Qualitative Understandings of the Persistent Use of Traditional Contraceptive Methods Using Socio-Ecological Model among Older Reproductive-age Women in Bangladesh

Qualitative Understandings of the Persistent Use of Traditional Contraceptive Methods Using Socio-Ecological Model among Older Reproductive-age Women in Bangladesh | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Qualitative Understandings of the Persistent Use of Traditional Contraceptive Methods Using Socio-Ecological Model among Older Reproductive-age Women in Bangladesh Mashiat Abedin, Mohammad Bellal Hossain This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5868830/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The continued use of traditional contraceptive methods (TCM) among older reproductive-aged women (aged 35–49 years) in Bangladesh poses a significant public health issue. Existing research in Bangladesh suggests that women of this age use TCM more than their younger counterparts do. However, the reason why TCM use is higher among Bangladeshi older reproductive-age women is yet to be explored. The current study attempted to understand the use of TCM among Bangladeshi women aged 35 years or older. Methods: This qualitative study used purposive sampling from the Khulna district to conduct ten in-depth interviews among women aged 15-49 years and seven key informant interviews among family planning service providers. The socio-ecological model was adopted in this study. Data was collected in January 2024. The interviews were audio-recorded and transcribed verbatims afterward. Thematic data analysis was performed. Results: The study found that women’s poor knowledge and fear of the side effects of modern contraceptive methods and perceptions related to the effectiveness, risk and benefits, ease of use, and cost shaped the use of TCM at the individual level. The interpersonal factors included the influence of spouses, mothers-in-law, and peer groups. Community norms and beliefs were pivotal as well. Institutional-level factors included providers’ attitudes, health facility-related issues such as distance from the house, waiting in queues, and unavailability of products, and policy-level influences such as lack of updated policy molded the TCM use among older reproductive age women in Bangladesh. Conclusion: A complex interplay of various level factors shapes the use of TCM in Bangladesh. As a result, comprehensive reproductive health education programs should be considered so that women can make informed choices about the use of contraceptives and switch from traditional to modern contraceptive methods, such as long-acting methods. This will ultimately lead to better reproductive health outcomes in Bangladesh. Traditional contraceptive methods older reproductive-age women Bangladesh Plain English Summary The study explores the persistent use of traditional contraceptive methods (TCM) among Bangladeshi women aged 35–49, examining factors that influence their preferences. It identifies key issues such as limited awareness of modern methods, fear of side effects, cultural and religious beliefs, and convenience of TCM. These methods, including withdrawal and safe days, are considered safe and affordable, though they have higher failure rates. The qualitative study in Khulna district involved interviews with women and family planning providers. Using the Socio-Ecological Model, the research highlights individual, interpersonal, community, institutional, and policy influences. Women cited misconceptions about modern contraceptives, resistance from spouses or in-laws, and perceived social stigma as barriers. Providers’ inconsistent attitudes, irregular home visits, and challenges in accessing healthcare facilities also hindered modern contraceptive use. Community approval for family planning has increased, but misconceptions about modern methods remain. Religious beliefs further discourage modern contraceptive adoption, positioning TCM as a culturally acceptable choice. Institutional factors, such as poor service quality and supply issues, exacerbate reliance on TCM. The study underscores the need for targeted education, supportive counseling, and improved healthcare services. It suggests involving influential figures, like spouses and religious leaders, to promote awareness and acceptance of modern methods. Updated policies addressing these barriers could help women transition to more reliable contraceptive methods, enhancing reproductive health and contributing to gender equality and sustainable development. Introduction The continued use of traditional contraceptive methods (TCM) among older reproductive-age women (ages 35-49) in Bangladesh poses a significant public health issue. Despite achievements towards supporting the use of modern contraceptives, many older women remain dependent on traditional practices such as withdrawal, periodic abstinence, and folk methods (1). In Bangladesh, the contraceptive prevalence rate (CPR) among married women is 64%, with 54.7% and 9.3% using modern methods and TCM, respectively. Over the years, the use of TCM has been higher among 35-49-year-old women compared to their younger counterparts. It was the highest among those aged 40-44 in 2022 (1). Women aged 35-49, representing 15.73% of the female population in Bangladesh, face higher risks of unintended pregnancies (2,3). One-third of pregnancies in Bangladesh are unplanned, of which 63% are experienced by women aged 35 and above (3). The TCM users have a higher proportion of unintended pregnancies compared to modern method users (3). Unsafe abortion is often a danger associated with unintentional conception (3,4). Bangladesh is experiencing an epidemiological transformation, with older women facing elevated levels of obesity and non-communicable diseases such as hypertension and diabetes (1). These conditions will likely increase maternal health complications during pregnancy and adverse birth outcomes (5–7). Existing research in Bangladesh has focused on the overall contraceptive practices among women, overlooking the variations in contraceptive behavior and preferences across age groups (8–17). While these studies identify determinants of TCM use among Bangladeshi women, such as age, spousal interaction, and socioeconomic and spatial factors, they do not fully capture the broader spectrum associated with TCM use. Factors like media and visits by family planning workers have been studied (10,13), but other critical demand-side issues, like the perception of women, and supply-side factors, like healthcare facility-related issues, policies, etc., have yet to be explored for TCM use in Bangladesh. The studies' findings show that various issues influence the decision to use TCM. From the demand perspective, women’s views about modern contraceptive methods are frequently influenced by the lack of knowledge, misconceptions, and a preference for TCM believed to be less complicated, e.g., no side-effects more convenient to use compared to modern ones. On the supply side, matters such as poor standard of family planning services, lack of counseling on side effects, and challenges with logistics (such as lengthy commutes to clinics or contraceptive shortages) contribute to the use of TCM (18,19). However, these factors have not yet been studied in terms of TCM use in Bangladesh. The research gap is especially apparent in quantitative studies, which typically do not investigate the reasons behind TCM use among older women. Qualitatively exploring the complex justifications, beliefs, and lived realities that support TCM use is imperative. There are no such qualitative studies in Bangladesh that uncover these issues. Therefore, there is a need for targeted investigation considering the intricate dynamics of demand and supply issues regarding why TCM use is higher among older reproductive-age women in Bangladesh. This gap impedes the formulation of appropriate policies and initiatives that respond to the needs of older reproductive-age women and undermines the efforts to achieve sustainable development goals (SDGs), especially those linked to health and gender equality (20). The current study explores why the use of TCM is higher among older reproductive-aged women in Bangladesh, thereby bridging the knowledge gap and guiding effective policies and practices. Theoretical orientation of the study This study adopted the Socio-Ecological Model (SEM), which presents an extensive structure for exploring the interplay between individuals and their surrounding social settings. It includes several tiers of influence—individual, interpersonal, community, institutional, and policy—on behavior (21). Given that contraceptive behavior is influenced by various circumstances like knowledge and perception, interpersonal relations, community norms and beliefs, access and quality of care, national policies etc., (18,22,23), this model provides a comprehensive understanding of the factors affecting TCM use. While multilevel factors have been studied about contraceptive use in general and modern methods, specifically in the context of Bangladesh (16,17,25) using quantitative methods, the SEM has not been applied to address the dynamics of TCM use among older women in Bangladesh by using a qualitative approach. Therefore, this study employed SEM to understand the use of TCM among older women of reproductive age in Bangladesh. Materials and methods Research strategy and design This study adopted the qualitative research strategy based on interpretive epistemology (24) to understand the use of TCM by exploring the unique perceptions of Bangladeshi women and the meanings they give to their experiences. In addition, the study adopted a cross-sectional research design, as the data were collected at a single point in time (24). Study area This study was conducted in the Khulna district of the Khulna division in Bangladesh. The use of TCM has been consistently high in this division. For example, the rates over the last decade have varied from 10.6% in 2011 and 10.7% in 2014 to 12.5% in 2017 and 10.2% in 2022 (1) We purposively selected married women aged 35-49 who reside in three sub-districts or Upazilas of Khulna district: Rupsha, Batiaghata, and Dumuria Upazila. Study participants The study population consisted of older reproductive-age women, that is, 35-49 years of age, who were using TCM, such as periodic abstinence or withdrawal. The utilization of TCM is consistently higher among this age group (1). The study also included family planning service providers from the Maternal and Child Welfare Centre (MCWC), Upazila family planning office, and Union Health & Family Welfare Center (UH&FWC) in Bangladesh. Sampling procedure and sample size Data was collected from 17 participants using a purposive sampling technique. Ten were women aged 35-49, while the remaining seven were family planning service providers in Khulna, Bangladesh. Data collection Data collection for the study was done in January 2024. The qualitative data were collected from the older reproductive-aged women through face-to-face in-depth interviews (IDIs) and the family planning service providers and program managers through key informant interviews (KIIs) using a semi-structured interview guide. These three types of respondents were interviewed as SEM-related contraceptive use requires data from both the demand and supply sides. Two separate semi-structured interview guides were developed based on extensive literature reviews and refined based on emerging interview results. Therefore, the semi-structured interview guides were used to structure the interviews but provided flexibility. The interview duration ranged between 30–45 minutes. The interviews were conducted in the native language, Bengali after the participants were informed of the study's objectives and their consent was obtained. Data analysis The study adhered to the thematic analysis approach developed by Braun and Clarke (25) to give an organized framework for finding, examining, and summarizing themes in the qualitative data. The audio recordings of the interviews were transcribed and read numerous times to ensure a deeper understanding of the participants’ responses. A hybrid coding approach was adopted to integrate both theory-driven and data-driven codes. An initial coding framework was generated after examining the subsections of the transcripts, and new codes were assigned if they could not be classified using the initial classification. Then, the codes were arranged according to broad themes that encapsulated the perspectives and experiences of the participants. The themes were revised and refined to ensure they adequately depicted the data. Meaningful participant quotes were used to validate these themes, providing evidence of the participants’ lived experiences. Results Background characteristics of the participants A total of 17 interviews were taken, of which 10 were in-depth interviews of older reproductive-aged women. Most women were aged 35-39 years with more than one living child. Many of them were users of the periodic abstinence or safe days method, with only one of them practicing the withdrawal method. Table 1 presents the background characteristics of women. Table 2 presents information on the supply-side