement or no change in sexual behavior or satisfaction after their operation. But some people report less sexual satisfaction and desire afterwards (table 5.13). Apart from the side effects and anticipated consequences on health (actual and feared), many potential users of family planning methods lose interest in practice and discontinue the methods owing to such situational obstacles as distance of service points from home, lack of privacy in the clinics, and lack of proper facilities (Mia and others 1977) (table 5.14). Similar findings were reported in another study (Proggani 1979). Akbar (1980) examined the difficulties that family welfare assistants face in persuading their clients (table 5.15). Fear of side effects followed by religious objection and excuses are the two most overriding problems. The other difficulties suggest that more attention should be given to male members of the society, with whom family welfare assistants have little direct contact. - 120 Table 5.12 Poststerilization Physical Complaints, Selected Studies in Bangladesh Studies No change Pain Swelling Weakness Infection Hoque 1968 63.34 15.5 1o6 6.6 Mannan 1969 41.0 21.0 300 3100 15O Quddus and others 1969 60.6 2.0 - Ahmed and others 1970a 61.0 1904 17.4 15.9 4.9 Khan and others 1977 42.0 29o3 38.5 3908 4.9 29.0 15.0 31.3 42.1 Sourceg Ali and others (1978). - 121 - Table 5.13 Sexual Aftereffects of Surgical Sterilization Mean age of Interval* Sexual effects Author and year clients (Months) Same Improved Deteriorated (percent) Islam (1967) - 1 - 24** 99.00 - 1 N = 619 Islam (1969) 38.0 yrs 1 - 24** 64.6 5.3 30.1 Khan (1968) 40.33 yrs 3 - 24 60.0 12.0 16.0 N = 50 Ouddus et al. (1969) - 3 59.0 9.0 29.0 N = 135 Mannan (1969) 46.35 yrs 3 - 36 58.00 15.0 27.0 N = 100 Ahmed (1970a) 50.5 yrs 6 - 12 39.39 3.03 44.95 N = 164 Ahmed et al. (1970b) 38.5 yrs 6 - 17 32.0 1.0 59.0 (wives of vasectomized persons N = 104) Khan et al. (Shibpur) 48.6 yrs 12 70.0 0.3 29.7 (1977) N = 304 Khan et al. (Salna) 46.3 yrs 12 85.0 0.4 14.6 (1977) N = 281 Averages (all studies) ** 63.00 5.75 27.93 * Interval between operation and interview. ** Estimated by the authors. Source: Ali and others (1978). 122 - Table 5014 Reason for Discontinuation of Use of Family Planning Methods Percent Reasons for Discontinuation N 505 Distance from clinics 26 Cost of methods 23 Waiting at the center 10 Family Planning personnel did not help 6 No sitting arrangement 16 Lack of privacy 82 Don't get medicine along with contraceptive g6 Note: More than one i-esponse was possibleo Source Mia and othero (1977)D pO 81. - 123 - Table 5.15 Difficulties Faced by Family Welfare Assistants to Persuade Couples to Accept Family Planning Percentage of FWAS Difficulty N-152 Fear and doubts about side effects 70 Religious objection and excuses 60 Ignorance and illiteracy 37 Indifference and apathy 33 Opposition/objection of husbands 24 Source: Akbar (1980), p. 122. 124 Table 5.16 Reason for Not Currently Using Family Planning for Currently Married, Nonpregnant Women, Bangladesh, 1979 Relative frequency Reason N = 10D822 Menopause or unable to have more children 1208 Breastfeeding or not resumed sexual union or postpartum amenorrhea 105 Side effect of method 9.0 Wants children 32.5 Wife's or husband's dislike 7.0 Religious reason 7.2 Lack of supplies irregularity in supplies 208 Other reasons 1Oo9 Does not know of any method or reason not specified 7.3 All 100l0 Source: NIPORT (1981), po 79. - 125 - About 87 percent of the currently married nonpregnant women are not currently using any method. The main reasons for their nonuse are in table 5.16. (NIPORT 1981). It thus appears that the delivery system for contra- ceptives has serious limitations in the terms of supply, the management of side effects, and the way program personnel deal with potential users. Contraceptive Acceptor Characteristics 1/ The user rate increases gradually from that of the 20-24 age group and reaches its peak with the 35-39 age group. In general, age and acceptance show a curvilinear relation, as do age and acceptance by method (table 5.18). On the average, vasectomy acceptors are the oldest (about 36), followed by tubectomy acceptors (about 30); abortion users are the youngest (about 