REPRODUCTIVE HEALTH PRACTICES IN RURAL BANGLADESH: STATE, GENDER AND ETHNICITY Runa Laila This dissertation is part of the research programme of CERES, Research School for Resource Studies for Development. The research was funded by the Royal Netherlands Embassy in Dhaka, Bangladesh. © Runa Laila 2016 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the author. Printed in The Netherlands. Printer: Ipskamp Drukkers, Enschede. ISBN 978-90-6490-063-1 Coin on the cover page: This is a Bangladeshi one Taka coin that says: "Bangladesh, Planned Family - Food for All, 1977, 1 Taka". REPRODUCTIVE HEALTH PRACTICES IN RURAL BANGLADESH: STATE, GENDER AND ETHNICITY REPRODUCTIEVE GEZONDHEID OP HET PLATTELAND IN BANGLADESH: STAAT, GENDER EN ETNICITEIT Thesis to obtain the degree of Doctor from the Erasmus University Rotterdam by command of the Rector Magnificus Professor dr H.A.P Pols and in accordance with the decision of the Doctorate Board The public defence shall be held on 29 Augustus 2016 at 10.00 hrs by Runa Laila born in Dhaka, Bangladesh International Institute of Social Studies Erasmus University Rotterdam Doctoral Committee Promotor Emeritus Prof. dr. B.N.F. White Other Members Prof. dr. S. Faiz Rashid Prof. dr. I. Hutter Dr. W. Harcourt Co-promotor: Dr. A. Chhachhi Dedicated to all women of the Gachhabari village who gave me the opportunity to represent their voices in this thesis. Contents List of Figures, Charts, Diagrams, Graphs, Tables, Maps and Appendices xiii Acronyms xvii Acknowledgements xxi Abstract xxvi Samenvatting xxxi 1 INTRODUCTION 1 1.1 Women’s reproductive health practices in rural Bangladesh 1 1.2 Justification of the research problematic 8 1.2.1 The adoption of MDGs in Bangladesh: current achievements and gaps 12 1.2.2 Critical concerns regarding contraception use practice 17 1.2.3 Abortions/Menstrual regulation as a means for fertility reduction 21 1.3 Research Objectives 23 1.4 Research Questions 24 1.5 Organisation of the dissertation 24 2 ANALYTICAL FRAMEWORK AND RESEARCH METHODOLOGY 27 2.1 Introduction 27 2.2 Integrating the capabilities and social relations frameworks 27 2.2.1 The Household 32 2.2.2 The Community 34 2.2.3 The state 36 2.3 Research methodology 39 2.3.1 The research location 39 2.3.2 Rationale for a qualitative research approach 41 2.3.3 Matrix: research questions, information needs and methods 42 2.3.4 Methods of information accumulation 45 2.3.5 Data analysis and synthesis 53 2.3.6 The research process and reflexivity 54 ix X REPRODUCTIVE HEALTH PRACTICES IN RURAL BANGLADESH 2.3.7 Ethical dilemmas in qualitative research 60 3 STATE, POLICY AND REPRODUCTIVE HEALTH DISCOURSES IN BANGLADESH 67 3.1 Introduction 67 3.2 A Brief Overview of Population Policy and its shift in the mid- 1990s 67 3.2.1 Phase1: Population policy focusing on family Planning Program 68 3.2.2 Phase 2: A shift to Sector Wide Approach to reproductive health care services 69 3.2.3 Policy actors, conceptual premises and logics behind the policy shift 71 3.3 The underlying assumptions, biases and silences in the policy 77 3.3.1 Assumptions underlying service delivery mechanism 88 3.4 Contested meanings of reproductive health among development actors 94 3.4.1 Donor agencies: UNFPA and USAID 94 3.4.2 Political Parties 98 3.4.3 Production of knowledge on reproductive health: research institutions 103 3.4.4 Development NGOs 107 3.4.5 Women’s organisations 112 3.5 Conclusion 116 4 THE VILLAGE OF GACHHABARI 119 4.1 Introduction 119 4.2 Changing population and ethnic composition in Gachhabari 121 4.3 The class and ethnic structure of Gachhabari 126 4.4 Availability of health care services in and around Gachhabari 132 4.4.1 Public health care providers 134 4.4.2 NGO health care providers 136 4.4.3 Private health care providers 137 4.5 Patterns of health care service use in Gachhabari 137 CONTENTS XI 5 GENDER, ETHNICITY AND CONTRACEPTION AND ABORTION PRACTICE IN GACHHABARI 141 5.1 Introduction 141 5.2 Overview of Contraception prevalence and methods in Gachhabari 141 5.2.1 Men’s Contraception practice and rationales: similarities and differences 146 5.2.2 Women’s contraceptive practice 156 5.3 The experience of unwanted pregnancy 172 5.3.1 Use/abuse of MR services: husband’s consent, cost and time limit 174 5.3.2 Unsafe abortion practices and consequences 177 5.4 Conclusion 188 6 CULTURE AND HEALTH SEEKING PRACTICES IN PREGNANCY AND CHILDBIRTH IN GACHHABARI 191 6.1 Introduction 191 6.2 Cultural and socio economic rationales for childbirth at home in Gachhabari 191 6.2.1 Birth as “natural”: normal vs. complicated delivery 192 6.2.2 Faith and Trust in traditional birth attendants 195 6.2.3 Concern about purdah/privacy 197 6.2.4 