actors. All of them were family planning service providers working at various levels and institutions under the Directorate General of Family Planning in Bangladesh. Table 1 is about here Table 2 is about here Factors shaping traditional method use Following SEM, this study identified the individual, interpersonal, community, institutional, and policy-level factors influencing TCM use among older reproductive-aged women in Bangladesh. Table 3 summarizes the study's main findings in themes and sub-themes. Table 3 is about here Individual level factors Lack of knowledge about modern methods. Many participants knew little about modern methods, lacking an understanding of what they are or how they should be used, leading to widespread fears about potential side effects. “I don't understand that much. I haven't used [modern method]. Many people say about Copper-T, I do not understand them, I do not have a good knowledge about this.” (IDI-9) Providers also reported poor awareness among women about modern methods, resulting in having misconceptions about modern methods and choosing TCM. This emphasizes the pressing need for targeted awareness initiatives to overcome misunderstandings, increase knowledge, and enable women to make educated choices about reproductive health. “A lot of them have misconceptions [about modern methods]. They do not know about it [modern methods]. That's why they do this [safe period]. They don't know what the other options are.” (KII-6) Fear of side-effects of modern methods . The fear of adverse effects was a major reason why women in Bangladesh chose TCM. Women who had observed or suffered from harmful consequences such as dizziness, weight gain, and nausea link these issues directly to modern methods, prompting them to use TCM, which they believed to be safer. “I see my sister-in-law having many problems. She uses injections. She has a problem with her vision; she does not see properly. She has irregular periods after three to four months intervals. Now, she does not see almost anything. She has become fatter. Now, she has stopped taking injections. Pills also deteriorate the body regularly, such as dizziness, vomiting, and other health problems…” (IDI-4) The providers reported that the fear of adverse side effects of modern methods acted as a barrier to the utilization of modern methods, like oral pills and injectables. They attempted to alleviate these fears and anxieties by emphasizing that adverse effects tend to be brief as the body adapts to hormonal changes. Still, their efforts frequently failed to influence women's beliefs, resulting in a continued use of TCM as a safer choice. “For example, if you use it for the first time, it will take some time to adapt to the body. This takes two or three more months. Then, there are some changes in the menstrual period. These are hormonal methods, so if these are absorbed in the body, the ability to have children is hindered. Maybe that's why they think something is wrong with their body. If they have a little patience, they can understand that their ability will return. That's why it is called the reversible method.” (KII-1) Greater understanding of traditional contraceptive methods . Women have a greater sense of TCM, such as the safe-days method or periodic abstinence, confidently identifying the “fertile” and “infertile” days. “I am counting safe days and keeping track of the date of menstruation. If my period starts on the 10th of the month, we keep track of when it starts… so that's how we maintain it. A week before the start of menstruation is safe.” (IDI-2) However, the providers felt that the women were not fully aware of the safe days and miscalculated fertile days. They further highlighted the fact that even educated women were not fully aware of how to use TCM, making them vulnerable to unwanted pregnancy. “Let me share an experience. A project manager at a reputed organization and his wife follows [safe period]. The days that he thinks are safe are dangerous periods. And that's how they conceived a baby. But we know that it is a dangerous time.” (KII-1) Perceived effectiveness of traditional methods. The users of the safe days’ method were confident in their ability to calculate safe days correctly due to their regular monthly cycles. The absence of unplanned pregnancies strengthened their satisfaction with its effectiveness, demonstrating a sense of control and confidence in managing their reproductive health. As a result, they saw no reason to transition to modern methods. “Yes, it works well, we do it. I think I can maintain this well. It's straightforward for those who understand, and it's difficult for those who do not understand how to do it [counting safe period].” (IDI-2) However, opposing viewpoints from healthcare experts emphasized a divergence, stating that many women had difficulty with keeping correct counts, resulting in a substantial failure rate and unwanted pregnancies. This disparity underlines the mismatch between individuals' self-evaluated capability and professionals' concerns about the reliability of TCM, stressing the importance of improved education and counseling to close this gap. “They can't do it [count safe days] properly. You must maintain it. But since they cannot keep account [of the safe days], the failure rate is quite high. As a result, they have many children.” (KII-6) Perceived ease of use of traditional methods. The participants felt that using TCM was more convenient than modern methods, indicating a preference based on their perceived ease of use and minimum disruption to their everyday tasks. For example, some women did not remember to take pills regularly, while others found it challenging to use a condom or missed due dates for injectables. This perception of TCM as an easy alternative highlights a significant barrier to the adoption of modern methods, implying that strengthening accessibility and constant follow-up for modern contraceptives may be critical in promoting their use among older reproductive-age women. “There is no unnecessary trouble (with TCM), like I forget to take pills, forget to take injections, I can't remember the time, I can't always keep an account. There is no hassle. If you consume pills or use any other methods, you must stand in lines at the hospital and waste time. Also, you must wait for the workers [to visit home]; sometimes they do not have it and do not visit regularly.” (IDI-1) Perceived low risk about TCM. The participants had a low-risk perception of TCM. They believed their method was less harmful and had no unintended consequences like unplanned pregnancy. They felt safe adopting these methods because they had no firsthand undesirable experiences or heard of bad outcomes. “It seems this is good for my health; there is no risk [of unintended pregnancy]. I think this is good for me. I'm fine with Allah's mercy. I trust it [safe period], and if I keep an account [of safe period], there is no problem.” (IDI-1) Furthermore, health practitioners noted a major gap in women's awareness, stating that many were ignorant of the larger health hazards linked with TCM, including sexually transmitted infections (STI). This assumption regarding TCM's safety, along with fear of modern methods, generated the decision to use TCM, indicating a need for comprehensive counseling to correct misconceptions and encourage safer contraceptive behaviors. " I think those using traditional methods are unaware of the health risks. If they knew about HIV-AIDS or other sexually transmitted diseases, they would not have used the Azal method [withdrawal] or other [TCM]. In this case, we generally recommend the use of condoms to avoid health risks." (KII-2) Perceived cost of modern methods. Few women viewed modern methods as financially inaccessible. They thought that permanent methods like ligation required expensive surgeries, indicating their poor awareness regarding the availability of cost-subsidized, long-acting, and permanent methods. This notion was supported by the participants' inclination for cost-free TCM, such as recording safe periods, which they believed to be affordable and appropriate for their socioeconomic situation compared to modern methods. “Also, we're not so rich, and we do not have much money to do that [ligation], so I think this method [safe period] is good for people like us.” (IDI-1) Perceived health benefits. Many women believe that TCM offers fewer health hazards than modern contraception, which they link with a variety of adverse effects such as weight gain and other physical discomfort. This perception was supported by individual and family experiences in which older generations have used TCM without harmful health impacts, strengthening the view that it was safe. “If I use something else, it will not adjust with my body. So, I use it [safe period]. Our grandmothers, aunts, and mother used it [safe period] and did not have a problem with this; they are healthy. I have not put on weight. I have remained the same before and after marriage.” (IDI-4) “I talk to people, but I never heard them say they have a disease or anything due to this [using safe period].” (IDI-1) Furthermore, providers typically refrained from suggesting modern methods to women with pre-existing health issues, which supported women's choice for TCM. "They [women] think that it [modern method] can increase their health risks at this age. When they cross 30/40, they can have high blood pressure and diabetes. That is why we do not suggest modern methods if they have diabetes or pressure. That's why they are more prone to traditional methods. And they try to avoid modern methods." (KII-2) Perceived embarrassment. The matter of embarrassment associated with modern contraception, such as condoms and injections, underlined longstanding societal beliefs that discourage open family planning discussion. Participants mentioned how societal criticism led to their unwillingness to use modern methods. For example, disposing of condoms was considered a shameful deed that might result in condemnation from family members, particularly in-laws, whilst visiting medical facilities for injectables was regarded as publicly reporting their contraception use, exposing them to potential scorn and disgrace. This stigma associated with contraceptive use fostered the adoption of TCM, which was viewed as more discreet. “Before my marriage, I used to see that people would make fun of those who used to go to healthcare centers for family planning methods. I think it's about condoms. You must throw it away or dispose of it after use, and you know, there's my family. What if my sisters-in-law and mother-in-law see it while throwing it? It's such a shame.” (IDI-2) Exposure to mass media . Exposure to mass media plays a critical part in increasing awareness and shaping the attitude of women regarding different contraceptive methods and prompting them to consider modern contraception. The participants admitted to seeing or hearing family planning messages on television or radio before; however, not much has happened recently. This explains women’s lack of knowledge of modern methods, especially long-acting and permanent ones, leading to continued use of TCM. "Yes. I have seen it [family planning messages] on TV, for example, having one child is enough, be it a girl or a boy. I remember they used to show drama on TV as well, but not anymore." (IDI-9) Interpersonal level Spousal opposition to modern methods . Partner opposition to modern methods was a barrier to their use, typically driven by fears of adverse outcomes such as obesity and other health problems. The spouse's refusal to let his wife choose pills or injections symbolized a larger socio-cultural effect in which male opinions profoundly shaped reproductive decisions. “He [husband] does not like pills or injections. He says that these [pills and injections] will make me obese and there will be many diseases.” (IDI-4) In response, the providers acknowledged the importance of religious figures, such as Imams, who wield communal power. By using Imams to promote the advantages of modern methods, they hoped to use their authority to resolve spousal opposition and increase its approval. “The men of the family can be explained by the Imam (who leads prayers in a mosque). The men will not listen to me, but they accept their words from the Imams. We give them a list of names and ask them to motivate and discuss such things.” (KII-4) Cooperation to use traditional methods. Most participants reported that their husbands cooperated and supported the use of TCM, especially when they observed modern methods, such as oral pills, to have negative side effects. “You know, my husband saw that there is a problem with that [pills], and it [safe period] is safe. That is why he accepted it. We discussed [safe period] after my sister told me about it [safe period], and he told me to follow it.” (IDI-8) Spousal attitude. Spouses' positive attitudes about TCM facilitated its use among women in Bangladesh. Husbands felt that TCM was much safer and better, so they supported their wives and encouraged the use of TCM. This scenario indicates how partner involvement and mutual satisfaction with TCM led to its continued use, demonstrating the importance of