26). Acceptance and the number of living children have a positive linear relation: the more living children women have, the more they use family planning (table 5.19). This pattern is the same for current and for ever- users and for different time periods. During 1968-75 there has been a positive change: even women of zero or single parity have started to adopt family planning. Fertility differences by method are not great: vasectomy, tubectomy, and IUD acceptors all have more than four living children; pill acceptors have three; sterilization acceptors have more living children that the users of other methods (table 5.20). For most methods, the majority of users have three to four children. The number of children a couple has is more closely related to family planning acceptance than the age of the woman. Diferences in Family Planning Acceptance Residence Rural-urban differences are far more pronounced for contraceptive use patterns than for knowledge. A study by the BFS (1978) shows that 28 percent of the urban women claim to have ever used contraception, compared with 12.3 percent of rural women. Similarly, 22.6 percent of urban women exposed to the risk of childbearing were currently using contraception, while only 8.5 percent rural were current users (table 5.21) But the different use rates of contraception in rural and urban areas were not reflected in different fertility rates. In all age groups, the fertility for urban women is not lower. The mean number of children for older women (married for 20 years or more) is the same as for rural women and is slightly higher for urban younger women than rural. This apparent contradiction can be explained: older women use contraception to prevent additional births, younger women to keep the family small (Alauddin 1980b). 1/ This section is largely drawn from a study by Hong (1980), Characteristics of Bangladesh, Dacca, 1980. 1 26 ITable 5017 Current Contraceptive Use by Age of Women- Bangladesh, 196869, 1975-76, and 1979 Percentages of currently married women currently using any method Nis, BFS BCPS Age 1968-69 1975-76 1979 15 l 16 2o6 15-19 - 5.1 5o2 20=24 1 9.3 11~l 25-29 4 9.9 13.8 30-34 7 13.6 170O 35-39 6 17.0 17.1 40-44 2 111 15.9 45.49 2 7.8 9.2 All 3c7 9.6 12.1 Source: Pakistan Population Planning Council, po68g Ministry of Health and Population Control, ppo A275 and A291;, NIPORT, po 610 - 127 - Table 5.18 Percentage Distribution of Family Planning Acceptors, by Method and Age Group, Bangladesh Abortion Vasectomy Tubectomy IUD Pill la Chitta- 2 3 4 4 5 6 7 3 8 gong Dacca Dacca CDS CDS Dacca Dacca Dacca Dacca Dacca Age 1978-79 1974-77 1968-69 1978 1978 1978-79 1978-79 1970 1968-69 1978 15-19 12.9 13.8 - - - - 10.2 - 8.6 20-24 38.4 33.9 - - - 4.1 21.9 38.6 5.7 22.7 25-29 29.1 26.3 0.3 1.2 37.9 38.3 43.7 30.8 33.5 37.1 30-34 14.1 16.4 2.1 10.2 32.6 45.5 22.1 12.0 28.5 19.3 35-39 4.9 6.5 15.6 21.1 20.6 11.7 11.7 6.6 27.2 12.1 40-44 0.6 3.1 15.8 24.4 7.4 0.4 5.1 0.2 45-49 - - 66.2 43.Ob 1.4 1.4 - 1.7 - - Women 817 354 791 402 417 290 506 590 471 652 Mean age 25.6 26.4 44.8c 43.6c 31.8 30.0 28.7 26.1 32.1 17.7 a. Age group -20, 21-25, 26-30, 31-35, 36-40, 41-45. b. Including persons 50 years and over. c. This is the mean age of husbands at the time of vasectomy. To compare these men's ages with women acceptors using any methods, the table subtracts eight years from men's mean age. Eight years is the average age difference between husbands and wives in Bangladesh. Source: 1. Bhuiyan and Begum, table 1. 2. Begum, et al, table 1. 3. Pakistan Academy for Rural Development, p. 19, p. 26. 4. Ali, et al, table 1. 5. Jabeen, et al, table 1. 6. Begum and Rahman, table 1. 7. Khan, et al, table 1. 8. Bairagi, et al, table 1. . 