Gender Based Violence in relation with Sexual & Reproductive Health Rights and Family Planning Services

A roundtable on ‘Gender Based Violence in relation with Sexual & Reproductive Health Rights and Family Planning Services’ was held on Monday, 13 December 2021, organized by USAID Shukhi Jibon, Pathfinder International Bangladesh and Prothom Alo. Selected excerpts of the roundtable are presented in this supplement.

Sultana Kamal, former caretaker government advisor and founder president, Manabadhikar Shongskriti Foundation

Md Abdus Salam Khan, Joint Secretary (Planning), Medical Education and Family Welfare Division, Ministry of Health and Family Welfare

Tania Haque, Professor, Department of Women and Gender Studies, Dhaka University

Dr. Mohammad Sharif, Director (Maternal and Child Health) and Line Director (MCRAH), Directorate of Family Planning

Md Aminul Islam, Line Director, Family Planning-Field Services Delivery Program, Directorate of Family Planning

Zakia Akhter, Deputy Director (foreign procurement), Logistics and Supply Unit, Directorate of Family Planning

Dr. Rafiqul Islam Talukdar, Assistant Director and Deputy Program Manager, CCSDP, Directorate of Family Planning

Samina Choudhury, Project Management Specialist, Office of Population, Health, Nutrition and Education, USAID Bangladesh

Liza Talukder, Project Management Specialist (SBCC), Office of Population, Health, Nutrition and Education, USAID Bangladesh

Caroline Crosbie, Project Director, USAID Shukhi Jibon and Senior Country Director, Pathfinder International

Fatema Shabnam, Adolescent and Youth Specialist, USAID Shukhi Jibon, Pathfinder International

Shamima Parveen, Gender Manager, USAID Shukhi Jibon, Pathfinder International

Opening remarks: Abdul Quayum, Associate Editor, Prothom Alo

Moderator: Firoz Choudhury, Assistant Editor, Prothom Alo

All women have their own thoughts and views about having children. In most cases, the family does not appreciate this. Besides, there are some problems related to side effects of various methods of family planning. As a result, a woman’s reproductive health is affected. These matters and more will be discussed at today’s roundtable.

At the outset of the project, USAID Shukhi Jibon carried out a facility assessment. The results revealed that there were many misconceptions in society. There is this belief in our society that men become weak and impotent as a side effect of family planning methods,particularly when they receive permanent method, and so it is best for men to avoid all this. In many instances women visits service centers to collect condoms whenever necessary.

According to UNFPA data in 2019, 214 million women globally want to prevent pregnancy but are unable to do so as they are unable to obtain contraceptive methods. Every day 830 women dies globally due to preventable maternal health related complications. Every year 33,000 girls are being forced into child marriage. Gender-based violence is one of the most common human rights violations in the world. Each year about one in every five women become sufferer of violence by their intimate partners.

According to a survey in 2015, 73% of womenhave experienced violence at least once in their life. And 50% of thiswas physical violence, 27%sexual violence 29% mental abuse and 11% economic abuse. Also, 55%of women faced controlling behavior atleast once in their lifetime. When it comes to receiving family planning services, 38% women do not get permission from their husbands. One third was prevented from adopting family planning methods.

In some cases, men disliked women using family planning methods and they used this as an excuse which leads to gender-based violence. Around 90% of the family planning users were between 18 and 35 years of age. Andit was seen that women of the ages between 18 and 30 were the most subject of violence. This was the age that women used family planning and reproductive health services. So, there was an age-specific link between gender-based violence and users of family planning and reproductive health services.

Due to the patriarchal social structure in Bangladesh, women are subordinate in the society. This led to an increase rate in gender-based violence. Gender-based violence is closely linked with family planning services. The service providers silently observed gender-based violence. Though service providers providing support to the GBV survivors, but they are not able to recognize that it is linked/related with family planning services.

Power-based society identifies certain group as weak – sometimes on the basis of gender, sometimes on the basis of ethnic identity. This leads to the opportunity to exert power over one group by the other. Women are sufferers of this power structure derived manipulation. There is a propensity to view women’s reproductive abilities as a weakness and a commodity. Such attitudes lead to violence against women.

Discrimination against women is clearly evident in the case of reproductive health. On the one hand the burden of family planning falls on the shoulder of and on the other hand women do not have the freedom to take decisions in this aspect. It is extremely unfortunate that not only women are sufferers of physical and sexual violence at home and outside, but they are also sufferers of mental and emotional violence on a regular basis. One in every three women globally has been sufferer of physical or sexual violence and 35% women at one time or the other in their lives is subject to violence from their partners. This violence is somehow or the other related to reproductive health.

