This nationally representative study demonstrates that one in every eight women had MR in their reproductive age in Bangladesh. The MR was highly prevalent amongst women aged more than 20 years old. The significant determinants of MR were geographic region, SES, employment, parity and NGO membership status.
The proportion of MR was disproportionate with the regional concentration, which showed that women from Sylhet and Chittagong division were less likely to have MR compared with women from Dhaka division. In contrast to women from Dhaka division, women in Sylhet and Chittagong may have less knowledge and access to MR services, and they face higher restriction and social stigma, which are consistent with previous studies [4, 20, 21]. In addition, MR services are available in the capital city of Bangladesh due to the highest concentration of most of the public and private clinics, hospitals, and NGOs than other divisions. However, the Union Health and Family Welfare Centres (UH & FWCs) and NGOs provide MR services particularly in the sub-urban and rural areas, and only about half of the all UH and FWCs are capable of providing MR services in Bangladesh, which has precipitous decline accounted to three-quarters of the national decline between 2010 and 2014 [7, 11, 22]. Evidence also suggests that social or religious factors, conservative health beliefs, reluctance to perform MR, lack of proper training, sufficient stuff or equipment and space could explain the sharp decline of MR services, especially in the UH and FWCs. Furthermore, religious or social reasons (43%), health beliefs (32%) and reluctance to perform MR (24%) were mentioned by about half of the UH and FWCs officials as the reasons of this deterioration [11, 23]. Hence, clandestine abortions may become choice for the women, which are mostly unsafe and increase abortion complications as well as burden related to abortions [3].
Consistent with studies conducted in developing countries, our study revealed that women with higher SES were more likely to have MR than their counterparts [4, 21, 24,25,26,27,28,29]. Women from higher SES have more control over their reproductive behavior, access to better living standard and health care particularly both public and private health care services [27]. In contrast to our results, some studies showed a reverse association between higher SES of women and lower risk of MR [30, 31]. However, most of these studies were conducted in developed countries in which structural mechanisms are entirely different from developing countries [30, 32].
Employed women had higher odds of MR than the unemployed women, which is consistent with previous literature [24, 26, 29, 33]. The possible explanation could be the overall empowerment of women, which enable them to act on fertility choice, traditional role of mothers, reduce the family size, avoidance of unintended pregnancy and access to MR services [4, 22,23,24, 26, 28, 29, 33].
Inconsistent with other studies [24, 30] education was not associated with MR in our unadjusted model, which has been omitted from the final model. In Bangladesh, education is merely associated with income generating activities or healthcare decision-making process. For instance, a large number of women with no education working in garments industries while many highly educated women are not in formal employment and involve only in household duties [34]. Results indicate that parity or number of the children was positively associated with the MR. This evidence is consistent with the previous study, which also argued that the number of living children or parity are associated with higher likelihood seeking MR services in Bangladesh [30]. The plausible mechanism could be the use of MR services to limit or delay births for reducing their family size, which is highly prevalent in the South Asian countries [35]. The NGO membership of women had a positive effect on the likelihood of having MR compared with the non-membership status of the women. The reason could be their empowerment, participation in income generating activities, social network and access to MR services. For instance, Bangladesh Rural Advancement Committee, the largest NGO in the world, works for improving reproductive health in Bangladesh.
In line with a previous study [32], moderate and higher level of women empowerment were positively associated with the likelihood of MR in the initial analysis, but significance was disappeared after adjusting other determinants. The plausible reason could be the prevailing patriarchal social structure and husband’s control over women’s healthcare decision as they are the key decision maker in the South Asian context, particularly in Bangladesh [32, 36]. Consequently, even empowered women decide about their own healthcare jointly with husband or by someone else. For example, family member of husband such as in-laws may have an influence on the decision making process of women’s use of MR due to the existing sociocultural settings [32, 36, 37].
Strength and weakness
The strengths of this study were using the recent and large nationally representative database, with a high response rate (98%). Secondly, the present study used multilevel modelling for adjusting cluster variations. The study acknowledges some potential limitations as well. For example, we cannot infer a causal relationship between determinants and MR due to the cross-sectional nature of the data. Moreover, the inclusion of all potential explanatory variables might introduce table two fallacy. Although unintended pregnancy is the root cause of MR, we were unable to use this variable in our model due to the lack of precise data. Since the BDHS collected relevant data from ever-married women only, this is a limitation for not capturing information of MR that might happen to any unmarried women or pregnancy outside of marriage that might underestimate the true prevalence of MR.