spousal support for reproductive choices. “My husband says that this [safe period] is good. I feel physically fine. Besides, we have spent many years this way, and he is happy. He thinks there is nothing bad about it. He also says that you had a problem with pills, but this one is safer. We are better.” (IDI-1) Influence of mother-in-law . Family members, especially mothers-in-law, play a crucial role in shaping women’s choices and decisions about using family planning methods. Opposition of the mother-in-law to modern methods often leads to the use of TCM. “Honestly speaking, she doesn't like this [family planning]. She says don't we have [children] in our times... What's wrong with having [children] if Allah gives you? If Allah gives mouth, He will feed them as well… We have not used such useless things. We have brought up five or six sons and daughters, you can do it as well. After marriage, my mother-in-law told me not to use these things.” (IDI-1) However, providers remarked that mothers-in-law's dominance has waned over time, with many no longer opposing the use of modern contraception. “The role of the family is important… The mothers-in-law have become quite aware of things even in our village. We had eight to ten children, and we had no problems - Nowadays, this example doesn't work” (KII-2) Peer influence . Peer groups such as sisters or friends shape the use of TCM among women in Bangladesh. Some participants mentioned their sister as the source of information and support for using TCM. However, even when peers disapproved, participants continued using TCM because of their low-risk perception. “My elder sister uses this method as well. She told me to use this method. She also told me that if I follow the rules properly, there will be no problem.” (IDI-8) Community level Community approval of contraception use . The community's approval of contraception use has grown dramatically, creating a more accepting setting for women to select the contraceptive methods that satisfy their requirements, whether modern or traditional. “I don't think nowadays no one has any headache or anything about anyone. People use a method that is good for them, or that suits their body. No one talks about that. They use whatever is convenient for them… I see most of the people consuming pills. That's what I hear the most.” (IDI-1) Even family planning workers, who once faced prejudice and were often disliked in communities, are now welcomed and seen as trusted, demonstrating an optimistic shift in community norms. However, some lingering negative opinions about modern methods exist at the individual level. “Society plays a crucial role, and it has changed over time. There was a time when people could not even say they worked in family planning due to various reactions. The FWAs couldn't go home, and people used to chase them out. Now, people welcome them with open arms. However, a limited part is negative; it was there before and will remain so.” (KII-1) Common fear of medical complications . Fear of medical complications and false beliefs, such as implants breaking inside the body during daily activities or IUDs migrating inside the body, lead to discontinuation of modern methods and switch to TCM. These fears and misconceptions were frequently perpetuated and reinforced through community interaction among neighbors and relatives and affected individual choices to avoid using modern contraceptives. “If you do an operation like ligation, you must undergo many cuts. What if the cut is not stitched well? Many people find it difficult to come home and work after the operation… Sometimes, it may lead to cancer as well… Also, there can be problems in the uterus and cervix, and sometimes it must be cut off as well. So, I am scared. My neighbor told me not to do it.” (IDI-1) Even health professionals acknowledged the existence of preconceptions about modern methods among women, thus the need to create tailored educational programs to overcome these misunderstandings among women. “Many people think IUD mixes with blood and heart, go inside, and they fear that it will be displaced.” (KII-6) Religious beliefs . Religion played an important role in the use of TCM and the non-use of modern methods among older reproductive-age women. Only one participant was Hindu, and the rest were Muslims. According to Muslim women, modern methods, such as injectables, implants, and ligation, were heinous and prohibited since they included alterations to the body that were regarded as inconsistent with religious teachings. Therefore, they rejected modern methods to ensure religious adherence. “According to religion, it is not right to have any pills or anything. Like using a condom or a pill is sin. They [religious leaders] also think the same because it is a sin to use a pill...” (IDI-8) Women, on the other hand, justified their use of TCM in comparison to the sinful aspect of modern methods in the religion. They believed that TCM, such as the safe day's method, was natural, acceptable, and non-sinful and aligned better with their beliefs. Thus, it was legitimate to use it according to the religion. “Why will it [safe days] be forbidden? I don't do any sin. Is this my sin? No! We are doing many things in the world; we are doing sinful things. I don't think it is sinful. How do those who use injections and have irregular periods and sporadic bleeding pray?” (IDI-9) Furthermore, providers highlighted the religious reasonings of women against the use of modern methods, such as divine punishment and retribution in the afterlife. As a result, they attempt to cope with it by enlisting spiritual figures, such as imams, to clarify myths and advocate for modern contraception. “Allah will not forgive them, that part of the body will be burnt in Hell- In this case, we approach the heads of mosques, such as the imam, to motivate the people and share benefits [of using modern methods].” [KII-6] Institutional level Providers’ attitude . The participants voiced mixed feelings about health providers' behavior. Some women found them accommodating, but others mentioned anger if they ignored providers' advice. The inconsistency in professional attitude led to a loss of faith and a poor experience for women, particularly when healthcare workers encouraged them to adopt certain methods like implant ligation without providing an adequate reason or acknowledging their fears. “Sometimes they behave well, and at other times they get angry… they insist on keeping [products]… When I said no, she got angry. She told me furiously, "What are you doing? You don't want to take the pill? You don't want to do ligation? What is this? You have two children." They behave so strangely, do not make explain properly, do not come to us regularly, but still get angry!” (IDI-1) In response, the program managers believed they delivered thorough training to improve their communication skills and foster good rapport and trust, especially at the grassroots level. They emphasized using BCC (Behavior Change Communication) to develop the abilities to resolve individual issues, convey correct information, and offer respectful and patient-friendly care. “We have BCC [Behavioral change communication] strategies. We train them to talk to someone. However, more training needs to be done because they repeatedly do the same work. That's why sometimes we give them refresher training, so their work is better.” (KII-3) Irregular visits . Some participants reported inadequate, irregular home visits by Family Welfare Assistants (FWAs). FWAs are grassroots healthcare workers who provide reproductive and maternal health services to communities in their designated locations, such as contraceptive distribution, counseling, and, if needed, referrals to higher-up health professionals. They serve as a critical link between women and the larger health system, and their irregular attendance can result in missed chances for education, contraception distribution, and prompt referrals. Consequently, women felt less supported, which contributed to the continued use of TCM rather than modern options. “Earlier, they used to come and call everyone out, “Khala/Chachi (aunts).” Now they don’t come that often.” (IDI-9) Quality of service. Some women expressed skepticism and apprehension because of previous poor experiences or perceived maltreatment by health professionals, preventing them from seeking family planning services from health centers. Fear of meeting harsh attitudes from practitioners and satisfaction with the TCM prompted women to avoid healthcare centers completely. This demonstrates that strengthening interpersonal components of care is critical to getting women to use modern family planning options. “No, I didn't go [to healthcare centers]. If those who come to our homes behave like this, then the ones [at the healthcare centers] may behave like this, and there may even be people from higher-up positions. I am afraid of how they will behave. And I am satisfied with my method [safe period], so I do not go.” (IDI-1) Healthcare center-related issues. Women reported healthcare center issues, such as distance from the house, waiting in lengthy queues, and unavailability of products, which led to frustration and contributed to the non-use of modern methods since the hassle and scarcity of resources deter women from accessing essential services. “If you go there, you will find that there are often long lines and many problems with the serials…. Many times, they say there are no more products available. They give a date and say, "Come later on this day, we don't have it right now, you can take it next time." It's so troublesome.” (IDI-8) On the other hand, the providers highlighted patient-friendly care by fostering an enabling, courteous, and individualized atmosphere that concentrates on the welfare of those receiving healthcare, making them feel at ease, valued, and adequately cared for. “Our union-based health care centers work as a team. Those who go to the field are always in contact with those at the centers. They also refer to whether there is any complication in using any method. If there is any complication after taking family planning, the government will bear the cost. This is how we have been able to create a patient-friendly environment.” (KII-1) The key informers further explained how they ensured that women who seek family planning services at health centers have full access to them. They stated the financial considerations for long-acting and permanent method services provided to women according to the government's instructions. “If someone comes to get clinical services in that FWC (Family Welfare Center) … we pay a transportation cost. Once sixty taka is given to them, it is used for follow-up. Three follow-ups are done monthly. The amount for the three months is also given. They are informed when the FWV (Family Welfare Visitor) motivates them to take the procedure. And it is mentioned in the citizen charter.” (KII-1) Policy level Lack of updated policy . The family planning initiatives in Bangladesh have emphasized the promotion of modern contraceptive methods to combat growing numbers and promote the well-being of mothers and children. The traditional methods have been a part of the general family planning scenario but are rarely promoted in mainstream policy due to high failure rates, often resulting in unintended pregnancies. “In fact, according to the government policy, we talk about the modern method, not the traditional method. And the reason is because you don't know what will happen if they use it, such as unintended pregnancy” (KII-5) Additionally, the providers discussed the ongoing initiatives to revise national policy, including consultations with stakeholders to accommodate varied family planning needs, doorstep care, and a greater knowledge of women's needs. Given the number of older reproductive-age women using TCM in Bangladesh, instead of sidelining traditional methods in policy discourse, it is imperative to adopt an inclusive approach and raise awareness about the negative consequences of using TCM among women. “The national policy that was in place in 2012 is now being further modified. Meetings have also been held with various stakeholders and will likely be completed this year. Family planning activities have been included in the national policy with the coordination of all stakeholders. School education, door-to-door services, the complexity of service provision, and the needs of women- everything has been included.” (KII-1) Discussion This study showed that individual, interpersonal, community, institutional, and policy factors shaped the use of traditional contraceptive methods among Bangladeshi women aged 35–49. At the individual level, women’s knowledge about TCM and modern methods and perceptions related to their effectiveness, risk and benefits, side effects, ease of use, and cost molded the use of TCM. The study found that participants were familiar with family planning benefits but lacked awareness of modern methods. Instead, they monitored their "safe" days, exhibiting a low-risk perception. This finding is similar to a study in Indonesia, where women knowledgeable about family planning and fertile periods were more likely to utilize TCM ( 26 ). Furthermore, women think the TCM they use is effective because they have been using it for a long time but have not encountered any unintended consequences, which is concurrent with other studies worldwide ( 19 , 27 ). Most participants found TCM easier to use than modern methods as they did not need to remember to take pills or visit health facilities to get injectables. This result is congruent with other study findings ( 19 , 27 – 29 ). Moreover, our participants found using modern methods shameful, which is concurrent with some studies where participants reported that they were ‘embarrassed’ to buy a condom ( 29 – 32 ). The participants have very low-risk perceptions related to the use of TCM, considering them reliable and safe in preventing unwanted pregnancy. Some accepted the risk but believed it could be minimized correctly, while others believed modern methods were riskier. This is in line with a study in Turkey ( 19 ) and differs from other studies where TCM users express concern about the risk of unintended pregnancy ( 29 ). Unwanted side effects of modern methods, like becoming overweight, infertility, dizziness, nausea, vomiting, fatigue, diminished appetite, and irregular periods, experienced by women and their family members or neighbors, lead to their discontinuation and use of TCM ( 26 , 33 , 34 ). Various investigations have confirmed it worldwide ( 15 , 35 ). This calls for more scientific research to develop modern methods with minimal side effects, ensuring women's health remains unaffected. Traditional methods were free of cost, while modern methods were primarily purchased from the private sector (57%), with 37% supplied by the public sector in Bangladesh. For example, 14% of users get pills from government field workers, while 59% of people obtain pills from pharmacies/drugstores ( 1 ). In this case, when women do not have access to pills due to irregular visits of workers or stockouts, they resort to pharmacies, resulting in costly prescriptions. Women may consider the private sector more courteous, accessible, and trustworthy. A coordinated approach is required to strengthen public family planning services, including health infrastructure and enhancing professional training. A similar outcome was noted elsewhere ( 36 – 38 ). Likewise, withdrawal users in Turkey reported that this method was not costly, while modern methods were ( 19 , 27 ). Exposure to mass media shapes the adoption of TCM among older women. Women reported knowing about family planning through television advertisements, dramas, etc., but they observed a decrease in such coverage. Previous studies found that TV and radio are essential for delivering information regarding family planning in Bangladesh, though exposure to family planning through mass media remains constrained ( 39 , 40 ). The most efficient way to convey information about contraception was through the mass media, consistent with other findings ( 41 ). Mass media messages weighing the benefits and risks of using TCM versus modern methods could help women make informed choices. Policymakers should consider alternative mediums, including social networking sites, to address and resolve women's fears about the adverse effects of modern methods while highlighting the risks of TCM, such as unplanned pregnancies. At the interpersonal level, male partners’ opposition to modern methods hindered women from using them ( 19 , 30 ). Supportive husbands favored the use of TCM due to their perceived benefits. This mutual decision-making among spouses was in line with other studies elsewhere ( 19 , 27 ). Mothers-in-law's aversion to modern methods impedes adoption of oral pills, injectables etc., as they have substantial power in a typical household in Bangladesh, involving reproductive decisions. The scenario is consistent with the findings of previous studies ( 42 – 44 ). However, previous research implied that living with mothers-in-law may promote the usage of modern methods and TCM in India, as well as modern methods like pills, injectables, and implants in Nepal and Bangladesh ( 45 ). This emphasizes the need to include husbands and mothers-in-law in family planning discussions, such as courtyard meetings. Peer support played a key role as women were more inclined to opt for the method utilized by their social circle since they valued their opinions and previous experience. This emphasizes the possible use of a “ social networking strategy ” to disseminate information about contraceptives via interpersonal interactions ( 46 , 47 ). The use of contraceptives is common. However, community and religious beliefs acted as barriers to the uptake of modern methods and thus facilitated TCM use. Religion affected the use of contraceptives among Bangladeshi women, with modern methods often seen as forbidden, while TCM was accepted ( 8 , 9 , 11 , 12 , 16 , 18 , 48 ). Women believed that using modern methods, especially permanent ones, was wrong in terms of religion, dreading aftermaths like being denied a proper religious burial or facing eternal punishment ( 49 ). Furthermore, cultural myths and beliefs negatively affected the uptake of modern contraceptives, aligning with published research worldwide ( 18 , 22 , 30 , 50 – 53 ). This underscores the significance of involving influential individuals like Imams in addressing the acceptability of long-acting permanent methods (e.g., IUD, ligation) in religion and dispelling misconceptions. Contraceptive use was shaped by institutional-level factors such as lack of proper healthcare infrastructure, absence of quality care and services, and poor behavior of family planning service providers, which calls for a client-centered care service. This aligned with a study conducted in West Africa ( 54 ). Other studies reported that users preferred the availability of services at convenient times, with lower waiting periods, and located near their residences ( 32 , 55 ). The providers ' undesirable attitudes, such as yelling and neglecting concerns about side effects, further hampered service utilization ( 56 ). Furthermore, commodity availability issues underscore the urgency for improved supply chain monitoring and greater consistency of consumption estimations with product availability ( 56 , 57 ). Bangladesh demonstrated achievements in family planning despite challenges like illiteracy, lower gender equality, and poverty. The 4th Health, Population, and Nutrition Sector Program (HPNSP) 2017-22 targeted raising the CPR from 62–75% by 2022, focusing on underperforming regions like Sylhet and Chattogram. Bangladesh Family Planning 2030 (FP2030) pledges to expand modern contraceptives' supply, access, and adoption ( 1 , 58 ). The existing policies, such as the Bangladesh Population Policy 2012, aimed to increase CPR to 72% by 2015 ( 59 ). Still, they need to be updated to incorporate the complexity of family planning and the shifting patterns of demographics. These policies emphasize modern methods, which are much more reliable, safer, and effective compared to TCM due to its adverse consequences like unintended pregnancies and sexually transmitted diseases. This underscores the need for a transition beyond a “ one-size-fits-all” approach to family planning that includes tailored strategies to meet the distinct requirements for the reproductive well-being of Bangladeshi women aged 35–49. Strengths and limitations The study is one of its kind to specifically explore the traditional contraceptive behavior of older reproductive-age women in Bangladesh using SEM and offer a comprehensive view of the process through which women make their choices for TCM. It has imperative implications for the existing family planning initiatives aimed at the intended demographic group. This study has some limitations, too. Due to time and resource constraints, the study was conducted only in three sub-districts of Khulna district. Nonetheless, it was sufficient to provide a genuine situation of TCM use among older women. In addition, the opinions of the participants' husbands were not explored. Conclusion The study used the socio-ecological model to explore traditional methods among 35–49-year-old women. Individual, interpersonal, community, institutional, and policy factors, such as poor knowledge of modern contraceptive methods, perceived ease of use and risk related to the use of TCM, fear of side effects of using modern methods, familial influence, community norms and beliefs, providers’ attitudes, quality of services, and other health facility related issues such as distance from the house, waiting in queues, unavailability of products, and lack of mass media coverage shaped the TCM use. As a result, family planning services should be strengthened to promote modern methods and address related fears, enhance knowledge, and highlight the risks of TCM through comprehensive counseling. The participation of influential individuals such as husbands, mothers-in-law, and religious figures is critical in disseminating and normalizing modern methods in society. Furthermore, providers should deliver client-oriented services, and policymakers should prioritize improving resources and media outreach to shape women’s perception of risk related to TCM use. Reproductive health programs should help women make informed choices and switch from TCM to modern methods, such as long-acting methods. This will improve women's reproductive health and foster gender equity, contributing to sustainable development in the country. Abbreviations CPR: Contraceptive Prevalence Rate IDIs: In-depth Interviews KIIs: Key Informant Interviews SDGs: Sustainable Development Goals SEM: Socio-Ecological Model TCM: Traditional Contraceptive Method Declarations Ethics approval and consent to participate This study was approved by the Department of Population Sciences, University of Dhaka. The study participants were provided with information about the purpose of the research, the kind of questions to be asked, and their freedom to refuse or cancel the interview at any moment during the process. Before each interview, they were asked if they agreed to participate and allowed the session to be recorded while maintaining confidentiality and anonymity. People who did not provide approval were immediately omitted from the sample. All transcripts and excerpts in the findings section contain anonymous identifiers to protect participants' identities. Consent for publication Not applicable Availability of data and materials The data supporting this study's findings are not publicly available due to restrictions that were applied to them. However, the authors will make the data available upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding The research did not receive any funding from any sources. Authors' contributions MA and MBH conceptualized and designed the study. MA collected and analyzed the data while MBH supervised MA. Both authors contributed to interpreting the results, drafted and edited the manuscript, and finally approved it for submission. Acknowledgments Not applicable Authors' information (optional) Not applicable References National Institute of Population Research and Training (NIPORT) and ICF. Bangladesh Demographic and Health Survey 2022: Key Indicators Report. Dhaka, Bangladesh, and Rockville, Maryland, USA; 2023. Bangladesh Bureau of Statistics. Population & Housing Census 2022: Preliminary Report. Dhaka, Bangladesh; 2022. Noor F, Rahman M, Rob U, Bellows B. Unintended pregnancy among rural women in Bangladesh. Int Q Community Health Educ. 2011;32(2):101–13. Khan MN, Harris ML, Huda MN, Loxton D. A population-level data linkage study to explore the association between health facility level factors and unintended pregnancy in Bangladesh. 