128 Table 5.i9 Contraceptive Use by Number of Living Childreng Bangladesh, 1968=69 and 1975-76 Percentage of currently Percentage of ever married married women currently women who have ever used using any method any method Number of NIS BFS NIS BFS living children 1968-69 1975-76 1968-69 197576 0 2.5 1 308 1 606 1 908 2 2 7.9 3 12.6 3 4 1iLl 8 1503 4 4 iio5 7 16.4 5 5 13.3 8 16.9 6 5 15.2 9 24.2 7 10 16.3 15 22.5 Source: Pakistan Population Planning Council, po 680 Ministry of Health and Population Control, ppo A295 and P2820 - 129 - Tables 5.20 Percentage Distribution of Contraceptive Acceptors by Method and Number of Living Children, Bangladesh Vasectomy Tubectomy IUD Pill 1 2 3 4 2 3 1 2 2 5 Living Dacca BFS CDS Dacca BFS CDS Dacca BFS BFS Dacca children 1968-69 1975-76 1976 1978/79 1975/76 1978 1968/69 1975-76 1975-76 1978 0-2 7.6 4.8 15.7 2.6 11.1 16.0 13.8 14.8 26.0 41.8 3-4 50.6 33.3 36.3 42.4 33.4 38.1 46.9 18.5 30.1 38.2 5-6 31.4 35.3 35.5 34.1 15.9 55.6 39.3 66.7 43.0 20.0 7+ 8.9 12.7 34.7 15.9 Mean 4.4 - 4.4 4.7 - 4.3 4.2 - - 3.0 Sources: 1. Pakistan Academy for Rural Development, p. 26. 2. Recalculated based on Ministry of Health and Population Control. A 290. 3. Ali, et al., table 1. 4. Jabeen, et al., table 1. 5. Bairagi, et al., table 1. - 130 Social class Contraceptive use patterns seem to correspond to social classes. Sorcar (1977) reported higher social status for acceptors of family planning methods than for nonacceptors0 It was also found that family planning acceptors tend to be more frequent anong service holders and traders than among farmers and wage earners. Stoeckel and Chowdhury (1973) observed that the occupational status group 'Business and Skilled' have more knowledge of family planning, a more favorable attitude toward it, and higher practice rates than do others. Studies on sterilization acceptors, however, show that landless and poor class couples are overrepresented. Khan and Choldin (1965) reported that the lower class and landless laborers were accepting sterilization more than other categories of people. Ali and others (1977) reported similar findings0 Greater acceptance of sterilization by the lower class has been regarded as a reaction of these people to the stress of economic hardship and to program incentives rather than to a planned response stimulated by aspirations for improved living conditions (Khan 1980)o The motivating factors need further studyo Occupation Ratcliffe and others (1968) found that most vasectomy clients (62 percent) are day laborers, the next most numerous are farmers owning some land0 Of the three indicators of socioeconomic status (occupation, education, and landholding) used in a study by Stoekel and Chowdhury (1973), only occupation was found to be consistently related to knowledge, attitudes and practice0 Businessmen and skilled workers, having the highest socioeconomic status, also had greater knowledge, more favorable attitudes and higher use of family planning0 Income Sorcar (1977) found that income is positively related to the adoption of family planning0 Chaudhury (1975) observed that income is positively related with support for abortiono The External Evaluation Unit of the Planning Commission (1979) found a consistent relation between family income and contraceptive use: women of higher income were more likely to be either current or ever users than women of low income0 But this does not hold true for sterilization0 Most sterilized cases, however, are likely to be poor, illiterate, landless laborers (Ratcliffe and others 1968). Similar findings have also been reported by Ali and others 1977, Ali and others 1978, and BAVS 1978. - 131 - Table 5.21 Rural-Urban Current Contraception in Bangladesh Percentage of ever users Study and Year Rural Urban NIS, 1968-69 1.9 3.7 BFS, 1975-76 8.5 22.6 BCPS, 1979 10.3 19.2 BCPS, 1981 17.5 29.2 - 132 Religion The BFS (1978) found that 7,5 percent of the Muslims and 1008 percent of the non-Muslims were using contraceptive methods. About 6908 percent of the Muslims as compared to 63.3 percent of the non-Muslims had no intention to use some method in the future. Stoeckel and Choudhury (1973) found that nearly twice as many Hindus as Mus'Lims approve of family planning, three times as many Hindus had ever practiced coitraception, and four times as many Hindus were currently using contraception0 But ';hese differences largely disappeared for unskilled laborers. Education Some studies on the use of contraceptive devices in Rargladesh tend to confirm the direct relation between level of education and use of contraceptiveg. Alauddin (1979) found that women's education is the single most important factor determining the knowledge of clinical met'hcds of contraception0 THe positive relation between