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Baseline Study: Documenting Knowledge, Attitudes and Behaviours of

Rohingya Refugees and the Status of Family Planning Services in UNHCR’s

Operation in Cox’s Bazar, Bangladesh

December 2012

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Table of Contents Executive Summary ................................................................................................................................. 4

Key Recommendations ....................................................................................................................... 5

Immediate Recommendations ........................................................................................................ 5

Long-term Recommendations ........................................................................................................ 6

Introduction ............................................................................................................................................ 8

Objectives ............................................................................................................................................... 9

Literature Review .................................................................................................................................... 9

Methodology ......................................................................................................................................... 11

Household Survey ............................................................................................................................. 11

Facility Assessments .......................................................................................................................... 12

In-depth Interview ............................................................................................................................ 12

Focus Group Discussions (FGDs) ....................................................................................................... 13

Ethical Consideration ............................................................................................................................ 13

Presentation of Findings ....................................................................................................................... 14

Household Survey ................................................................................................................................. 14

Facility Assessment ........................................................................................................................... 17

Qualitative Findings .......................................................................................................................... 19

Discussion.............................................................................................................................................. 23

Limitations ............................................................................................................................................ 24

Appendices ............................................................................................................................................ 25

Appendix I: Household Survey Data Tables ...................................................................................... 25

Appendix II: Health Facility Assessment Summery ........................................................................... 35

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Acknowledgements

The report was researched and written by Dr. Zinia Sultana on behalf of United Nations High

Commissioner for Refugees (UNHCR) and reviewed by Mihoko Tanabe of Women’s Refugee

Commission (WRC), Stacy De Jesus of Center for Disease Control and Prevention (CDC), Dr. Herve

Isambert and Nadine Cornier of UNHCR. The study was a joint effort between UNHCR and WRC.

Technical assistances were provided by Mihoko Tanabe and Stacy De Jesus during planning and

implementation of the study. Nadine Cornier (UNHCR) was responsible for providing overall project

direction.

The researcher would like to acknowledge the generous support of UNHCR Cox’s Bazar ‘Health and

Nutrition’ team: Dr. Taimur Hasan and Md. Mezanur Rahman for their contribution to enable the

project to be completed. Special thanks to Dr. Taimur Hasan for facilitation of coordination

throughout the study. A note of thank is also offered to Ikhteruddin Bayzid for assisting with

transports for the survey team and to A. K. Muhammad Saiful Haque for providing information from

UNHCR proGres database for the study.

The researcher is grateful to the data collection team, focus group discussion facilitators and data

entry staff: Selina Akhter, Sein Nu, Sahida Jahan, Mitu Barua, Monwara Parvin, Rina Barua, Rokhsana

Akhter, Sajeda Haque, Sajeda Yasmin, Md. Nurul Amin, Fazlul Kabir Chy and Nazmul Alam. In

addition, the researcher would like to express appreciation to the community volunteers for helping

the data collection team to locate the selected households during conducting household survey.

The project would not have been possible without the participation of refugee leaders, men, women

and adolescents in the in-depth interviews, focus group discussions and household survey.

Appreciation also extends to the administrators and service providers of each facility visited for their

time to share important perspectives on family planning situation in and around the refugee camps.

Finally and most importantly, the researcher offers sincere gratitude to Mihoko Tanabe, Nadine

Cornier and Stacy De Jesus. This project would not have gone forward without the guidance and

support of them.

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Acronyms and Abbreviations

ANC Antenatal Care BMC Block Management Committee CDC Centers for Disease Control and Prevention CHWs Community Health Workers CMC Camp Management Committee CPR Contraceptive Prevalence Rate CTBA Community Trained Birth Attendant ECP Emergency Contraceptive Pill FGD Focus Group Discussion FP Family Planning GoB Government of Bangladesh HIS Health Information System IAWG Inter-agency Working Group IUD Intra Uterine Device IEC Information, Education and Communication KTP Kutupalong MCH Maternal and Child Health MOH Ministry of Health NRS Northern Rakhine State NYP Nayapara RH Reproductive Health RHU Refugee Health Unit RTMI Research, Training and Management International TBA Trained Birth Attendant UNFPA United Nations Population Fund UNHCR United Nations High Commissioner for Refugees WRC Women’s Refugee Commission WRA Women of Reproductive Age (15-49 years)

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Executive Summary The report addresses a family planning (FP) study undertaken by the United Nations High

Commissioner for Refugees (UNHCR) and the Women’s Refugee Commission (WRC) among Rohingya

refugees residing in two official camps (Kutupalong and Nayapara) in Cox’s Bazar, Bangladesh from

November to December, 2012. It aims to document the knowledge, beliefs, perceptions and

practices of refugees, as well as the quality of services provided in order to improve programming

and subsequently increase uptake of FP services among refugee population.

The baseline study employed a multi-pronged approach that includes a literature review of family-

planning related information, data and available services among the refugees in the host country; in-

depth interviews with community leaders to learn about challenges and barriers to increasing

uptake among refugee community; a household survey that was adapted from CDC’s reproductive

health assessment toolkit to gather family planning-related knowledge, attitudes and behaviors

among women of reproductive age (WRA); focus group discussions (FGDs) with women, men, and

adolescent boys and girls in the camps to gather data on attitudes and barriers; and facility

assessments to examine service availability, quality of services and provider opinion.

Key Findings:

The results of the study depict the awareness on FP services among refugees living in Kutupalong

(KTP) and Nayapara (NYP) camps. The household survey indicates the contraceptive prevalence rate

(CPR) as 37.7% for any method and 36.9% for modern methods among WRA. The FP services in both

the camps are integrated with Director General of Family Planning Services of Bangladesh

Government which targets only married couples as eligible for the service. Therefore, the CPR has

been calculated in the study for ever married women, and was found at 44% for any method and

43% for modern methods, respectively. The most preferred methods are injectable (57.6%) and oral

contraceptive pills (32.9%) among the women currently using any FP method. None of the

participants used the intrauterine device (IUD). Knowledge of emergency contraceptive pills (ECP)

and traditional FP methods is very limited. The survey further revealed that 2.4% of women have an

unmet need for FP services. Among those who are not using contraceptive methods, “wanting more

children” and “not having sex/infrequent sex” were reported as the most common barrier to using

FP. The proportion of women not currently using a contraceptive method but intend to use in next

12 months is 6%.

The in-depth interviews and FGDs show that the refugees are satisfied with the current FP service

delivery system at the camp level. The decision about using FP is generally made by the couple.

According to the participants, resistance from the community has been reduced as refugees are now

more aware about advantages of using FP methods. They are concerned about provision of basic

needs for the children and family, the refugees believing that it would be easier to meeting their

needs when the family size is small. However, opposition by the husband to use FP methods still

exists to a limited extent. As a part of the national FP programme, commodities are free and easily

accessible for married couples, but the services are not available to unmarried adolescents. There is

a well-functioning referral system to the Upazilla Family Planning Offices for clients who opt for long

term and permanent methods. The facility assessments revealed that infection prevention and

systems of maintaining privacy are not satisfactory in these government FP clinics.

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Key Recommendations The following recommendations are based on qualitative and quantitative findings of the study:

Immediate Recommendations

• Develop strategy to target adolescents for providing information on family planning: Given

the young age at which most of the refugees commonly marry, it is important to sensitize them

before they become sexually active to avoid experiencing unwanted pregnancy just after being

married. Information and education on sexual and reproductive health, including FP should be

integrated with all programmes in the camps that target adolescents. Coordination with UNHCR’s

Community Service Unit should be established in this regard.

Address the misconception in the community related to FP services by organizing

sensitization programmes for elderly people: As brought out by the FGD participants, elderly people

in the community still have some misconceptions and myths related to FP and related services. Even

though the resistance from the community has been reduced through different community

awareness programmes, continuous sensitization programmes such as drama, quiz and discussions

targeting elder members of the community might help reducing it further.

• Review the existing information, education and communication (IEC) materials and

develop pictorial formats: Most of the refugees in the camps are not able to read and write.

Therefore, existing IEC materials should be revised into pictorial formats to disseminate the

messages on FP. The messages should include advantages, possible side effects and what to do if

users experience side effects, along with the information on all available methods. New IEC materials

could be developed addressing the problems of early pregnancy and the impact on the health of the

mother, baby and family when child spacing is not maintained in a family.