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Tables Table 1: Background Characteristics of Women ID Age (Years) Number of Living Children Contraceptive Use Education Religion Current Previous IDI-1 38 2 Safe Period Oral Pills Class 8 Islam IDI-2 35 2 Safe Period Oral Pills Class 12 Islam IDI-3 35 1 Safe Period Oral Pills Class 5 Islam IDI-4 35 1 Safe Period - Masters Islam IDI-5 35 1 Withdrawal, Safe Period Oral Pills Masters Hindu IDI-6 36 2 Safe Period Oral Pills, Injection Class 5 Islam IDI-7 35 2 Safe Period Oral Pills Class 10 Islam IDI-8 35 2 Safe Period Oral Pills Class 10 Islam IDI-9 40 1 Safe Period - Class 12 Islam IDI-10 46 3 Safe Period Folk Method Class 5 Islam Table 2: Information of the Key Informant Interviewees ID Number Occupation KII-1 Assistant Director, FP KII-2 Assistant Director, FP KII-3 Upazila Family Planning Officer KII-4 Family Welfare Visitor KII-5 Medical Officer KII-6 Family Welfare Visitor KII-7 Family Welfare Assistant Table 3: Main Findings of the Study Individual Level Lack of Knowledge about Modern Methods Fear of Side-effects of Modern Methods Knowledge of Traditional Methods Perceived Effectiveness of Traditional Methods Perceived Ease of Using Traditional Methods Perceived Low Risk of Traditional Methods Perceived Cost of Modern Methods Perceived Health Benefits Perceived Embarrassment Exposure to Mass Media Interpersonal Level Spousal Influence Opposition to Modern Methods Cooperation to use Traditional Methods Spousal Attitude Influence of Mother-in-Law Peer Influence Community Level Community Approval of Contraceptive Use Common Fear of Medical Complication Religious Beliefs Institutional Level Providers’ Attitude Irregular Visits Quality of Service Healthcare Center-related Issues Policy Level Lack of Updated Policy Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5868830","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":410806347,"identity":"a25b3803-065a-49f9-a8e8-83986082ad75","order_by":0,"name":"Mashiat Abedin","email":"","orcid":"","institution":"Department of Population Sciences, University of Dhaka","correspondingAuthor":false,"prefix":"","firstName":"Mashiat","middleName":"","lastName":"Abedin","suffix":""},{"id":410806348,"identity":"7cdf1776-0913-4a22-84d8-3597a5dfb015","order_by":1,"name":"Mohammad Bellal Hossain","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuUlEQVRIiWNgGAWjYBACAwbmxgMMBTaMDSAeYwMzMVoYGw4wGKSRruUwCVrM2RsbDvwwOC+74QDzww+MO6wJa7HsOdhwsMfgtvGGA2zGEoxn0olw2I3EhgM8BrcTNxxgMGNgbDtMhJb7DxsO/jE4B9TC/o1ILTcYGw7zGBwAauEh0hbLnsSGwzIGycYzD/MUSyQS4xdz9sMHH76psJPtO96+8cNHYkIMAUAxkkCKhlEwCkbBKBgFuAEA+4FBXXzZ5pUAAAAASUVORK5CYII=","orcid":"","institution":"Department of Population Sciences, University of Dhaka","correspondingAuthor":true,"prefix":"","firstName":"Mohammad","middleName":"Bellal","lastName":"Hossain","suffix":""}],"badges":[],"createdAt":"2025-01-20 22:23:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5868830/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5868830/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":75580785,"identity":"d7e5d4bc-ed16-458f-9718-3e78273e520b","added_by":"auto","created_at":"2025-02-06 05:38:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1377252,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5868830/v1/ec911220-e9ca-44a9-a633-68b7b0589166.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Qualitative Understandings of the Persistent Use of Traditional Contraceptive Methods Using Socio-Ecological Model among Older Reproductive-age Women in Bangladesh","fulltext":[{"header":"Plain English Summary","content":"\u003cp\u003eThe study explores the persistent use of traditional contraceptive methods (TCM) among Bangladeshi women aged 35–49, examining factors that influence their preferences. It identifies key issues such as limited awareness of modern methods, fear of side effects, cultural and religious beliefs, and convenience of TCM. These methods, including withdrawal and safe days, are considered safe and affordable, though they have higher failure rates. The qualitative study in Khulna district involved interviews with women and family planning providers. Using the Socio-Ecological Model, the research highlights individual, interpersonal, community, institutional, and policy influences. Women cited misconceptions about modern contraceptives, resistance from spouses or in-laws, and perceived social stigma as barriers. Providers’ inconsistent attitudes, irregular home visits, and challenges in accessing healthcare facilities also hindered modern contraceptive use. Community approval for family planning has increased, but misconceptions about modern methods remain. Religious beliefs further discourage modern contraceptive adoption, positioning TCM as a culturally acceptable choice. Institutional factors, such as poor service quality and supply issues, exacerbate reliance on TCM. The study underscores the need for targeted education, supportive counseling, and improved healthcare services. It suggests involving influential figures, like spouses and religious leaders, to promote awareness and acceptance of modern methods. Updated policies addressing these barriers could help women transition to more reliable contraceptive methods, enhancing reproductive health and contributing to gender equality and sustainable development."},{"header":"Introduction","content":"\u003cp\u003eThe continued use of traditional contraceptive methods (TCM) among older reproductive-age women (ages 35-49) in Bangladesh poses a significant public health issue. Despite achievements towards supporting the use of modern contraceptives, many older women remain dependent on traditional practices such as withdrawal, periodic abstinence, and folk methods (1). In Bangladesh, the contraceptive prevalence rate (CPR) among married women is 64%, with 54.7% and 9.3% using modern methods and TCM, respectively. Over the years, the use of TCM has been higher among 35-49-year-old women compared to their younger counterparts. It was the highest among those aged 40-44 in 2022 (1).\u003c/p\u003e\n\u003cp\u003eWomen aged 35-49, representing 15.73% of the female population in Bangladesh, face higher risks of unintended pregnancies (2,3). One-third of pregnancies in Bangladesh are unplanned, of which 63% are experienced by women aged 35 and above (3). The TCM users have a higher proportion of unintended pregnancies compared to modern method users (3). Unsafe abortion is often a danger associated with unintentional conception (3,4). Bangladesh is experiencing an epidemiological transformation, with older women facing elevated levels of obesity and non-communicable diseases such as hypertension and diabetes (1). These conditions will likely increase maternal health complications during pregnancy and adverse birth outcomes (5–7).\u003c/p\u003e\n\u003cp\u003eExisting research in Bangladesh has focused on the overall contraceptive practices among women, overlooking the variations in contraceptive behavior and preferences across age groups (8–17). While these studies identify determinants of TCM use among Bangladeshi women, such as age, spousal interaction, and socioeconomic and spatial factors, they do not fully capture the broader spectrum associated with TCM use. Factors like media and visits by family planning workers have been studied (10,13), but other critical demand-side issues, like the perception of women, and supply-side factors, like healthcare facility-related issues, policies, etc., have yet to be explored for TCM use in Bangladesh. The studies' findings show that various issues influence the decision to use TCM. From the demand perspective, women’s views about modern contraceptive methods are frequently influenced by the lack of knowledge, misconceptions, and a preference for TCM believed to be less complicated, e.g., no side-effects more convenient to use compared to modern ones. On the supply side, matters such as poor standard of family planning services, lack of counseling on side effects, and challenges with logistics (such as lengthy commutes to clinics or contraceptive shortages) contribute to the use of TCM (18,19). However, these factors have not yet been studied in terms of TCM use in Bangladesh. The research gap is especially apparent in quantitative studies, which typically do not investigate the reasons behind TCM use among older women. Qualitatively exploring the complex justifications, beliefs, and lived realities that support TCM use is imperative. There are no such qualitative studies in Bangladesh that uncover these issues. Therefore, there is a need for targeted investigation considering the intricate dynamics of demand and supply issues regarding why TCM use is higher among older reproductive-age women in Bangladesh.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis gap impedes the formulation of appropriate policies and initiatives that respond to the needs of older reproductive-age women and undermines the efforts to achieve sustainable development goals (SDGs), especially those linked to health and gender equality (20). The current study explores why the use of TCM is higher among older reproductive-aged women in Bangladesh, thereby bridging the knowledge gap and guiding effective policies and practices.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eTheoretical orientation of the study\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003e\u0026nbsp;This study adopted the Socio-Ecological Model (SEM), which presents an extensive structure for exploring the interplay between individuals and their surrounding social settings. It includes several tiers of influence—individual, interpersonal, community, institutional, and policy—on behavior (21). Given that contraceptive behavior is influenced by various circumstances like knowledge and perception, interpersonal relations, community norms and beliefs, access and quality of care, national policies etc., (18,22,23), this model provides a comprehensive understanding of the factors affecting TCM use. While multilevel factors have been studied about contraceptive use in general and modern methods, specifically in the context of Bangladesh (16,17,25) using quantitative methods, the SEM has not been applied to address the dynamics of TCM use among older women in Bangladesh by using a qualitative approach. Therefore, this study employed SEM to understand the use of TCM among older women of reproductive age in Bangladesh.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003ch2\u003e\u003cstrong\u003e\u003cem\u003eResearch strategy and design\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis study adopted the qualitative research strategy based on interpretive epistemology (24) to understand the use of TCM by exploring the unique perceptions of Bangladeshi women and the meanings they give to their experiences. In addition, the study adopted a cross-sectional research design, as the data were collected at a single point in time (24).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cem\u003eStudy area\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in the Khulna district of the Khulna division in Bangladesh. The use of TCM has been consistently high in this division. For example, the rates over the last decade have varied from 10.6% in 2011 and 10.7% in 2014 to 12.5% in 2017 and 10.2% in 2022 (1) We purposively selected married women aged 35-49 who reside in three sub-districts or Upazilas of Khulna district: Rupsha, Batiaghata, and Dumuria Upazila.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cem\u003eStudy participants\u003c/em\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study population consisted of older reproductive-age women, that is, 35-49 years of age, who were using TCM, such as periodic abstinence or withdrawal. The utilization of TCM is consistently higher among this age group (1). The study also included family planning service providers from the Maternal and Child Welfare Centre (MCWC), Upazila family planning office, and Union Health \u0026amp; Family Welfare Center (UH\u0026amp;FWC) in Bangladesh.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cem\u003eSampling procedure and sample size\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eData was collected from 17 participants using a purposive sampling technique. Ten were women aged 35-49, while the remaining seven were family planning service providers in Khulna, Bangladesh.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cem\u003eData collection\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eData collection for the study was done in January 2024. The qualitative data were collected from the older reproductive-aged women through face-to-face in-depth interviews (IDIs) and the family planning service providers and program managers through key informant interviews (KIIs) using a semi-structured interview guide. These three types of respondents were interviewed as SEM-related contraceptive use requires data from both the demand and supply sides. Two separate semi-structured interview guides were developed based on extensive literature reviews and refined based on emerging interview results. Therefore, the semi-structured interview guides were used to structure the interviews but provided flexibility. The interview duration ranged between 30\u0026ndash;45 minutes. The interviews were conducted in the native language, Bengali after the participants were informed of the study\u0026apos;s objectives and their consent was obtained.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cem\u003eData analysis\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study adhered to the thematic analysis approach developed by Braun and Clarke (25) to give an organized framework for finding, examining, and summarizing themes in the qualitative data. The audio recordings of the interviews were transcribed and read numerous times to ensure a deeper understanding of the participants\u0026rsquo; responses. A hybrid coding approach was adopted to integrate both theory-driven and data-driven codes. An initial coding framework was generated after examining the subsections of the transcripts, and new codes were assigned if they could not be classified using the initial classification. Then, the codes were arranged according to broad themes that encapsulated the perspectives and experiences of the participants. The themes were revised and refined to ensure they adequately depicted the data. Meaningful participant quotes were used to validate these themes, providing evidence of the participants\u0026rsquo; lived experiences.