female education and use of contraception holds true when allowance is made for the effect of age, parity, wife's labor force participation, husband's income, and exposure to mass media communication (Chaudhury 1977). Chaudhury (1978) also found that education is the best predictor of fertility behavior and even education up io grade 6 or 9 has a significant effect0 But Khan and Choldin (1965) reported that education does not seem to be related to the edoption of family planning, a finding that nevertheless should be interpreted with caution. Purdah Maloney and others (1980) found purdah to be negatively correlated with ever-use of modern contraceptivre methods (r -0.5). Purdah, among all other religiosity variables, was found to have the highest dearee of association with contraceptive acceptance0 It was also negatively correlated (r = -019) with ever-use of all kinids of contraception combined0 Education is negatively related to the observance of purdah, and in turn to fertility0 With the increase of literacy and education, ihe practice of purdah is likely to decrease and have a desirable influence on fertility norms0 Literacy for females currently aged 45 and above is oniy 4.6 percent, that for those aged 25-44 is 16 percent, that for those aged i5-24 is 30 percentS and that for those aged 10-14 the literacy rate is 32 percent0 It has also been suggested that a higher proportion of younger women attending school are becoming literate (Islam and others 1979), a trend also observed in census data0 Rural Development and Modernization The factors thus far identified as having an association with fertility and family planning, either positive or negative, relate only to individuals0 But another set of factors, subsumed under the rubric of - 133 - "development and modernization," have already contributed or are likely to contribute to demographic transition. In recent years, the hypothesis that joint efforts in rural development and population planning programs--rather than population planning programs alone-are likely to reduce fertility significantly has been widely accpeted in Bangladesh and elsewhere. Several projects were started during the 1970s to empirically test the hypothesis. Some other studies provided mixed but encouraging results to support it (Alauddin 1979, External Evaluation of Planning Commission 1979, Dixon 1978 [cited in Javillonar and others 1979], and Mia 1978). Alauddin observed that development-related factors--such as the proportion of families sending their children to school meals, level of education desired for children, access to educatinoal institution, and presence of a youth club in the village--have a significant relation with the knowledge of family planning methods. The availability of sanitation facilities, correlated with the level of education of the village, is significantly associated with knowledge of clinical contraceptive methods. Other modernization variables--modern agricultural practices; village access to health, family planning, and educational institutions, family planning workers' visits to villages, mean level of education desired for children--are positively related to knowledge of non-clinical methods. But the proportion of people engaged in agricultural activity is negatively related to knowledge of nonclinical methods. At the individual level, a woman's own education is the best predictor of knowledge of both clinical and nonclinical methods. Besides a woman's education, village level knowledge has strong positive association with individual knowledge of contraception, which in turn is the strongest predictor of contraceptive practice. Development programs and family planning programs have an almost equal contribution to village-level contraception. The combined effects of development and family planning are greater than the sum of effects of either separately. The effects of most development variables are indirect, through the extension of knowledge. Accessibility to means of transportation and visits to a village by family planning workers are significantly associated with a high level of individual contraceptive practice (Alauddin 1980, p.66). An evaluation study (cited in Government of Bangladesh 1976) shows a significant