• Arrange training for staff in managing side effects: The staff working in the camp clinics

reported training needs on management of side effects such as amenorrhea (stoppage of

menstruation), spotting (bleeding in between menstruation) and menorrhagia (severe menstrual

bleeding). They also need to be trained on counseling clients who have misconceptions related to

contraceptive use, for instance, lump in lower abdomen due to stoppage of menstruation, weakness,

headache and depression for using contraception, and lack of sexual interest and pleasure for using

permanent method.

• The Implementing Partner working in the camps for FP programme should procure

emergency contraceptive pills (ECPs) and provide information and education to the refugees about

the option: According to the household survey results, the refugees have very little information

about ECPs. Therefore, appropriate measures need to be taken to provide them with adequate

information. At the same time, secondary sources for stocks of ECPs should be explored as it has

been stocked out from the government supply since last year. Information on ECPs should be

delivered cautiously, mentioning that it should not be used as a regular contraceptive method.

• Engagement of male, religious and community leaders should be strengthened: To

strengthen male engagement, it is important to continuously promote male refugees and make

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them responsible for organizing special FP days and various communication activities for their group.

The messages from Quaran and Hadith that promote FP or child spacing should be disseminated

widely in the community by distributing the booklet called “FP in the light of Islam” to all religious

and community leaders who can read the booklet and inform others. The well-informed religious

leaders from the host community could be invited to the camp to talk to the refugees in the

awareness-raising programmes.

• Community Outreach programme should focus on counseling women who want more

children or who report living irregularly with their husband but are not using any contraceptive

method, while respecting individual choice: It has been identified that the women who are at risk of

getting pregnant and are not using any contraceptive methods mostly reported “want more babies

now” or “not having sex/irregular sex with husband” as barriers to using FP methods. It needs to be

confirmed that these women clearly understand the benefits of FP and are aware of available

methods. It is important to inform the latter group about the method they might want to use when

the husband comes to the camp infrequently.

UNHCR HIS should use exact number of women of reproductive age for the denominator

to calculate CPR: The study identified a disparity between CPR in the HIS (55%) and CPR from the

survey (37.7%) among WRA. The reason for this disparity was recognized as considering an

estimated percentage (20%) of the total population to obtain the total number of 15-49 years

women in the HIS. The differences between the estimated figure of WRA in the HIS and the actual

figure from UNHCR database for refugees (proGres) found to be noteworthy. Therefore, it is

recommended that the exact number of WRA generated from the monthly updated proGres

database be used in the HIS to calculate the most accurate CPR, which would help monitoring of

the real coverage of contraceptive use among refugees in both the camps.

Long-term Recommendations

Implementing Partners should explore the possibilities for introducing Menstrual

Regulation (MR) services to refugees: MR is a vacuum aspiration method performed within 10

weeks of a woman’s last menstrual period to pull out the lining of the uterus which would normally

be shed in menstruation.1 The procedure is offered by the government health care service to

women who are at risk of being pregnant but want to establish a case of non-pregnancy. The

purpose is to reduce the risk of unsafe abortion as well as maternal mortality and morbidity. In

order to provide access to services to the refugees as in host community, the provision of the MR

service from government health complexes should be explored. Considering the cultural and social

sensitivity towards abortion, the community needs to be sensitized before this service is offered to

refugees. Once it is acceptable to the community, a referral system to Upazilla Family Planning

Office in Teknaf should be established after ensuring that proper infection prevention systems are

in place.

Ukhiya and Teknaf Family Planning Office to ensure privacy of the client: Both of the

private facilities’ infrastructure needs to be improved to provide privacy and confidentiality to

1 Menstrual Regulation, Magnus Hirschfeld Archive for Sexology. Accessed from http://www2.huberlin.de/sexology/ECE2/html/menstrual_regulation.html on 20 January, 2013.

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clients, such as, using a proper curtain to hide the patient who is being examined in the counseling

room or creating a separate waiting room so that all the clients are not waiting inside the

counseling room together.

Improve the infection prevention system in Upazilla Family Planning clinics where long-

term and permanent methods are being provided to refugees: The issue of post-surgical infection

of women who have chosen permanent FP methods in public facilities was raised by facility staff at

camps and also participants of FGDs. The poor infection prevention system in both Upazilla Family

Planning offices was noticed during the facility assessment visit. The waste and sharps disposal

plan needs to be improved in the KTP FP clinic. Staff training is necessary on how to follow

standard precautions in health facilities. A regular monitoring and evaluation system should be

established to ensure infection prevention control measures are standardized across all facilities.

Introduction The refugee context in Bangladesh is identified as one of the most challenging protracted refugee

situations in the world. As a result of continuous persecution, discrimination and exploitation of

Rohingyas (Muslim inhabitants of Rakhine state) in Northern Rakhine State of Myanmar, influxes of

around 250,000 Rohingya refugees took place in 1978 and 1991-92 to Cox’s Bazar, the south-eastern

district of Bangladesh. In both cases, the influxes were followed by large scale repatriation.2

As of 30 November 2012, there are a total 30,369 registered refugees residing in two official camps:

Kutupalong (KTP) and Nayapara (NYP) in the area of Ukhiya and Teknaf in Cox’s Bazar district. There

are 14,648 males and 15,721 females in both camps. The total population in KTP camp is 12,359 and

in NYP 18,010.3 The distance between two camps is 36 km. A large number of persons of concern

remain unregistered, comprising roughly 200,000 and living in host communities. Around 40,000 of

them live in makeshift sites adjacent to the official camps.4 UNHCR is only permitted to assist

refugees in official camps; it has no access to undocumented persons with similar profiles. Refugees

face certain restrictions in their freedom of movement and in their ability to access employment,

education and basic social services.

Access to family planning (FP) services is a human right5 and neglecting FP can have serious health

consequences. Restoring access to safe, effective contraceptives can reduce unwanted pregnancies,

unsafe abortion and resulting maternal death and disability. It also provides women and girls the

autonomy to determine the number and spacing of their children, access to educational and

livelihoods opportunities, and possibilities for families to manage scarce resources more effectively.

The Statement on Family Planning for Women and Girls as a Life-saving Intervention in Humanitarian

Settings, developed by the Women’s Refugee Commission on behalf of partners and endorsed by

the steering committee6 of the Inter-agency Working Group (IAWG) on Reproductive Health in Crises

in May 2010 outlines existing standards on providing contraceptives from the onset of an emergency

and throughout protracted crisis and recovery. It further describes methods of service delivery and

recommendations for governments, donors and implementing agencies.

While UNHCR has focused on emergency obstetric care, gender-based violence and HIV/AIDS in the

past several years in most of its operations, FP activities have not been given sufficient attention to

ensure adequate access for refugees and other persons of concern. FP coverage in camp settings has

reportedly been low; programs in the field are often very poor to non-existent. However, in 2010,

2 UNHCR, Policy Development and Evaluation Service, ‘State of Denial’, 2011. 3 UNHCR, Cox’s Bazar, Camp Population Statistics for the month of November, 2012. 4 UNHCR, 2012 Country Operation Profile- Bangladesh, Accessed from http://www.unhcr.org/pages/49e487546.html on 19th December, 2012. 5 Under international law, universal access to family planning is a human right. According to Article 16(1) of the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), all individuals and couples have the “right to decide on the number, spacing and timing of children”. The Progarmme of Action from the 1994 International Conference on Population and Development also notes the right of couples and individuals, “to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so” (Article 7.3). Moreover, General Comment No. 14 para 12 of the Committee on Economic, Social and Cultural Rights states that the right to the highest attainable standard of health includes the “right to be informed and to have access to safe, effective, affordable and acceptable methods of family planning”. 6 IAWG on RH in Crises Steering Committee agencies include American Refugee Committee, CARE International, Centers for Disease Control; Columbia University School of Public Health, International Medical Corp, International Rescue Committee, Jhpiego, JSI Research and Training Institute, Marie Stopes International, UN High Commissioner for Refugees, UN Population Fund; Women’s Refugee Commission, World Health Organization.

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several country programs reported an increase in uptake in contraceptive methods that could be

linked with changes in service provision.