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003e\u003cstrong\u003e\u003cem\u003eBackground characteristics of the participants\u003c/em\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eA total of 17 interviews were taken, of which 10 were in-depth interviews of older reproductive-aged women. Most women were aged 35-39 years with more than one living child. Many of them were users of the periodic abstinence or safe days method, with only one of them practicing the withdrawal method. Table 1 presents the background characteristics of women. Table 2 presents information on the supply-side actors. All of them were family planning service providers working at various levels and institutions under the Directorate General of Family Planning in Bangladesh.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 is about here\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 is about here\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cem\u003eFactors shaping traditional method use\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eFollowing SEM, this study identified the individual, interpersonal, community, institutional, and policy-level factors influencing TCM use among older reproductive-aged women in Bangladesh. Table 3 summarizes the study's main findings in themes and sub-themes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 is about here\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cem\u003eIndividual level factors\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLack of knowledge about modern methods.\u003c/em\u003e\u003c/strong\u003e Many participants knew little about modern methods, lacking an understanding of what they are or how they should be used, leading to widespread fears about potential side effects.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I don't understand that much. I haven't used [modern method]. Many people say about Copper-T, I do not understand them, I do not have a good knowledge about this.”\u0026nbsp;\u003c/em\u003e(IDI-9)\u003c/p\u003e\n\u003cp\u003eProviders also reported poor awareness among women about modern methods, resulting in having misconceptions about modern methods and choosing TCM. This emphasizes the pressing need for targeted awareness initiatives to overcome misunderstandings, increase knowledge, and enable women to make educated choices about reproductive health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“A lot of them have misconceptions [about modern methods]. They do not know about it [modern methods]. That's why they do this [safe period]. They don't know what the other options are.” (KII-6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFear of side-effects of modern methods\u003c/em\u003e\u003c/strong\u003e. The fear of adverse effects was a major reason why women in Bangladesh chose TCM. Women who had observed or suffered from harmful consequences such as dizziness, weight gain, and nausea link these issues directly to modern methods, prompting them to use TCM, which they believed to be safer.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I see my sister-in-law having many problems. She uses injections. She has a problem with her vision; she does not see properly. She has irregular periods after three to four months intervals. Now, she does not see almost anything. She has become fatter. Now, she has stopped taking injections. Pills also deteriorate the body regularly, such as dizziness, vomiting, and other health problems…” \u0026nbsp;(IDI-4)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe providers reported that the fear of adverse side effects of modern methods acted as a barrier to the utilization of modern methods, like oral pills and injectables. They attempted to alleviate these fears and anxieties by emphasizing that adverse effects tend to be brief as the body adapts to hormonal changes. Still, their efforts frequently failed to influence women's beliefs, resulting in a continued use of TCM as a safer choice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“For example, if you use it for the first time, it will take some time to adapt to the body. This takes two or three more months. Then, there are some changes in the menstrual period. These are hormonal methods, so if these are absorbed in the body, the ability to have children is hindered. Maybe that's why they think something is wrong with their body. If they have a little patience, they can understand that their ability will return. That's why it is called the reversible method.” (KII-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eGreater understanding of traditional contraceptive methods\u003c/em\u003e\u003c/strong\u003e. Women have a greater sense of TCM, such as the safe-days method or periodic abstinence, confidently identifying the “fertile” and “infertile” days.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I am counting safe days and keeping track of the date of menstruation. If my period starts on the 10th of the month, we keep track of when it starts… so that's how we maintain it. A week before the start of menstruation is safe.” (IDI-2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, the providers felt that the women were not fully aware of the safe days and miscalculated fertile days. They further highlighted the fact that even educated women were not fully aware of how to use TCM, making them vulnerable to unwanted pregnancy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Let me share an experience. A project manager at a reputed organization and his wife follows [safe period]. The days that he thinks are safe are dangerous periods. And that's how they conceived a baby. But we know that it is a dangerous time.” (KII-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePerceived effectiveness of traditional methods.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe users of the safe days’ method were confident in their ability to calculate safe days correctly due to their regular monthly cycles. The absence of unplanned pregnancies strengthened their satisfaction with its effectiveness, demonstrating a sense of control and confidence in managing their reproductive health. As a result, they saw no reason to transition to modern methods.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Yes, it works well, we do it. I think I can maintain this well. It's straightforward for those who understand, and it's difficult for those who do not understand how to do it [counting safe period].” (IDI-2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, opposing viewpoints from healthcare experts emphasized a divergence, stating that many women had difficulty with keeping correct counts, resulting in a substantial failure rate and unwanted pregnancies. This disparity underlines the mismatch between individuals' self-evaluated capability and professionals' concerns about the reliability of TCM, stressing the importance of improved education and counseling to close this gap.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“They can't do it [count safe days] properly. You must maintain it. But since they cannot keep account [of the safe days], the failure rate is quite high. As a result, they have many children.” (KII-6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePerceived ease of use of traditional methods.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe participants felt that using TCM was more convenient than modern methods, indicating a preference based on their perceived ease of use and minimum disruption to their everyday tasks. For example, some women did not remember to take pills regularly, while others found it challenging to use a condom or missed due dates for injectables. This perception of TCM as an easy alternative highlights a significant barrier to the adoption of modern methods, implying that strengthening accessibility and constant follow-up for modern contraceptives may be critical in promoting their use among older reproductive-age women.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“There is no unnecessary trouble (with TCM), like I forget to take pills, forget to take injections, I can't remember the time, I can't always keep an account. There is no hassle. If you consume pills or use any other methods, you must stand in lines at the hospital and waste time. Also, you must wait for the workers [to visit home]; sometimes they do not have it and do not visit regularly.” (IDI-1)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePerceived low risk about TCM.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThe participants had a low-risk perception of TCM. They believed their method was less harmful and had no unintended consequences like unplanned pregnancy. They felt safe adopting these methods because they had no firsthand undesirable experiences or heard of bad outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“It seems this is good for my health; there is no risk [of unintended pregnancy]. I think this is good for me. I'm fine with Allah's mercy. I trust it [safe period], and if I keep an account [of safe period], there is no problem.” (IDI-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFurthermore, health practitioners noted a major gap in women's awareness, stating that many were ignorant of the larger health hazards linked with TCM, including sexually transmitted infections (STI). This assumption regarding TCM's safety, along with fear of modern methods, generated the decision to use TCM, indicating a need for comprehensive counseling to correct misconceptions and encourage safer contraceptive behaviors.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\" I think those using traditional methods are unaware of the health risks. If they knew about HIV-AIDS or other sexually transmitted diseases, they would not have used the Azal method [withdrawal] or other [TCM]. In this case, we generally recommend the use of condoms to avoid health risks.\" (KII-2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePerceived cost of modern methods.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eFew women viewed modern methods as financially inaccessible. They thought that permanent methods like ligation required expensive surgeries, indicating their poor awareness regarding the availability of cost-subsidized, long-acting, and permanent methods. This notion was supported by the participants' inclination for cost-free TCM, such as recording safe periods, which they believed to be affordable and appropriate for their socioeconomic situation compared to modern methods.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Also, we're not so rich, and we do not have much money to do that [ligation], so I think this method [safe period] is good for people like us.” (IDI-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePerceived health benefits.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eMany women believe that TCM offers fewer health hazards than modern contraception, which they link with a variety of adverse effects such as weight gain and other physical discomfort. This perception was supported by individual and family experiences in which older generations have used TCM without harmful health impacts, strengthening the view that it was safe.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“If I use something else, it will not adjust with my body. So, I use it [safe period]. Our grandmothers, aunts, and mother used it [safe period] and did not have a problem with this; they are healthy. I have not put on weight. I have remained the same before and after marriage.” (IDI-4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I talk to people, but I never heard them say they have a disease or anything due to this [using safe period].” (IDI-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFurthermore, providers typically refrained from suggesting modern methods to women with pre-existing health issues, which supported women's choice for TCM.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"They [women] think that it [modern method] can increase their health risks at this age. When they cross 30/40, they can have high blood pressure and diabetes. That is why we do not suggest modern methods if they have diabetes or pressure. That's why they are more prone to traditional methods. And they try to avoid modern methods.\" (KII-2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePerceived embarrassment.\u003c/em\u003e\u003c/strong\u003e The matter of embarrassment associated with modern contraception, such as condoms and injections, underlined longstanding societal beliefs that discourage open family planning discussion. Participants mentioned how societal criticism led to their unwillingness to use modern methods. For example, disposing of condoms was considered a shameful deed that might result in condemnation from family members, particularly in-laws, whilst visiting medical facilities for injectables was regarded as publicly reporting their contraception use, exposing them to potential scorn and disgrace. This stigma associated with contraceptive use fostered the adoption of TCM, which was viewed as more discreet.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Before my marriage, I used to see that people would make fun of those who used to go to healthcare centers for family planning methods. I think it's about condoms. You must throw it away or dispose of it after use, and you know, there's my family. What if my sisters-in-law and mother-in-law see it while throwing it? It's such a shame.” (IDI-2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eExposure to mass media\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e.