When we look into the reasons behind child marriage, unfulfilled expectations, unwanted pregnancies, we find gender-based violence as key reason behind all this. When an adolescent girl is married off, she cannot even express her opinion against early pregnancy. For all these reasons, unwanted pregnancies and maternal mortality rates are increasing.

Family planning reduces maternal mortality and infant mortality. But many are subject to discrimination when taking such services. In Bangladesh, 49.4%of the population are women and 50.6% are men. Provision of family planning services and availing the services are still rather inadequate compared to demand.In most cases a woman cannot marry according to her wishes. She even cannot take decision about her pregnancies get pregnant. In Bangladesh, around 75 % of the people willing to take family planning services, but we are only able to provide services to 62% of the eligible couples.

According to the BDHS survey, presently on average women have 2.3 children each in Bangladesh against desired number 1.6. If we can respect mothers, give them independence and cooperation, then this problem can be resolved. In many cases women have to take services from the male service providers, even though they prefer female services providers. She undergoes mental stress because of this.

The shortage of service providers is another problem. We need space for counseling, to protect the confidentiality and provide privacy to the clients who visit facilities to receive services. The service providers need to be further trained to provide better quality services.

The gender-based violence prevalent in society is closely linked to family planning and reproductive health services. We have made our action plans focusing on these issues and working accordingly. With the support of the USAID Shukhi Jibon Project, Pathfinder International, we have managed to bring these matters forward and have developed Manual on “Gender Integration in Family Planning Services”, “Training Manual – Gender Based Violence” and a toolkit to prevent gender-based violence.

One of the major challenges we face in providing family planning services is less male involvement. Women are more visible among the clients while providing family planning services. According to the report on adopting family planning methods inOctober 2021, we have 78.55 % of beneficiaries availing our services, of which only 3.4% are men. Condom users are only 9.5%.

Pregnant mothers are often subject to violence. They undergo home delivery rather than being taken to hospital because of family norms, superstitions and the wishes of the family members. Even in the case of maternal health, they are sufferers of violence in our society. The Directorate General of Family Planning will be able to play a major role in countering this violence if the service providers are trained on these issues and policies are formulated to increase male involvement.

Women are sufferers of violence in most families in developed and underdeveloped countries worldwide. Violence can be greatly reduced if men cooperate with their partners in decision making process.

At the Upazila and union level, all the facility and community-based services providers need to be introduced to the concept of gender-based violence and trained accordingly. With proper relevant training, service providers would be able to identify gender-based violence and provide services as needed to ensure that the women who visit service centers receive quality services.

We have developed training manual and providing training to theservice providers accordingly to provide improved services. You are aware that the Ministry of Women and Children Affairs works to prevent gender-based violence. Out of the 500 Upazilas in the country, there are only 67 to 70 Upazilas, where the Ministry of Women and Children Affairs has one-stop crisis cells and centers. Apart from this, in all Upazila health complexes at the Upazila level, the resident medical officer or RMO primarily provides services to women who suffers from gender-based violence. A strong referral linkage needs to be established among the centers of the family planning directorate and the centers of the health directorate and the ministry of women and children affairs.

Complications related to maternal health, reproductive health and family planning issues; women usually keep it private. They can’t visit the health centers with their problems; even if they visit, they do it with their female friends or some other women. In most cases they don’t bring their husbands. We need to work in a more united manner to break this secrecy.

We see that the entire issue including childbirth, reproductive health, family planning is considered as a woman's issue. The entire family planning process, the projects and everything is women centric. And 90%of the contraceptive methods are centered on women and women’s body. Even the number of women among service providers is higher. As the argument goes, women can be easily encouraged in this matter, while men cannot be. Men have to earn a living and so the entire reproductive issue is women centric. That is a lame excuse.After a woman get married, she faces certain questions. When will she have a child, why isn’t she having child, why hasn’t she had a son - are asked. And if she gives birth to a child with disability, that too becomes only her responsibility. In this case, we see that the place of responsibility is being given to women, but the place of rights is being discriminated.

If you take maternity leave into consideration, women have been institutionally entrusted with all the responsibility of reproduction and child rearing. Parental leave is now a demand of the day. Both mother and father have equal responsibility in rearing the child. So institutionally this responsibility cannot be given only to women.