Balancing wage/household labour and childbirth 202 6.3 Rural health providers: issues of cost, access and care 206 6.3.1 Suspicions and insecurity of hospital births 210 6.3.2 Dealing with delivery or reproductive/sexual health related problems 214 6.3.3 Men’s views and perspectives on reproductive health problems 219 6.4 Conclusion 221 7 THE POLITICISATION OF ETHNIC IDENTITY, MATRILINEAL ETHOS AND FERTILITY AMONG GAROS IN GACHHABARI 223 7.1 Introduction 223 7.2 Comparison of fertility among Garo, Hindu and Bengali women 224 7.2.1 Matrilineal ethos and the aspiration for daughters/sons 228 7.2.2 Religious beliefs and the role of the Church 230 7.2.3 Relative economic return from children 232 XII REPRODUCTIVE HEALTH PRACTICES IN RURAL BANGLADESH 7.2.4 Ethnic tensions and the perceived need to increase fertility 233 7.3 State, politics of ethnicity and collective need for higher fertility 236 7.3.1 Historical and political economy in Madhupur and its link to the Garo identity 236 7.3.2 Exclusion from the forest development projects 242 7.3.3 Collective Action to preserve land and identity 245 7.3.4 Changing livelihoods: class differentiation and changing gender power relations 246 7.3.5 Changing matrilineal-matrilocal norms and intra-household dynamics 252 7.4 Conclusion 258 8 CONCLUSION 261 8.1 Main Findings 261 8.1.1 The state: Policies and discourses 261 8.1.2 Intra-household dynamics in use of contraception 264 8.1.3 The question of access to health care services in rural Bangladesh 266 8.1.4 The intersectionality of women’s agency 268 8.2 Policy Implications 271 8.3 Contribution to the literature and implication for further research 275 8.4 Concluding remarks 277 References 281 Appendices 309 List of Figures, Charts, Diagrams, Graphs, Tables, Maps and Appendi- ces Figures, charts, diagrams and graphs Diagram 1.1 Trends in total fertility rates in Bangladesh 1975-2014 5 Diagram 1.2 Trends in births attended by skilled health attendants & facilities 2004-2014 15 Diagram 1.3 Trends in births delivered by C-section (percentage) 2004- 2014 16 Diagram 1.4 Trends in contraception use among currently married women (Percentage), 1975-2014 17 Graph 1.1 Trends in contraceptive method use in Bangladesh 1975- 2014 18 Diagram 1.5 Source of supply of contraceptive methods 2004-2014. 19 Diagram 1.6 Source of supply of contraceptive methods by sector and type 2014 20 Figure 2.1 Dynamics of empowerment 30 Diagram 3.1 “Word cloud” of Strategic Plan for HPNSDP 2011 - 2016 77 Diagram 5.1 Use of different contraceptive methods in the study village 142 Charts 5.1, 5.2 & 5.3 Use of contraception according to ethnicity 143 Diagram 5.2 Contraception choice per income group (Y-axis: number of users, X-axis: Income group) 145 Diagram 7.1 Number of pregnancies and living children per woman, by ethnic groups 224 Diagram 7.2 Distribution of age at first marriage of women by ethnic groups 225 Diagram 7.3 Average number of living children by age group of women and ethnic groups 227 xiii XIV REPRODUCTIVE HEALTH PRACTICES IN RURAL BANGLADESH Maps 2.1 Map of the village 40 Tables 1.1 MDG 5: Improve Maternal Health (Targets with indicators) 13 2.1 Matrix of research questions, information needs and data collection techniques 43 3.1 Selected words and corresponding frequency of Strategic Plan for HPNSDP 2011 - 2016 78 3.2 Word concurrence in the Strategic Plan for HPNSDP 2011 – 2016 80 3.3 The argument structure of the Strategic Plan for HPNSDP 2011 - 2016 81 4.1 Population distribution based on ethnicity in Gachhabari 122 4.2 Educational level of the household members above 15 years old 127 4.3 Land ownership 128 4.4 Household Income Distribution 128 4.5 Occupations (main source of income) of adults above 15 years old 130 4.6 Employment status of employed adults above 15 years old 131 4.7 Use of health care services per household 138 4.8 Health care providers visited among the study population 138 4.9 Reasons for visiting health care providers 139 5.1 Contraceptive prevalence rate 142 5.2 Types of contraception use per ethnicity 144 9.1 (Appendix) Population distribution based on ethnicity in the studied village 356 9.2 (Appendix) Sex composition of the total population 357 9.3 (Appendix) Age Group according to Sex composition 357 9.4 (Appendix) Sex composition of the reproductive age group according to Ethnicity 358 LIST OF FIGURES, CHARTS, DIAGRAMS, GRAPHS, TABLES, MAPS AND APPENDICES XV Pictures and drawings Picture 2.1 PRA technique: Traditional health attendants drawing body mapping 48 Picture 2.2 Garo husband and wife smoking together during a break while working in the field 53 Picture 2.3 researcher with Garo Participants 57 Picture 2.4 researcher