Therefore, UNHCR intended to document knowledge, beliefs, perceptions and practices of refugees

as well as the quality of services provided in UNHCR operations to improve programming and

subsequently increase uptake of FP services among women, men and adolescents. Finding and

recommendations from this baseline study will be used to inform and improve FP programming in

the country programme.

Objectives

Goal

To document knowledge, beliefs, perceptions and practices of refugees, as well as the state of

service provision in UNHCR operations to improve programming and subsequently increase uptake

of FP services among women, men and adolescents in such settings.

Objectives of the baseline study

• To increase baseline information to guide policy and planning.

• To document promising practices.

• To collect information:

- For improving quality of services through training and guiding health and community

providers, and improving infrastructure as required.

- For adapting programmes according to barriers, beliefs, fears and perceptions, in terms of

information, education and communication efforts and service delivery.

- For expanding access through a broader choice of contraceptive methods, community-based

distribution and linkages with national programmes or other in-country initiatives as

appropriate.

Study Question:

This study aimed to answer the primary question: What are the barriers and challenges at the

community and health facility-levels that hinder increased uptake of contraceptives among the

selected refugee communities, and what are the practical ways that the challenges can be

addressed?

Literature Review Bangladesh is the eighth most populous country in the world and the fifth largest in Asia with a

population of 160 million. It is the most densely populated country in the world (1,000

persons/square km). A recent assessment by the United States Agency for International

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Development (USAID) identified influencing factors for rapid population growth in Bangladesh as

young age at marriage, decreased death rate, early childbearing age and low rate of contraceptive

use.7

The official FP programme started in Bangladesh in 1960. In 1976, the National Population Council

was established when growth in population was declared as the number one problem of the

country. The Ministry of Health and Family Welfare (MoHFW) has two directorates (Director General

Health Services and Director General FP) to deliver health, nutrition and population services to the

people.8 The ‘Health, Nutrition and Population Sector Programme’ (HNPSP) was launched by the

government in 2003. The program proposed Health, Nutrition, and Population Sector Strategic Plan

(HNPSSP) in 2011 which intends to revitalize FP programming by delaying age at marriage and child

birth, and increasing access to long-term and permanent FP methods with the aim of reaching a

contraceptive prevalence rate (CPR) of 72% by 2016.9

The current FP services target only married couples. The national FP guidelines stated that

unmarried, widowed and divorced persons are not permitted to receive the services. In addition, the

client should have at least one child in order to receive injectable method and implant. To be eligible

to receive a permanent method, the client should have two children and the age of the younger

child should be more than 2 years of age.10 These conditions also apply to refugees who intend to

receive any of these methods.

According to the Bangladesh 2011 Demographic and Health Survey, CPR among currently married

women is 61%, which is a 6% increase from 2007 (BDHS, 2007). However, the rate varies between

regions. The CPR among currently married women in the region where refugee camps are situated

(Chittagong) is 51%. The percentage of unmet need is 12% among married women in the country,

whereas, it is 19% in Chittagong region. All over the country, 52% of married women are using

modern FP methods and the percentage of traditional method users is 9%. The predominant source

for FP services is the Public Sector at 52.1%, followed by the Private Medical Sector (private hospital

and doctor, pharmacy) at 38.4%. Additional sources include other private sources (market,

family/friends) (4.4%) and the NGO sector (4.3%). Among Bangladeshi women, the most preferred

method is the OCP (27%); the second preferred method is the injectable contraceptive (11%).11

Existing FP services in KTP and NYP camps in Bangladesh are being provided through one national

NGO, Research, Training and Management International (RTMI). The organization is an

implementing partner of UNHCR and UNFPA to provide reproductive health services to the

refugees.12 The service is integrated with Director General FP services of Bangladesh as a part of

national FP programme.

All the services offered to the clients by FP department of Bangladesh are free of cost. The

temporary FP methods are supplied by the government FP offices to RTMI for refugees. The

available methods at FP clinic in the camps include OCPs, male condoms and injectables. Clients are

7 USAID/BABGLADESH, Population and Family Planning Programme Assessment, 2010. 8 UNFPA-ICOMP Regional Consultation, Bangladesh Family Planning Programme-Achievements, gaps and way forward, 2010. 9 Director General Family Planning, Government of Bangladesh, Accessed from www.dgfp.govt on 25 December, 2012. 10 Family Planning Manual, Director General Family Planning Bangladesh, 2007. 11 Bangladesh Demographic and Health Survey, 2011. 12 Email communication with RTMI Programme Officer on 17 December, 2012.

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referred to the nearby government FP clinics for IUDs, implants, tubal ligation and vasectomy. ECPs

are included in the national guidelines as an emergency option for contraception after unsafe sex,

such as condom breakage, missed taking of OCPs for three consecutive days, or delay for more than

two weeks for a scheduled Depo injection. However, ECPs have been stocked out since last year and

the government has not taken the initiative for its procurement. Female condoms are not promoted

and supplied because of low demand among women. Both of these items are available locally from

the market and pharmacies.13

Beside these methods, the Department of FP of Bangladesh provides Menstrual Regulation as a

backup for contraceptives that averts unsafe abortion and associated maternal morbidity and

mortality, as well as saves scarce heath system resources.14 Menstrual Regulation (MR) is defined as

"an interim method to establish a case of non-pregnancy in a woman who is at risk of being

pregnant," which is performed within 10 weeks of a woman’s last menstrual period.15 The service

was introduced and incorporated into the essential services package by the Government of

Bangladesh (GoB) in 1998 through the Health and Population Sector Programme (HPSP), despite

having highly restrictive abortion laws.16

According to UNHCR’s HIS, the CPR for 2012 (January-November) in KTP and NYP refugee camps is

57% and 53%, respectively and the combined CPR in both the camps is 55%. The estimated

percentage (20%) of the total population is used as the denominator for the indicator, which does

not reflect the real figure of WRA in both camps. The actual number of WRA can be obtained from

the updated ‘proGres’ database.17 Coverage stands at 43% when using the number of WRA from the

proGres database as the denominator and the same number from the HIS as the numerator for that

specific period.

The most recent UNHCR household survey (2010) in Northern Rakhaine State of Myanmer revealed

the CPR as 20.8% for Maungdow and 22.4% for Buthidaung Township, where most of the residents

are of a similar ethnicity (Rakhaine Muslim) as the refugees of the camps in Cox’s Bazar. The CPR was

found as 43.4% in Rathedaung Township where only one third of heads of households are of similar

ethnicity as the refugees.18

Methodology

Household Survey The household survey was conducted in both camps using an adapted version of CDC’s Reproductive

Health Assessment Toolkit for Conflict-Affected Women. The survey gathers FP-related knowledge,

attitudes and behavior information among women of reproductive age (15-49 years).

13 Communication over phone with Upozilla Family Planning Officer, Ukhiya and Teknaf, 18 December, 2012. 14 Johnston B, H et al (2010) Health System Costs of Menstrual Regulation and Care For Abortion Complications in Bangladesh. 15 Banson, J et al (2010) Reductions in abortion-related mortality following policy reform: evidence from Romania, South Africa and Bangladesh. 16 Chowdhury SN, (2012), A situation analysis of the menstrual regulation programme in Bangladesh. 17 proGres is UNHCR database application used to register and store information of refugees. Accessed from http://www.unhcr.org/pages/49c3646cf5.html on 29 January, 2013. 18 UNHCR, 2010 Household Survey, Northern Rakhine State, 2010.

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Since the population characteristics are similar in both the camps, the sampling frame was prepared

by combining lists of WRA from the proGres database. The database of registered refugees was last

updated in April 2012.

A total 525 households were randomly selected by generating random numbers of the households in

Excel. To conduct the survey, eight interviewers and two supervisors were trained by the study

coordinator on survey methodology, RH terminology, ethical aspects of the study, roles and

responsibilities of the survey team, interviewer techniques and filling out the questionnaire and

locator form. All of the members of the interview team were female and they could speak the local

Chittagonian dialect that is spoken by the refugees. The consent form, locator form and

questionnaire were translated into Bangla by the study coordinator and then reviewed by a second

translator. Back translation into English was also done by another translator before conducting

training for the survey team. The tools were revised after piloting in KTP camp. Finally, one

supervisor and six interviewers were selected upon their performance in training and piloting to

conduct the survey. The study coordinator and supervisor were each responsible for supervising

three interviewers during data collection. Refugee volunteers helped interviewers to locate the

selected households. Data collection in KTP and NYP camps took place consecutively from 18-26

November. Each camp is divided into seven blocks. One refugee volunteer from each block was

engaged to locate the selected households from his/her specific block; they also informed all women

of the selected households to be present at the day of interview in advance. The interviews were

conducted at households of the selected participants. The other members of the households were

informed that the interview is to collect information on women’s health and were requested to

allow interviewing alone at home to maintain privacy. The interviewers obtained informed consent

and used the locator form to randomly select one WRA from each household. Up to three attempts

were made at each household before a WRA was recorded as absent.