Secondly, the daycare center law is absolutely woman centric. According to the Labor law, if any woman worker has a child under five, she can receive daycare facilities from any company. A child from one to three years of age perhaps has proximity with the mother, but a father too can take responsibility of a four to five-year-old child. We need to change this law.

Thirdly, there is a great need for reproductive health education. There are three types of education systems in our country – Bangla, English and madrasa medium. Reproductive education should be introduced in all three mediums.

Discussing family planning is still a sensitive issue in our society. We feel hesitant to discuss this with anyone other than very close friends, relatives or health service providers. The actual number of women facing violence is underreported. Many women who face violence do not report or reveal the violence they experience. And if the violence is related to family planning issues, then proper authorities perhaps are not even aware of the incidents.

In our society the husband’s decision is considered to be the main decision. Patriarchy is so entrenched within us that many do not give any importance to the fact that the formation of a planned family requires joint decision of both husband and wife. It is unfortunate that our country is still one of the top countries in the world with high rates of child marriage. During the pandemic period, the number of child marriages increased further. Consequently, the number of teenage mothers has also naturally increased or will continue to increase. A woman doesn’t have much control over when or whom she will get married to, when she will have a child, how long will she need to wait before having the next child, or where she will give birth safely.

We are now emphasizing on behavioral changes in order to address and eliminate gender-based violence and encourage family planning. Since family and society have pivotal role to play in bringing behavioral changes, there needs to be a socially spontaneous, constructive, and welcoming environment in the family, at school and society, so that the adolescents get clear and correct information about reproductive health and family planning from ayoung age. That way, they will be able to prepare themselves to build a ideal family in future based on both husband and wife’s mutual discussions and decisions.

A woman faces gender-based violence at some point in her life. USAID’s Shukhi Jibon project, along with the Ministry of Family Welfare is working to strengthen the family planning program including sexual and reproductive health. Our work and activities focus on adolescent girls and boys, pregnant mothers, and persons who want to avail family planning services but are unable to do so. We are working in adherence to the Bangladesh government’s slogan for - not marrying before the age of 18 and not having children before the age of 20.

According to the latest report of Bangladesh Demographic and Health Survey, the average age of marriage for a woman is 16.3. In our country, 59% adolescent girls are becoming mothers. In fact, there are even cases of adolescent mothers giving birth to multiple children.Child marriage is one of the biggest forms of violence against women.The government is working to prevent this. Even if the marriage does take place, at least the pregnancy should be delayed. Conceiving a child at an early age is harmful to both mother and child. A pregnant mother should undergo at least four antenatal checkups. But even if she wants, she often cannot. She cannot go to the health center to give birth and cannot use a family planning method of her choice.

There was a time when family planning services was all about contraception – the pill, condoms, injections, tubectomy, NSV. But now the family planning program is comprehensive in terms of coverage. It includes maternity, maternal and child health, reproductive health, adolescent reproductive healthcare and such. These services are being provided through the MCH unit, Field Service Delivery unit and CCSDP unit. We have 1103 youth-friendly clinics. Over 15%of the beneficiaries of these clinics are male. Sanitary pads are provided free of cost for adolescent girls from these youth-friendly clinics.

We have many achievements in the health sector. Even then, in some cases, we are lagging. Institutional delivery rate hasn’t crossed 50%. In Sri Lanka 99.5% of the deliveries are institutional and so the maternal mortality rate there is only 36 in every 100,000. In Bangladesh, it is 163 per every 100,000. One of the reasons for this high maternal mortality rate is the low incidence of institutional deliveries. The government is working on this. Delivery kits are provided by the family planning directorate and MCH unit to the union level. These include sanitary pads and 15 types of medicines.

The family planning programs in our country are not adequately publicized. And in most cases family members are an obstacle. I have also seen that even if a husband agrees, a woman cannot adopt any contraceptive method because of objections from other members of the family.

Child marriage is a major cause of violence against women in our country. Women become mothers at a very early age. In this country, 59% of the women become mothers at this early stage in life. Maternal mortality is on the rise because of this. An increase in maternal mortality means an increase in infant mortality. One is linked to the other. The government has taken an important measure in this regard. A total of 592 union health and family planning centers are being made into model union health and family planning centers. These centers will include youth-friendly clinics and all services.

We have many limitations. Even then we have community clinics, union health and family planning centers and such program programs which no other countries in the world have. I think the health and family planning centers at the union level are still neglected. Further necessary steps n should be taken to make these more effective.