\u003c/em\u003e Exposure to mass media plays a critical part in increasing awareness and shaping the attitude of women regarding different contraceptive methods and prompting them to consider modern contraception. The participants admitted to seeing or hearing family planning messages on television or radio before; however, not much has happened recently. This explains women’s lack of knowledge of modern methods, especially long-acting and permanent ones, leading to continued use of TCM.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"Yes. I have seen it [family planning messages] on TV, for example, having one child is enough, be it a girl or a boy. I remember they used to show drama on TV as well, but not anymore.\" (IDI-9)\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cem\u003eInterpersonal level\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSpousal opposition to modern methods\u003c/em\u003e\u003c/strong\u003e. Partner opposition to modern methods was a barrier to their use, typically driven by fears of adverse outcomes such as obesity and other health problems. The spouse's refusal to let his wife choose pills or injections symbolized a larger socio-cultural effect in which male opinions profoundly shaped reproductive decisions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“He [husband] does not like pills or injections. He says that these [pills and injections] will make me obese and there will be many diseases.” (IDI-4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn response, the providers acknowledged the importance of religious figures, such as Imams, who wield communal power. By using Imams to promote the advantages of modern methods, they hoped to use their authority to resolve spousal opposition and increase its approval.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The men of the family can be explained by the Imam (who leads prayers in a mosque). The men will not listen to me, but they accept their words from the Imams. We give them a list of names and ask them to motivate and discuss such things.” (KII-4)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCooperation to use traditional methods.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eMost participants reported that their husbands cooperated and supported the use of TCM, especially when they observed modern methods, such as oral pills, to have negative side effects.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“You know, my husband saw that there is a problem with that [pills], and it [safe period] is safe. That is why he accepted it. We discussed [safe period] after my sister told me about it [safe period], and he told me to follow it.” (IDI-8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSpousal attitude.\u003c/em\u003e\u003c/strong\u003e Spouses' positive attitudes about TCM facilitated its use among women in Bangladesh. Husbands felt that TCM was much safer and better, so they supported their wives and encouraged the use of TCM. This scenario indicates how partner involvement and mutual satisfaction with TCM led to its continued use, demonstrating the importance of spousal support for reproductive choices.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“My husband says that this [safe period] is good. I feel physically fine. Besides, we have spent many years this way, and he is happy. He thinks there is nothing bad about it. He also says that you had a problem with pills, but this one is safer. We are better.” (IDI-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInfluence of mother-in-law\u003c/em\u003e\u003c/strong\u003e. Family members, especially mothers-in-law, play a crucial role in shaping women’s choices and decisions about using family planning methods. Opposition of the mother-in-law to modern methods often leads to the use of TCM.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Honestly speaking, she doesn't like this [family planning]. She says don't we have [children] in our times... What's wrong with having [children] if Allah gives you? If Allah gives mouth, He will feed them as well… We have not used such useless things. We have brought up five or six sons and daughters, you can do it as well. After marriage, my mother-in-law told me not to use these things.” (IDI-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHowever, providers remarked that mothers-in-law's dominance has waned over time, with many no longer opposing the use of modern contraception.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The role of the family is important… The mothers-in-law have become quite aware of things even in our village. We had eight to ten children, and we had no problems - Nowadays, this example doesn't work” (KII-2)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePeer influence\u003c/em\u003e\u003c/strong\u003e. Peer groups such as sisters or friends shape the use of TCM among women in Bangladesh. Some participants mentioned their sister as the source of information and support for using TCM. However, even when peers disapproved, participants continued using TCM because of their low-risk perception.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“My elder sister uses this method as well. She told me to use this method. She also told me that if I follow the rules properly, there will be no problem.” (IDI-8)\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cem\u003eCommunity level\u003c/em\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCommunity approval of contraception use\u003c/em\u003e\u003c/strong\u003e. The community's approval of contraception use has grown dramatically, creating a more accepting setting for women to select the contraceptive methods that satisfy their requirements, whether modern or traditional.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I don't think nowadays no one has any headache or anything about anyone. People use a method that is good for them, or that suits their body. No one talks about that. They use whatever is convenient for them… I see most of the people consuming pills. That's what I hear the most.” (IDI-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEven family planning workers, who once faced prejudice and were often disliked in communities, are now welcomed and seen as trusted, demonstrating an optimistic shift in community norms. However, some lingering negative opinions about modern methods exist at the individual level.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Society plays a crucial role, and it has changed over time.\u003c/em\u003e\u003cem\u003e\u0026nbsp;There was a time when people could not even say they worked in family planning due to various reactions. The FWAs couldn't go home, and people used to chase them out. Now, people welcome them with open arms. However, a limited part is negative; it was there before and will remain so.” (KII-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCommon fear of medical complications\u003c/em\u003e\u003c/strong\u003e. Fear of medical complications and false beliefs, such as implants breaking inside the body during daily activities or IUDs migrating inside the body, lead to discontinuation of modern methods and switch to TCM. These fears and misconceptions were frequently perpetuated and reinforced through community interaction among neighbors and relatives and affected individual choices to avoid using modern contraceptives.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“If you do an operation like ligation, you must undergo many cuts. What if the cut is not stitched well? Many people find it difficult to come home and work after the operation… Sometimes, it may lead to cancer as well… Also, there can be problems in the uterus and cervix, and sometimes it must be cut off as well. So, I am scared. My neighbor told me not to do it.” (IDI-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEven health professionals acknowledged the existence of preconceptions about modern methods among women, thus the need to create tailored educational programs to overcome these misunderstandings among women.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Many people think IUD mixes with blood and heart, go inside, and they fear that it will be displaced.” (KII-6)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eReligious beliefs\u003c/em\u003e\u003c/strong\u003e. Religion played an important role in the use of TCM and the non-use of modern methods among older reproductive-age women. Only one participant was Hindu, and the rest were Muslims. According to Muslim women, modern methods, such as injectables, implants, and ligation, were heinous and prohibited since they included alterations to the body that were regarded as inconsistent with religious teachings. Therefore, they rejected modern methods to ensure religious adherence.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“According to religion, it is not right to have any pills or anything. Like using a condom or a pill is sin. They [religious leaders] also think the same because it is a sin to use a pill...” (IDI-8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWomen, on the other hand, justified their use of TCM in comparison to the sinful aspect of modern methods in the religion. They believed that TCM, such as the safe day's method, was natural, acceptable, and non-sinful and aligned better with their beliefs. Thus, it was legitimate to use it according to the religion.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Why will it [safe days] be forbidden? I don't do any sin. Is this my sin? No! We are doing many things in the world; we are doing sinful things. I don't think it is sinful. How do those who use injections and have irregular periods and sporadic bleeding pray?” (IDI-9)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFurthermore, providers highlighted the religious reasonings of women against the use of modern methods, such as divine punishment and retribution in the afterlife. As a result, they attempt to cope with it by enlisting spiritual figures, such as imams, to clarify myths and advocate for modern contraception.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Allah will not forgive them, that part of the body will be burnt in Hell- In this case, we approach the heads of mosques, such as the imam, to motivate the people and share benefits [of using modern methods].” [KII-6]\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cem\u003eInstitutional level\u003c/em\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eProviders’ attitude\u003c/em\u003e\u003c/strong\u003e. The participants voiced mixed feelings about health providers' behavior. Some women found them accommodating, but others mentioned anger if they ignored providers' advice. The inconsistency in professional attitude led to a loss of faith and a poor experience for women, particularly when healthcare workers encouraged them to adopt certain methods like implant ligation without providing an adequate reason or acknowledging their fears.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Sometimes they behave well, and at other times they get angry… they insist on keeping [products]… When I said no, she got angry. She told me furiously, \"What are you doing? You don't want to take the pill? You don't want to do ligation? What is this? You have two children.\" They behave so strangely, do not make explain properly, do not come to us regularly, but still get angry!” (IDI-1)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn response, the program managers believed they delivered thorough training to improve their communication skills and foster good rapport and trust, especially at the grassroots level. They emphasized using BCC (Behavior Change Communication) to develop the abilities to resolve individual issues, convey correct information, and offer respectful and patient-friendly care. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“We have BCC [Behavioral change communication] strategies. We train them to talk to someone. However, more training needs to be done because they repeatedly do the same work. That's why sometimes we give them refresher training, so their work is better.” (KII-3)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eIrregular visits\u003c/em\u003e\u003c/strong\u003e. Some participants reported inadequate, irregular home visits by Family Welfare Assistants (FWAs). FWAs are grassroots healthcare workers who provide reproductive and maternal health services to communities in their designated locations, such as contraceptive distribution, counseling, and, if needed, referrals to higher-up health professionals. They serve as a critical link between women and the larger health system, and their irregular attendance can result in missed chances for education, contraception distribution, and prompt referrals. Consequently, women felt less supported, which contributed to the continued use of TCM rather than modern options.