Using the updated proGres database to get the household addresses and providing information to all

women in advance helped the study to complete 507 questionnaires, resulting in a 96.5% response

rate.

The collected data were entered by two data entry staff in CSPro version 5.0. The two datasets were

then concatenated by the study coordinator and analysis was conducted in SPSS (version 21)

software.

Facility Assessments Two FP clinics at camp level run by RTMI and two referral centers at Ukhiya and Teknaf Government

Health Facility were assessed using UNHCR/WRC tools to examine service quality, availability of

services and to learn provider opinions. The tools consist of a health facility checklist, a short

interview with the provider, and an observation of FP consultation. The interviews with service

providers were conducted in Bangla after obtaining informed written consent. Since staff and the

study coordinator both speak Bangla, an interpreter was not required.

In-depth Interview A total of four refugee leaders were interviewed from both camps. One member of Community

Management Committee (CMC), one Imam and two female members of the Block Management

Committee (BMC) were identified from each camp for in-depth interviews to gather information

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about challenges and barriers to increasing uptake of FP services. The UNHCR camp office was

chosen as the interview place to maintain confidentiality.

The refugee leader pre-structured questionnaire was developed by UNHCR and WRC and translated

into Bangla. The interviews were conducted in the local dialect with the help of an interpreter who

could speak and understand the local dialect. The responses were noted in Bangla and then

translated into English at the time of transcription by the study coordinator. The consent form was

also translated into Bangla to obtain informed consent from the participants prior to the interview.

Each discussion lasted for an hour to an hour and a half.

Focus Group Discussions (FGDs) A total of six FGDs were conducted in both camps with adolescent boys and girls, and adult men and

women using UNHCR and WRC tools to learn about the attitudes and perceptions of these groups

towards FP services, and the challenges and barriers to increasing uptake. The age range for

adolescent group was 15-19 years, and for adult men and women, 20-45 years. Convenience

sampling was used with the help of community volunteers to identify at least one participant from

each block to ensure that participants were not from the same area of the camps. The volunteers

were asked not to select any refugee who is working as a volunteer with any agency providing health

services in the camps, to avoid the bias of being more aware of the issues. The pre-structured

question form was translated into Bangla by the study coordinator.

All interviews were recorded using a tape recorder and then transcribed by the study coordinator.

The FGDs in KTP camp consisted of nine adult men, eight adult women, seven adolescent boys and

seven adolescent girls. The two groups in NYP camp comprised of eight adult women and eight

adolescent girls.

UNHCR camp offices in both camps were chosen for the interview location to ensure confidentiality.

The discussions were conducted in the local dialect with the help of the interpreter. One male and

one female interpreter were assigned to help conduct the FGDs in the local dialect, with adolescent

boys and adult men’s groups, and with adolescent girls and women’s groups, respectively.

Discussions lasted between an hour and an hour and a half.

Informed consent was obtained verbally from all participants and the consent papers were signed by

the interpreters on behalf of the participants of each group.

Ethical Consideration Local authorities were informed and approvals were obtained to conduct the study in the camps.

The data collection team was trained on study ethics and ethical issues that relate to working with

refugee population. Verbal consent was secured after providing information to the participants

about the procedures and voluntary nature of their participation, assurance of confidentiality, and

that no risk or adverse consequences could be identified in participating or not participating in the

study. No names or any other identifying information was recorded during data collection. All audio

recordings of the FGDs were destroyed after transcribing the data for analysis. The completed

questionnaires were stored at the UNHCR Office in Cox’s Bazar and will be destroyed after five years

if no further analysis is required.

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Presentation of Findings

Household Survey Demographics: The sample size for the household survey was 525 women between the ages of 15-

49 years. A total 507 completed questionnaires were received with the response rate of 96.5%.

Almost all of the women were Muslim (99.8%).19 The percentage of women who ever attended

school was 27%. The mean age was 29.5 years (Standard Deviation, SD= 6.3). The average household

size was 6.3 and average number of children per family was 4.0.

More than half of the married women were married before age 18 (50.7%); the second highest

number of women could not remember their age at first marriage (34.3%).The majority of women

(85.6%) had ever been married. Among those who had ever been married, about 85.9% were

currently married, 7.6% were divorced or separated and 6.2% were widowed.20 21.4% of ever

married women reported that their husband had more than one wife.

Table 1: Demographic characteristics of women participated in the household survey (N=507)

Age

15-24 38.5% (199)

25-34 40.2% (208)

35-49 21.3% (110)

Ever attended school

Yes 27.0% (137)

No 73.0% (370)

Marital status

Married 85.6% (434)

Not married 14.3% (73)

Age at first marriage (N=434)

<18 years 50.7% (220)

>18 years 14.9% (65)

Don't remember 34.3% (149)

The proportion of women who had ever been pregnant was 98% among ever married women.

Among women who had ever been pregnant, 10 %of them reported having had a stillborn and 9.1%

had a spontaneous or induced abortion.

Knowledge of Contraception: Among all women, the most widely known methods of FP included

OCPs (86.6%), injectables (81.5%), male condom (64.9%), tubal ligation (46.2%), implants (42%) and

IUD (18.5%). A small proportion knew about the female condom (5.1%) and emergency

contraception (2.8%). Knowledge of traditional methods was found to be very low (rhythm/calendar

method at 0.6%, and withdrawal at 0.6%). Although the percentage of women who have ever heard

of (86.6%)or were instructed on how to use the pill (76%) were slightly higher than the women who

19 One participant was Hindu (0.2%). 20 One participant had no response (0.2%).

15

had ever heard of (81.5%) or instructed (75%) about injectables, the percentage of women who had

ever used a method was found to be higher for injectables (injectables 49.3% and pills 42%). The

result on awareness of FP methods is presented below in Graph 1.

*Percentages may add up to greater than 100% as respondent may give more than 1 response.

Use of contraception: Among all women interviewed, the proportion of women who reported having

ever used any FP method was 61.7%. Among ever married women, the CPR was 44%. Among WRA,

the proportion of women who are currently using any method was 37.7%, and the proportion of

those who are using modern methods (pill, condom, IUD, implants, injectables, emergency

contraception, tubal ligation and vasectomy) was slightly lower, at 36.9%. The results are shown in

Table A, B and C. The most commonly used methods being used by currently married women are

injectables (57.6%) and Pills (32.9%). Graph 2 presents the result on using different FP methods by

currently married women.

86.6%

18.5%

64.9%

5.1%

42.0%

81.5%

2.8%

46.2%

0.6% 0.6% 0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Wo

me

n W

ho

are

Aw

are

of

Me

tho

d

Family Planning Method

Graph 1: Awareness of Family Planning Methods Among Women of Reproductive Age

16

*Percentages may add up to greater than 100% as respondent may give more than 1 response.

According to the age group of women, the highest percentage of women using contraceptives are

aged 25-34 years (54.5%), followed by women aged 15-24 years (23.6%) and women aged 35-49

years (21.9%). This shows low coverage of contraceptive use among younger and older women who

are still within reproductive age. Among women who are currently using contraceptives, 95% of

them are living with their husbands and the remaining 4.2% are not. More than half of the surveyed

women who are using contraceptives have more than four children (52.9%); 27.2% have 3-4

children, 18.8% have 1-2 children and only 1.0% have no children. Table 6 shows the results.

Source of Modern Methods: Among women who reported using a contraceptive method, the

majority (84.8%) obtained it from FP clinics in the camps which are supplied by the Government FP

programme, and 13.1% received the service from Upazilla FP offices. A very small proportion

reported purchasing their contraceptives from the market (1.0%) and pharmacy (1.0%). Tables 4 and

8 show the distribution of locations according to the knowledge of women from where she would

obtain contraceptives and from where women currently using contraceptives obtained their

method, respectively.