Violence against women is often viewed differently. General conception is that physical violence is violence against women. But that is not the case.

The health and family welfare ministry work at a policy-making level and allocates funds as per the requirement of DGFP and DGHS. The government has adequate financial capacity and is making allocations accordingly. In many cases it is not possible to spend the allotted funds.

Despite many problems, our country has come a long way in reproductive health care services. This is a success of the government. In 1975, the overall birth rate in the country was 6.3 per women. A woman would give birth to nearly seven children during her reproductive period. At present this rate is down to 2.4%.

The Ministry of Health has been implementing a large-scaleprogram known as the sector program since 1998. The fourth sector program is now being implemented. Donor agencies like Pathfinder International and USAID are supporting the program. The main objective of the program is to achieve the Sustainable Development Goals (SDG). The last three sector program have been successfully implemented. As a result, the honorable Prime Minister was awarded for the successful fulfillment of the MDG. The media, NGOs, donors and others have contribution behind this.

Everything is included in Sustainable Development Goal-3 (SDG-3). Family planning, reproductive health and rights are prominent among the 27 goals. If this is achieved, the rest can be achieved easily. We are working towards this goal. Projects must be taken up for women’s own rights to be achieved. Non-government and private initiatives must also be taken up alongside government.

There is a link between gender-based violence and women’s right to reproductive health. Any form of violence arises from our attitude towards the other person, mindset and psychological perspectives, and also how we give them respect from within the family and society. It is good that presently women have a considerably advantageous position. No one can leave women out of anything and deny their presence. This is a great achievement.

The first family planning initiative in our country was about population control, not family planning services. Many people in Bangladesh were below the poverty line. The population was also large. One of the major demands of the women’s movement since 1972 was reproductive health of women. There was a demand for attention to be paid to the reproductive health of women affected by the war.

At the end of the day, the responsibility of family planning falls on women.However, even if the responsibility is given to women, they do not have the right to make decisions. This culture still exists in the society. Women's reproductive health needs to be considered in terms of their own individual rights. Without ensuring this, even a woman cannot bring it into her freedom. As a result, reproductive health work will not be easy to implement. In fact, the issue has to be looked at from the point of view of women's personal rights. It is said in human rights that human beings are born with certain rights. Unfortunately, a woman is born without some rights.

We have had a lot of structural development, we have courtyard meetings, discussions, community clinics have reached at upazila level, health care is being discussed and the media is very active. But even then, a woman should be recognized as a woman, her reproductive health as a right.

Reproductive health is taken to be pregnancy, maternal mortality, infant mortality and so on. But a woman’s reproductive health must be seen as her fundamental right. No matter what her marital status may be, this must be taken into consideration from the moment that she achieves reproductive ability. Our constitution does not mention reproductive rights, but Article 15 speaks of availing healthcare. The state is also committed to protecting women’s health rights and providing healthcare. Along with laws to establish women’s personal rights, there is also need for a change in social culture.

We may speak from different perspectives, but our objective is one and the same. And that is to eliminate gender-based violence from Bangladesh. People from all sectors of the society must come forward together to ensure quality family planning and reproductive health services and to prevent gender-based violence.

The Bangladesh government is committed to prevent gender-based violence. As part of this, the government is working on family planning and various other programs. I thank the Bangladesh government for this. Alongside the government, international agencies like the United Nations are playing a role too through their funding. I hope that these works will be made more advanced and dynamic in improving the living standards of the people of Bangladesh.

There has been much fruitful discussion at today’s roundtable. We hope the policymakers take into cognizance the recommendations that have emerged to eliminate violence against women in the context of reproductive health and family planning services. On behalf of Prothom Alo, I thank everyone and express our gratitude for taking part in the discussions.

· Everyone must be apprised of the link between gender-based violence and family planning and sexual reproductive health

· A woman should be provided with rights of getting family planning services.

· Further research is required about the link between family planning and gender-based violence

· Men should be involved more in family planning services

· People from all walks of life should come forward to prevent gender-based violence

· A connection should be created between the health directorate, the ministry for women and children affairs and the family planning directorate programs

· The number and the skills of the service providers should be increased

· The scope for safe motherhood and institutional delivery should be increased.

· The day care center law and related laws should be revised

· The activities at the union health and family planning centers should be strengthened

· The family planning programs should be publicized more

· To prevent child marriage with other programs there is a need for social movement