reduction of the population growth rate from the national average of 2.8 percent to 1.7 percent in 71 villages that have a Swanirvar program. The effectiveness of the program is shown by the rise in the age at marriage and the change of profertility norms to antifertility norms in many of these villages. Sanders and others (1976) documented an increase in contraceptive acceptance rate from 5 percent to 27 percent within a year or so, as a result of involvement of village leadership and wider participation of the villagers in planning and implementation of village health and family planning programs. A significant rise in contraceptive practice as a result of an integrated development and family planning has been reported by a follow-up study of the External Evaluation Unit of the planning Commission (1979). The current use of contraceptives was higher in mills where the family planning service system had been introduced than in mills without such services. In a - 134 - recent evaluation, Alauddin and Sorcar (1971a and 1981b) found current contraception and increasing income through income-employment-generating schemes to be highly related: 40 to 46 percent of the eligible couples of the income-generating families are currently using family planning 11ethods. 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Dacca: Institute of Statistics Research and Training, University of Dacca, 1976. Sanders, Keith F. and others 1976. "Impact of Family Planning through Village Leadership." Dacca: Community Development Foundation. Sattar, Ellen 1975. "Village Women at Work" in Women for Women. Dacca: University Press. Sattar, M.A. 1977. "Status and Role of Women in the ORganized Sector in Bangladesh." Paper presented at the ILO Sub-regional seminar on Status and Role of Women in the ORganized Sector, Dacca, December 12- 16. - 152 - Sen, AoKo 1977. "Starvation and Exchange Entitlements: A General Approach and its Application to the Great Bengal Famine," Cambridge Journal of Economics. Shahidullah, M. 179. "Differential Nuptiality Patterns in Bangladesh." Master's Thesis, Canberra; Australian National Ulniversity0 Siragelden, Ismail, M. Hussain and Mo Cain 1975a. "Family Planning in Bangladesh: an empirical investigation,"l Bangladesh Development Studies 3(1): 1-26. 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Human Fertility in Latin America. Ithaca: Cornell University Press. Ujang, Sharifah 1980. "Marry Late." The Bangladesh Times. Dacca; August 21. U.K. Ministry of Overseas Development 1977. Report on the 1974 Bangladesh Retrospective Survey of Fertility and Mortality. London and Dacca. U.S. Bureau of Census 1979. "A Compilation of Age-specific Fertility Rates for Developing Countries." (International Research Document No. 7). Washington, D.C.: U.S. Department of Commerce. Visaria, Pravin M. 1963. "The Sex Ratio of the Population of India." Ph.D. dissertion, Princeton University. World Bank 1979. "Bangladesh - Staff Appraisal of a Second Population and Family Planning Project" (Report No. 2323-BD) Populatin PRojects Department, Washington, D.C. W orld Bank Confronting Urban these studies is presented in Malnutrition: The Design of Migration in West Africa: Publications Nutrition Programs Demographic Aspects. of Related James E. Austin World Bank Staff Working Paper No. Describes a framework for 415. September 1980. vi + 385 pages llltere t systematically carrying out urban (including statistical annexes, nutrition programs that examines bibliography). several key considerations in nutri- Stock No. WP-0415. $15.00. tion education, on-site feeding, take- home feeding, nutrient-dense foods, ration shops, food coupons, fortifica- Economic Motivation versus tion, direct nutrient dosage, and food City Lights: Testing processing and distribution. Hypotheses about Inter- The Johns Hopkins University Press, Changwat Migration in 1980.136 pages. Thailand LC 79-3705. ISBN 0-8018-2261-0, Fred Arnold and $6.50 (f4.50) paperback. Susan H. Cochrane World Bank Staff Working Paper No. The Costs and Beneflts of 416. September 1980. 41 pages Family Planning Programs (including footnotes, references). George C. Zaidan Stock No. WP-0416. $3.00. 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