Barriers to FP: Unmet need for FP was defined as the percentage of women who are at risk for

pregnancy, want to space or limit their childbearing, but are not using a contraceptive method. It

includes women who report being fecund, sexually active, not pregnant, not postpartum, who do

not want a baby now or want a baby at least one year from now. The findings showed 2.4% women

have an unmet need for FP. The most common barriers among women with an unmet need for FP

were found to be fertility-related reasons, opposition by husband/respondent to use and perceived

method-related reasons.21

Intent to use a Method: The proportion of women who are not currently using a FP method, but plan

to in the next 12 months was 6%. The result is shown in the Table E.

21 Since the sample size for unmet need for FP services was too small (12), the percentages of different reasons reported as barrier by the women who are in risk of getting pregnant have been excluded here.

0.5%

0.5%

1.0%

1.6%

4.7%

1.0%

57.6%

4.2%

0.5%

5.2%

32.9%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0%

Others

Periodic Abstinence

Lactational Amenorrhoea

Vasectomy

Tubal Ligation

Emergency Contraception

Injectables

Implants

Female Condom

Male Condom

Pill

Women Who are Currenty Using Family Planning Methods

Fam

ily P

lan

nin

g M

eth

od

Graph 2: Family Planning Method being Used Among Women Who are

Currently Using Any Family Planning Method

17

Facility Assessment

Access to FP services: Refugees have access to FP services through RTMI which is integrated with the

national programme. The organization has been providing reproductive health services to the

refugees residing in KTP and NYP camps as an implementing partner of UNHCR and UNFPA since

October 2007. It took over FP services from RHU (Refugee Health Unit) of MoH in April 2009.22 The

methods provided at the camp clinics are OCPs, condoms and Depo injections. All methods are free

of cost from the government FP clinic at Ukhiya and Teknaf. Except ECPs, there was no stock out of

either temporary or permanent methods. Female condoms are not supplied and promoted due to

the low demand from the clients. RTMI has a referral system for long acting and permanent methods

to government FP clinics situated 15-20 minutes from each camp. The referral is scheduled only

twice a month due to shortage of staff in both the government facilities. Traditional methods are not

promoted. The staff are concerned that the refugees might not be able to practice traditional

methods accurately which consequently would have an impact on increasing failure rates.

According to the FP clinic staff at Teknaf FP office, MR services are available for women as a backup

for FP methods. The staff interviewed was trained on the procedure and the centre was supplied

with necessary equipment by the Government. She noted that none of the refugee women have

been referred to the center for the service as of yet.23 The Upazilla FP Officer stated that refugee

women are also allowed to receive the service as are the women from the host community.

Staffing and training: There is one field worker, two paramedic nurses, seven traditional birth

attendants (TBAs), seven community trained birth attendants (CTBAs) and one supervisor in each

camp working with RTMI to run the programme in the camps. The field worker is responsible for

identifying clients for FP services and counsels them to take the most suitable methods. She

arranges awareness sessions, too. Paramedic nurses deliver the services from the FP clinic. The

Community Volunteers (TBA and CTBA) visit individual clients to remind them of the next visit and to

provide community-based distribution of OCPs and condoms. One male counselor works in both

camps on alternate days to counsel male refugees, including refugee leaders and religious leaders,

on FP.24 25 The camp clinic is open five days a week from 8.30 to 16.30. No service is provided on the

weekends or evenings.

Both staff interviewed at the government facilities complained about shortage of staff at all levels.

The Medical Officer posts with the FP clinics in Ukhiya and Teknaf were never filled. Therefore, the

doctor from Cox’s Bazar visits twice a month to offer permanent methods. According to the service

provider in Ukhiya FP office, “Staffs are always under high workload due to vacancy of the posts.

Besides, working for several years at the same position makes them demoralized.”26 The staff

working in the camp clinic are trained on FP once a year; however, the paramedic nurse who was

interviewed in KTP did not receive any training in the last two years. FP clinic staff in Ukhiya were

22 Email Communication with Programme Officer, RTMI, 18th Dec, 2012. 23 Facility Staff Interview, Teknaf FP Office, 12th December, 2012. 24 Facility Staff Interview, KTP FP Clinic, 10th December, 2012. 25 Facility Staff Interview, NYP FP Clinic, 12th December, 2012. 26 Facility Staff Interview, Ukhiya Family Planning Office, 10th December,2012.

18

recently trained in MCH topics such as safe deliveries by skilled birth attendants, emergency

obstetric care and newborn care, but they did not receive training on FP in the last two years.

Quality of services: Generally, staff in all four facilities are respectful when working with clients. The

clients were informed about their next follow-up dates in all four centers. Staff put notes on the pill

boxes for follow-up dates and mentioned again the date of the next visit at the Ukhiya FP clinic. The

follow-up system is comparatively better in the camps than the government facilities. The

community volunteers are responsible for individual follow-up in the camps. In order to remind the

clients for follow-up visits, CTBA and TBAs visit their homes on the scheduled day to send them to

the clinic to receive the required method. As described by the facility staff, “These community

volunteers distribute pills and condoms at home for those who cannot visit the camp clinic on her

appointment day or to refugees who come to the clinic to collect pills/condoms. If any client misses

her dose or decides to discontinue, individual CTBAs or TBAs visit her home two to three times to

check whether she has changed her mind. For pill and condom users, waiting time is 7 days and for

Depo users the waiting time is 28 days to confirm the client as a defaulter.”27 When a client comes

to the FP clinic, the paramedic nurse is responsible for providing OCPs, condoms and Depo injection.

She is also responsible to refer clients for long term and permanent methods to the government FP

clinics.

The staff in the camp clinic admitted that unmarried adolescents cannot obtain a method from the

clinics. Since the commodities are received from the government, they report distribution to the

Government. In addition, there are monitoring visits from the government to check whether

government FP regulations are followed in the camps. Therefore, they are unable to offer the service

to unmarried adolescents. However, the unmarried adolescents can receive condoms from staff or

volunteers working with the HIV/AIDS programme in the camps.

Privacy and confidentiality: It has been observed that privacy and confidentiality is better maintained

at camp facilities compared to public facilities. There was no waiting room for the clients in public

facilities. In Ukhiya, around 12-15 clients were together in the room and were given pills, condoms

and the Depo injection without properly being informed of the process, including advantages and

risks of individual methods. It seemed that most of the clients were repeated users; for that reason

the service providers might feel reluctant to repeat all of the information. The FP office at Teknaf

had no curtain to maintain the privacy of the client during the examination. None of the days for the

facility assessment were scheduled during the provision of permanent methods. Therefore, the

privacy and confidentiality system could not be observed for consultations with permanent method

clients.

The service provider from both camps also informed that most of the clients demand

vitamin/mineral supplementation when they experience side effects but the providers are not able

to meet the demand. According to the providers, FP clients received the supplementations from

previous NGOs that provided FP services to the camps.

27 Facility Staff Interview, NYP FP Clinic, 12th December, 2012.

19

Infrastructure: Both staff interviewed from the government FP clinics complained that the existing

structures of the FP offices do not have adequate numbers of rooms and spaces for properly

delivering services. The counseling room in Teknaf FP Office lacks adequate space.

Record maintenance: The FP staff at the camps report weekly to the UNHCR HIS and monthly to the

government FP office from where they receive commodities. The staff in the referral centers are

using government registers to maintain the records.

IEC materials: The national guideline on FP was available in all four facilities. However, the general

impression was that the staff do not use them while counseling patients. The IEC materials were

found to be more in written form. Staff from all four facilities admitted that they distribute leaflets

only to people who can read. Considering the lower literacy rate among the refugees and host

community, there is a crucial need for pictorial IEC materials.

Infection prevention: Standard precautions are not properly maintained in the facilities. Sharps

disposal containers are not available in any of the Government facilities. No sharps and waste

removal plan is followed. Moreover, poor hygiene conditions were noticed in the counseling room at

Ukhiya FP office.

Barriers and suggestions from service providers: The service providers in KTP FP clinic shared the

issue of recent decrease in contraceptive uptake. A number of reasons were mentioned, such as,

intention of refugees to have more children to upturn the number they have lost in the recent

violence in Northern Rakhine State (NRH) of Myanmar; many males have left for Malaysia in the last

three months; the resettlement process has been put ‘on hold’ so refugees have lost their interest to

keep the family size small, an eligibility criteria for selection. Lastly, some women decided to

discontinue their method because they experienced side effects.

Husband opposition as a barrier to family planning uptake was reflected in the registration book

when the record maintaining system at camp clinic was reviewed. The staff made a remark on the

register for community volunteers to keep FP use confidential to other members of the family while

visiting clients’ homes to remind them of the follow up visits. According to the staff, they usually

follow this strategy to continue providing service to the women whose husbands oppose the service.

As a strategy to increase uptake and encourage continuing contraceptive use by the women, the

facility staff proposed providing vitamin and nutrition supplements to all women who are currently

using any FP method.

Qualitative Findings Health care during pregnancy and child birth: While nearly all participants expressed the necessity of

receiving health care for pregnancy and child birth at a facility for proper management of mother

and baby by trained clinical staff, one community leader shared that deliveries should be conducted

at home because it is embarrassing for women when she is on her way to the clinic and others could

see that she is having labour pains.28

28 In-depth Interview with community leaders , NYP camp, 29 November, 2012.

20

Family planning decision making: The majority of participants stated that the decision to use FP is

made by both husband and wife. They do not need to discuss it with any other member of the family

or community. In a few cases, the mother-in-law advises them about when and how many babies

they should have. One religious leader said, “I just want three kids but my mother wants more.”29

Knowledge and practice of family planning: About half of the male participants of FGDs said they

were informed about advantages of FP from different NGO staff and community volunteers.

Although all of the participants from the in-depth interviews knew about most of the temporary and

permanent methods, none of them had heard about the emergency contraception pill (ECP). Only

one religious leader mentioned traditional methods (withdrawal), which he had learned from a

religious book (Hadith). Three participants from the adult male FGDs were aware of traditional

methods. As a benefit of using FP, most participants stated that it helps mothers and babies stay

healthy, and makes it easier to look after the children and provide for their needs.

One adult male participant in the FGDs defined FP by saying, “It’s not only about limiting the number

of children but also to plan for everything that links to having a happy family which includes plans to

provide food, clothes and education for all of the children in the family.”30 In contrast, one adult

female participant stated that a family looks full when they have more children.31

One participant from the FGD in KTP said, “If we would have been here and got all this information

and services for family planning, we would not have that many children now.”32 The participant

shared that she learned about FP from NGO staff working in the field when they conducted

awareness sessions once a month at their shed. They do not have any specific meeting places; the

field worker selects a spacious room in the shed where she can talk with around 10 to 12 women at

a time on FP issues.

Community perception about family planning: All participants of the FGDs and in-depth interviews

agreed that the opposing attitude towards FP by the community has been reduced. They mentioned

that educating male and female refugees about advantages of using FP from different NGO staff and

community volunteers are a reason for improved attitudes in the community. They also recognize

that keeping the family small is beneficial, especially when they have no opportunity to work and

cannot afford to meet the needs of a large family.33 34 On the other hand, they also stated some

opposing comments by elderly community members who say, “We had no problem with large

families, why would you have problem with more children now?”35

Two refugee leaders shared that they need to increase the number of Rohingya Muslims since a

large number of them have been killed by Buddhists during the recent violence in Northern Rakhine

State.36

29 In-depth Interview with Community Leaders, KTP camp, 01 December, 2012. 30 FGD with Adult men, KTP camp, 05 December, 2012. 31 FGD with Adult women, KTP camp, 06 December, 2012. 32 FGDs with Adult women, KTP camp, 03 December, 2012. 33 In-depth Interview with Refugee Leaders, NYP camp, 29 December, 2012. 34 In-depth Interview with Refugee Leaders, KTP camp, 01 December, 2012. 35 In-depth Interview with Refugee Leaders, KTP camp, 01 December, 2012. 36 In-depth Interview with Refugee Leaders, NYP cam, 29 December, 2012.

21

Available services: The participants of the FGDs and in-depth interviews were satisfied with the

location and service delivery system of the FP clinics in the camps. They appreciated follow-up

strategies by sending community volunteers to report to the center for receiving their next dose. As

stated by one participant, “For pill and condom users, they even don’t need to come to the clinic; we

just need to collect it from the community volunteers.”37

The FP clinics have regular supplies from the government and all of them are free of cost. The

permanent method users receive incentives from the government FP office as a part of the national

programme. One participant from the FGDs thinks men are choosing the methods just to receive the

incentive.38

The majority of the participants from the FGDs and in-depth interviews demanded vitamin/mineral

supplementation for clients using FP services. They believe that it would help the user get rid of

weakness, headache and vertigo.

Sources and quality of services: Nearly all of the respondents mentioned the FP clinic in the camps

and Upazilla FP office as service delivery points. About half of them added community volunteers as

a source to obtain pills and condoms. They stated that they now have easy access to the services

compared to the situation they encountered a few years back. “We had to queue for hours to get a

dose for Depo injection, sometimes we returned home without getting any service because there

was no supply,” one adult woman in KTP remarked.39 She added that the number of staff was not

adequate which made the waiting time longer at that period. According to the participants, the

clients are pleased with the current services available in the FP clinics in the camps.

Barriers to the service: The refugee leaders and the participants in the FGDs acknowledged that the

community has become more aware about family planning. Therefore, the resistance from the

community has decreased.40 41 A few of the female participants from the FGDs informed that

husbands sometimes do not want them to use FP services; however, such cases are gradually

decreasing because husbands are also realizing the need.42

Role of religion: The religious leaders mentioned quotations both in favor of and in contrast to using

FP methods in Islam. According to the leaders, the Quaran says “You give more child so that more

people will call Allah in this world;” on the other hand, it also says, “You have to take proper care of

your family, if you are unable, you shouldn’t have more children.” They also said that Islam allows

birth spacing for two years.43 44

Interestingly, both of the religious leaders interviewed admitted the necessity of family planning. In

addition, they stated that they are using FP methods too. However, the leaders are afraid of losing

their acceptance in the community by promoting FP. Therefore, they do not encourage using FP

methods despite understanding and accepting the advantages. The female FGDs in NYP informed

37 FGD with Adult women, KTP camp, 06 December, 2012. 38 FGD with Adult men, KTP camp, 05 December, 2012. 39 FGD with Adult women, KTP camp, 03 December, 2012. 40 In-depth Interview with Refugee Leaders, NYP camp, 29 November, 2012. 41 In-depth Interview with Refugee Leaders, KTP camp, 01 December, 2012. 42 FGD with Adult women, NYP camp, 06 December, 2012. 43 In-depth Interview with Refugee Leaders, NYP camp, 29 December,2012. 44 In-depth Interview with Refugee Leaders, KTP camp, 01 December,2012.

22

that, although lessons by the religious leaders do not encourage using FP services, most of their

wives are receiving contraceptive methods.

The participants of the FDGs with adult males in KTP suggested sharing guidelines and any

information that might have a relation with religion and FP in a leaflet form so that they could have

the correct knowledge.

Services for adolescents: Adolescents generally do not seek health care when it concerns their sexual

and reproductive health; they share those problems with mothers or friends. Both groups of

adolescent boys and girls explained that it is strictly prohibited for a boy and girl to meet in the

community. If anybody sees them talking, community members would complain to the parents or

community leaders who will then decide whether to arrange a marriage. According to the

adolescents, it is not common for unmarried adolescents to have sexual relationships before

marriage, but there are some exceptions. In those cases, they use contraceptives from outside of the

camp. As one adolescent boy said, “Even if the service would be offered from the camp clinic, they

would not go considering the risk that the community might get informed noticing them going to the

FP clinic.”45 ”Getting pregnant before marriage is totally unacceptable by the community. To avoid

getting pregnant, they can use ECPs or may go through the procedures for conducting abortion using

medicine or medical equipments,” another adolescent boy suggested. In addition, one girl

mentioned that, sometimes unmarried adolescents use medicine or small roots from a special tree

to induce abortion.46

Adolescents do not have sexuality education at school. The children have access to former education

only up to primary level in the camps. Besides primary education, both camps have adult literacy and

computer training programme. Boys and girls from both groups proposed to have a youth center in

the camps to meet with their peers regularly for discussing problems, including RH issues, and

solutions. According to the girls, the average age of girls getting married and having sex is 16-18

years; whereas, boys mentioned 19-21 years for boys.

Adolescents in the FGDs heard about FP when the FP field worker met mothers or other married

family members. They could mention most of the modern methods but were not familiar with ECP.

Only one girl knew of ECP as a treatment for survivors of sexual violence.

The adolescent groups suggested inviting them for awareness sessions arranged for married couples,

so that they can learn from the discussion. When asked how the community feels about

contraceptive use among unmarried adolescents, the answer was “It would never be acceptable to

the community,” but they think they would be allowed to receive the information before being

married.47 48 49

As a suggestion to find out the various options to reach adolescents and talk about reproductive

health issues, boys suggested to talk to them in school; whereas, the girls proposed to meet at the

45 FGD with Adolescent boys, KTP camp, 05 December, 2012. 46 FGD with Adolescent girls, NYP camp, 06 December, 2012. 47 FGD with Adolescent girls, KTP camp, 03 December, 2012. 48 FGD with Adolescent boys, KTP camp, 05 December, 2012. 49 FGD with Adolescent girls, NYP camp, 06 December, 2012.

23

community level through outreach because most of the girls drop out from school at menarche.

Girls are encouraged by the community to stay at home during menstruation.

Discussion The FP programme in the camps had encountered inadequate support from the FP department of

the government in 2008 and early 2009.50 The service was also affected by very limited numbers of

staff to run the FP clinic and to carry out community based activities in the camps. As shown through

the study findings, the service is now well supported by the government which allows refugees to

enjoy easy and regular access to the service as the host community. The results from the household

survey supports the situation by showing that the majority of the clients are receiving services from

the FP clinics in the camps and from referral centers in the Ukhiya and Teknaf FP office. Facility

assessments in the camps found that a number of staff and volunteers with different capacities have

been involved to improve the service delivery system.

Different communication strategies targeting males, especially community and religious leaders, and

female might have a positive impact on reducing resistance towards using FP methods. Findings

from the FGDs and in-depth interviews revealed that refugees are informed about services and their

benefits through different outreach programmes in the camps.

The most preferred method among women is the injectable method. It might reflect the fact that

the majority of the women are uneducated and might feel more comfortable with injections because

it is not necessary to calculate days and remember to take pills every day. The other reason could be

that it is easier to use without informing the husband who could be an opposing factor for

contraceptive use. As found in the study, husbands or wives oppose using contraception in some

families. This indicates room for strengthening outreach by focusing on counseling, maintaining

respect for individual choice. The women who report barriers (want more baby/infrequent sex) for

FP services need to receive individual counseling support from FP staff and volunteers. Considering

the situation where refugees do not have the right for income generation activities in the camps, it is

very likely that a number of males would stay outside of the camp for livelihoods and would visit

their families infrequently. Therefore, wives of those husbands need to be informed about

appropriate methods for them so that they do not experience unwanted pregnancy for having

infrequent sex. They should also be informed about using the method that prevents sexually

transmitted infections, if the husbands have extramarital relations.

Religion was not found as a prohibiting factor for FP in the household survey. However, FGDs and in-

depth interview participants admitted it has both positive and negative perspectives towards FP.

The lack of knowledge around traditional methods has been identified in the study. In order to avoid

conservative families being cut off from the service for their opposing attitude towards modern

methods, information on traditional methods could be provided to them as well as sensitizing them

to the benefits of child spacing.

50 Letter exchanges between UNHCR and Deputy Director FP Bangladesh, 10 August, 2008, 4 January,2009, 18 February, 2009, and 7 April, 2009.

24

The discrepancy between CPR from the HIS and that calculated through this study was noted in the

study. The main reason was the assumptive figure (20% of total population) as a denominator for

the CPR calculation in the HIS. The difference between the CPR in the HIS and the CPR in the study

was 5.3%, using the exact number of WRA from proGres as the denominator. Since the current

version of the HIS software does not allow for the number of WRA to be entered, necessary

initiatives need to be taken to obtain the most exact CPR from HIS by updating the software to

enable entering of the total population and total WRA, separately.

Limitations The possibility of under-reporting sexual activity and use of contraception among unmarried

adolescents cannot be excluded because of the strong cultural belief and stigma against sex before

marriage. The challenge of maintaining privacy was encountered by interviewers while conducting

interviews at the household. Although private places were requested at home during the interview,

other family members or neighbors (female) were present with the respondent at the time of the

interview in some cases. For instance, mothers of unmarried adolescents could make talking about

her sexual life difficult and any person from the family of married women could potentially sway her

answer if she had any barriers from family members. However, women to women conversations

have not been as problematic in terms of soliciting honest responses in the setting. Therefore, the

study team chose to include the handful of responses in the analysis despite there was room for

reporting bias.

The general consensus of the community is that everything happens according to the wish of Allah:

even if they plan for a pregnancy, they can only get pregnant, “When Allah wants.” Therefore, the

results to the question, “When to you want to have your next child” to identify the desire of the

woman to space child birth may be affected by social and religious beliefs. Another question related

to the estimation of the need for FP among the community was, “Have you had sexual intercourse in

the past 30 days?” which is likely a cultural taboo question. These two questions have made it

difficult to calculate a reliable unmet need.

The field visit coincided with countrywide strikes by political parties that resulted in changes to the

schedule several times. Finally, the last FGDs with adult males and adolescents in NYP camp were

cancelled due to limited time. This may have limited the ability to reach saturation for the FGDs.

The consultation with clients in one of the public facilities could not be observed. On the day of the

assessment visit, they had no clients for FP consultations. Since permanent and long term methods

are provided only twice a month in public health facilities, it was not possible to observe the client

interactions in those referral centers.

Appendices

Appendix I: Household Survey Data Tables

Awareness, ever use, and problems with family planning methods

Table 2: Awareness of family planning methods among women of reproductive

age (WRA), Kutupalong and Nayapara camp, Cox’s Bazar, 2012 {N = 507}

Method % (n) women*

Pill 86.6%(439)

IUD 18.5%(94)

Male condom 64.9%(329)

Female condom 5.1%(26)

Implants 42%(213)

Injectables 81.5%(413)

Emergency contraception 2.8%(14)

Tubal ligation 46.2%(234)

Rhythm/calendar/counting days 0.6%(3)

Withdrawal 0.6%(3)

Other 0.2%(1)

*Percentages may add up to greater than 100% as respondent may give more than 1 response.

26

Key Indicator A: Proportion of women who have ever used any family planning method

among women of reproductive age (WRA), Kutupalong and Nayapara camp, Cox’s Bazar,

2012 {N = 507}

Indicator % (n) women

Ever used family planning method 61.7%(313)

Table 3: Proportion of women who have been instructed how to use or have ever used

family planning methods among women of reproductive age* Kutupalong and Nayapara

camp, Cox’s Bazar, 2012 {N = 507}

Method Instructed how to

use method

% (n) women

Ever used method

% (n) women

Pill 76%(386) 42%(213)

IUD 15%(78) 0.4%(2)

Male condom 56%(285) 6.7%(34)

Female condom 2.6%(13) 0.4%(2)

Implants 34%(175) 3.2%(16)

Injectables 75%(382) 49.3%(250)

Emergency contraception 2.1%(11) 0.6%(3)

Tubal ligation 37%(189) 2.37%(12)

Rhythm/calendar/counting days 0.4%(2) 0.2%(1)

Withdrawal 0.6%(3) 0%(0)

Other 0.2%(1) 0.2%(1)

*Percentages may add up to greater than 100% as respondent may give more than 1 response.

27

Table 4: Knowledge of where to get modern* family planning methods among women of

reproductive age† Kutupalong and Nayapara camp, Cox’s Bazar, 2012 {N = 507}

Method FP clinic in

the camps

% (n) women

Upazilla FP

clinics

% (n)

women

Market

% (n)

women

CBD

% (n)

women

Pharmacy

% (n)

women

Don’t Know

% (n)

women

Pill 78%(400) 0.2%(1) 0%(0) 0.9%(5) 0.6%(3) 5.7%(29)

IUD 1.6%(8) 12.1%(63) 0.2%(1) 0%(0) 0%(0) 4.5%(23)

Male

condom

54%(274) 0%(0) 0.2%(1) 0.8%(4) 0%(0) 9.9%(50)

Female

condom

0%(0) 0%(0) 0%(0) 0%(0) 0%(0) 0%(0)

Implants 2.6%(13) 31.5%(158) 0%(0) 0%(0) 0%(0) 7.8%(40)

Injectables 76.7%(389) 0.8%(4) 0%(0) 0%(0) 0%(0) 3.6%(18)

Emergency

contraceptio

n

1.6%(8) 0.2%(1) 0.2%(1) 0%(0) 0%(0) 0.8%(4)

Tubal

ligation

0.9%(5) 35.3%(179) 0%(0) 0%(0) 0%(0) 10.3%(52)

*Modern family planning methods include the pill, IUD, male and female condoms, implants, injectables, emergency hormonal contraception (EC), tubal ligation and vasectomy. †Percentages may add up to greater than 100% as respondent may give more than 1 response.

Table 5: Main problem reported with using specific family planning methods among women who

have ever heard of that method, Kutupalong and Nayapara camp, Cox’s Bazar 2012. {N = 507}

Method Lack of

access

% (n)

women

Opposition

to use

% (n)

women

Method-

related

% (n)

women

No problem

% (n)

women

Don’t Know

% (n)

women

Pill (439) 0.2%(1) 0%(0) 35.3%(156) 17.3%(76) 46%(204)

IUD (94) 0%(0) 0%(0) 6.4%(6) 3.2%(3) 90%(85)

Male condom (329) 0%(0) 0.3%(1) 0.9%(3) 12.5%(41) 86%(283)

Female condom(26) 0%(0) 0%(0) 0%(0) 11.5%(3) 84%(22)

Implants (213) 0.9%(2) 0.5%(1) 15.9%(34) 1.9%(4) 80%(171)

Injectables (413) 0%(0) 0.2%(1) 34.8%(144) 26.0%(107) 38%(160)

Emergency

contraception(14)

0%(0) 0%(0) 7.7%(1) 23%(3) 71%(10)

Tubal ligation (234) 0%(0) 0%(0) 6.0%(14) 8.1%(19) 85%(199)

Rhythm/calendar/counting

days (3)

0%(0) 33.3%(1) 33.3%(1) 0%(0) 33.3%(1)

Withdrawal (3) 0%(0) 33.3%(1) 0%(0) 0%(0) 33.3%(1)

Other (1) 0%(0) 0%(0) 0%(0) 0%(0) 100%(1)

Total 0.2%(3) 0.3%(5) 20.3%(359) 14.5%(256) 64.3%(1137)

Current Use of Family Planning

Key Indicator: B.1): Proportion of women who are currently using a modern* family

planning method among women of reproductive age, Kutupalong and Nayapara

camp, Cox’s Bazar, 2012 {N=507†}

Indicator % (n) women

Contraceptive prevalence (modern methods) 36.9%(187)

Key Indicator: B.2): Proportion of women who are currently using a modern* family

planning method among ever married women, Kutupalong and Nayapara camp,

Cox’s Bazar, 2012 {N=434†}

Indicator % (n) women

Contraceptive prevalence (modern methods) 43.0%(187)

*Modern family planning methods include the pill, IUD, male and female condoms, implants, injectables, emergency hormonal contraception (EC), tubal ligation and vasectomy. †The denominator may include women who are not at risk for pregnancy because they are currently pregnant, infecund, or have had a hysterectomy

Key Indicator: C.1): Proportion of women who are currently using any family

planning method among women of reproductive age, Kutupalong and Nayapara

camp, Cox’s Bazar, 2012 {N = 507*}

Indicator % (n) women

Contraceptive prevalence (any method) 37.7%(191)

Key Indicator: C.2): Proportion of women who are currently using any family

planning method among ever married women, Kutupalong and Nayapara camp,

Cox’s Bazar, 2012 {N = 434*}

Indicator % (n) women

Contraceptive prevalence (any method) 44.0%(191)

*The denominator may include women who are not at risk for pregnancy because they are currently pregnant, infecund, or have had a hysterectomy.

30

Table 6: Demographic characteristics of women who are currently using any family

planning method, Kutuplong and Nayapara camp, Cox’s Bazar, 2012 {N=191}

Characteristic % (n) women

Age

15-24 23.6%(45)

25-34 54.5%(104)

35-49 21.9%(42)

Relationship Status

Living with a husband/partner 95.8%(183)

Not living with husband/partner 4.2%(8)

Total pregnancies

0 1.0%(2)

1-2 18.8%(36)

3-4 27.2%(52)

>4 52.9%(101)

Sexually active in last 30 days

Yes 90%(172)

No 8.9%(17)

Table 7: Family planning method being used among women who are currently

using any family planning method Kutupalong and Nayapara refugee camp, Cox’s

Bazar, 2012 {N = 191}

Method % (n) women*

Pill 32.9%(63)

IUD 0%(0)

Male condom 5.2%(10)

Female condom 0.5%(1)

Implants 4.2%(8)

Injectables 57.6%(110)

Emergency contraception 1.0%(2)

Tubal ligation 4.7%(9)

Vasectomy 1.6%(3)

Lactational amenorrhea 1.0%(2)

Rhythm/calendar/counting days 0%(0)

Withdrawal 0%(0)

Periodic abstinence 0.5%(1)

Other 0.5%(1)

*Percentages may add up to greater than 100% as respondent may give more than 1 response.

32

Table 8: Location where family planning method was last obtained among women

who are currently using a modern* family planning method Kutupalong and

Nayapara camp, Cox’s bazar, 2012 {N = 191}

Method % (n) women

FP clinic in the camps 84.8%(162)

Upazilla FP clinics 13.1%(25)

Supermarket/Market 1.0%(2)

Pharmacy 1.0%(2)

*Modern methods include the pill, IUD, female and male condoms, implants, injectables,

emergency hormonal contraception (EC), tubal ligation and vasectomy.

Barriers to family planning

Key Indicator D: Proportion of women who are at risk for pregnancy,* desire to stop

or delay childbearing, and are not using family planning among women of

reproductive age Kutupalong and Nayapara camp, Cox’s bazar, 2012 {N = 507}

Indicator % (n) women

Unmet need* 2.4%(12)

*Women who are at risk for pregnancy are women who report being fecund, sexually, active,

NOT pregnant and NOT postpartum, who do not desire for a baby or want baby at least a

year later

Table 9: Barriers to family planning among women who are at risk for pregnancy, desire

to stop or delay childbearing and are not using family planning , Kutupalong and Nayapara

camp, Cox’s Bazar, 2012 {n=12}

Barriers to family planning % (n) women*

Fertility-related reasons 58%(7)

Opposition to use 25%(3)

Lack of knowledge 0%(0)

Method-related reasons 16.7%(2)

Lack of access 0%(0)

Other 0%(0)

*Percentages may add up to greater than 100% as respondent may give more than 1 response.

* Since the denominator is too small (12), these results should be interpreted with caution.

34

Intent to use a family planning method in the next 12 months

Key Indicator E: Proportion of women who are not currently using a family planning method,

but plan to in the next 12 months, Kutupalong and Nayapara camp, Cox’s Bazar, 2012

{N = 250}

Indicator % (n) women

Future intent to use family planning in next 12 months 6%(15)

Appendix II: Health Facility Assessment Summery

SL no Topic Indicator KTP FP

Clinic

Ukhiya

FP Clinic

NYP FP

Clinic

Teknaf FP

Clinic

1 Staffing # of doctors or clinical officers

providing any FP method

0 1 0 1

# of midwives, nurse-midwives

or nurses providing any FP

method

2 3 2 3

2 Training

Proportion of doctors or

clinical officers trained in FP

among all doctors and clinical

officers providing FP

0 100% 0 100%

Proportion of midwives, nurse-

midwives or nurses trained in

FP among all midwives, nurse-

midwives or nurse providing FP

50% 100% 100% 100%

3 Method

Mix

# of temporary methods

available

3 3 3 3

# of long-acting methods

available

0 2 0 2

# of permanent methods

available

0 2 0 2

# of traditional methods

promoted

0 1 0 1

Is EC available? No No No No

4 Relative

Score of

Quality

Measure

Score (Out of 15) 12 11 12 11

5 Capacity

to Meet

Infection

Prevention

standards

Score (Out of 15) 12 11 12 11