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Earlier, they used to come and call everyone out, “Khala/Chachi (aunts).” Now they don’t come that often.” (IDI-9)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQuality of service.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eSome women expressed skepticism and apprehension because of previous poor experiences or perceived maltreatment by health professionals, preventing them from seeking family planning services from health centers. Fear of meeting harsh attitudes from practitioners and satisfaction with the TCM prompted women to avoid healthcare centers completely. This demonstrates that strengthening interpersonal components of care is critical to getting women to use modern family planning options.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“No, I didn't go [to healthcare centers]. If those who come to our homes behave like this, then the ones [at the healthcare centers] may behave like this, and there may even be people from higher-up positions. I am afraid of how they will behave. And I am satisfied with my method [safe period], so I do not go.” (IDI-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHealthcare center-related issues.\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eWomen reported healthcare center issues, such as distance from the house, waiting in lengthy queues, and unavailability of products, which led to frustration and contributed to the non-use of modern methods since the hassle and scarcity of resources deter women from accessing essential services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“If you go there, you will find that there are often long lines and many problems with the serials…. Many times, they say there are no more products available. They give a date and say, \"Come later on this day, we don't have it right now, you can take it next time.\" It's so troublesome.” (IDI-8)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOn the other hand, the providers highlighted patient-friendly care by fostering an enabling, courteous, and individualized atmosphere that concentrates on the welfare of those receiving healthcare, making them feel at ease, valued, and adequately cared for.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Our union-based health care centers work as a team. Those who go to the field are always in contact with those at the centers. They also refer to whether there is any complication in using any method. If there is any complication after taking family planning, the government will bear the cost. This is how we have been able to create a patient-friendly environment.” (KII-1)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe key informers further explained how they ensured that women who seek family planning services at health centers have full access to them. They stated the financial considerations for long-acting and permanent method services provided to women according to the government's instructions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“If someone comes to get clinical services in that FWC (Family Welfare Center) … we pay a transportation cost. Once sixty taka is given to them, it is used for follow-up. Three follow-ups are done monthly. The amount for the three months is also given. They are informed when the FWV (Family Welfare Visitor) motivates them to take the procedure. And it is mentioned in the citizen charter.” (KII-1)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003e\u003cem\u003ePolicy level\u003c/em\u003e\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLack of updated policy\u003c/em\u003e\u003c/strong\u003e. The family planning initiatives in Bangladesh have emphasized the promotion of modern contraceptive methods to combat growing numbers and promote the well-being of mothers and children. The traditional methods have been a part of the general family planning scenario but are rarely promoted in mainstream policy due to high failure rates, often resulting in unintended pregnancies.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“In fact, according to the government policy, we talk about the modern method, not the traditional method. And the reason is because you don't know what will happen if they use it, such as unintended pregnancy” (KII-5)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, the providers discussed the ongoing initiatives to revise national policy, including consultations with stakeholders to accommodate varied family planning needs, doorstep care, and a greater knowledge of women's needs. Given the number of older reproductive-age women using TCM in Bangladesh, instead of sidelining traditional methods in policy discourse, it is imperative to adopt an inclusive approach and raise awareness about the negative consequences of using TCM among women.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“The national policy that was in place in 2012 is now being further modified. Meetings have also been held with various stakeholders and will likely be completed this year. Family planning activities have been included in the national policy with the coordination of all stakeholders. School education, door-to-door services, the complexity of service provision, and the needs of women- everything has been included.” (KII-1)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study showed that individual, interpersonal, community, institutional, and policy factors shaped the use of traditional contraceptive methods among Bangladeshi women aged 35\u0026ndash;49. At the individual level, women\u0026rsquo;s knowledge about TCM and modern methods and perceptions related to their effectiveness, risk and benefits, side effects, ease of use, and cost molded the use of TCM.\u003c/p\u003e \u003cp\u003eThe study found that participants were familiar with family planning benefits but lacked awareness of modern methods. Instead, they monitored their \"safe\" days, exhibiting a low-risk perception. This finding is similar to a study in Indonesia, where women knowledgeable about family planning and fertile periods were more likely to utilize TCM (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Furthermore, women think the TCM they use is effective because they have been using it for a long time but have not encountered any unintended consequences, which is concurrent with other studies worldwide (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost participants found TCM easier to use than modern methods as they did not need to remember to take pills or visit health facilities to get injectables. This result is congruent with other study findings (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Moreover, our participants found using modern methods shameful, which is concurrent with some studies where participants reported that they were \u0026lsquo;embarrassed\u0026rsquo; to buy a condom (\u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). The participants have very low-risk perceptions related to the use of TCM, considering them reliable and safe in preventing unwanted pregnancy. Some accepted the risk but believed it could be minimized correctly, while others believed modern methods were riskier. This is in line with a study in Turkey (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and differs from other studies where TCM users express concern about the risk of unintended pregnancy (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnwanted side effects of modern methods, like becoming overweight, infertility, dizziness, nausea, vomiting, fatigue, diminished appetite, and irregular periods, experienced by women and their family members or neighbors, lead to their discontinuation and use of TCM (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Various investigations have confirmed it worldwide (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). This calls for more scientific research to develop modern methods with minimal side effects, ensuring women's health remains unaffected. Traditional methods were free of cost, while modern methods were primarily purchased from the private sector (57%), with 37% supplied by the public sector in Bangladesh. For example, 14% of users get pills from government field workers, while 59% of people obtain pills from pharmacies/drugstores (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In this case, when women do not have access to pills due to irregular visits of workers or stockouts, they resort to pharmacies, resulting in costly prescriptions. Women may consider the private sector more courteous, accessible, and trustworthy. A coordinated approach is required to strengthen public family planning services, including health infrastructure and enhancing professional training. A similar outcome was noted elsewhere (\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Likewise, withdrawal users in Turkey reported that this method was not costly, while modern methods were (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eExposure to mass media shapes the adoption of TCM among older women. Women reported knowing about family planning through television advertisements, dramas, etc., but they observed a decrease in such coverage. Previous studies found that TV and radio are essential for delivering information regarding family planning in Bangladesh, though exposure to family planning through mass media remains constrained (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). The most efficient way to convey information about contraception was through the mass media, consistent with other findings (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Mass media messages weighing the benefits and risks of using TCM versus modern methods could help women make informed choices. Policymakers should consider alternative mediums, including social networking sites, to address and resolve women's fears about the adverse effects of modern methods while highlighting the risks of TCM, such as unplanned pregnancies.\u003c/p\u003e \u003cp\u003eAt the interpersonal level, male partners\u0026rsquo; opposition to modern methods hindered women from using them (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Supportive husbands favored the use of TCM due to their perceived benefits. This mutual decision-making among spouses was in line with other studies elsewhere (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Mothers-in-law's aversion to modern methods impedes adoption of oral pills, injectables etc., as they have substantial power in a typical household in Bangladesh, involving reproductive decisions. The scenario is consistent with the findings of previous studies (\u003cspan additionalcitationids=\"CR43\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). However, previous research implied that living with mothers-in-law may promote the usage of modern methods and TCM in India, as well as modern methods like pills, injectables, and implants in Nepal and Bangladesh (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). This emphasizes the need to include husbands and mothers-in-law in family planning discussions, such as courtyard meetings. Peer support played a key role as women were more inclined to opt for the method utilized by their social circle since they valued their opinions and previous experience. This emphasizes the possible use of a \u0026ldquo;\u003cem\u003esocial networking strategy\u003c/em\u003e\u0026rdquo; to disseminate information about contraceptives via interpersonal interactions (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe use of contraceptives is common. However, community and religious beliefs acted as barriers to the uptake of modern methods and thus facilitated TCM use. Religion affected the use of contraceptives among Bangladeshi women, with modern methods often seen as forbidden, while TCM was accepted (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Women believed that using modern methods, especially permanent ones, was wrong in terms of religion, dreading aftermaths like being denied a proper religious burial or facing eternal punishment (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Furthermore, cultural myths and beliefs negatively affected the uptake of modern contraceptives, aligning with published research worldwide (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan additionalcitationids=\"CR51 CR52\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). This underscores the significance of involving influential individuals like Imams in addressing the acceptability of long-acting permanent methods (e.g., IUD, ligation) in religion and dispelling misconceptions.\u003c/p\u003e \u003cp\u003eContraceptive use was shaped by institutional-level factors such as lack of proper healthcare infrastructure, absence of quality care and services, and poor behavior of family planning service providers, which calls for a client-centered care service. This aligned with a study conducted in West Africa (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Other studies reported that users preferred the availability of services at convenient times, with lower waiting periods, and located near their residences (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). The providers ' undesirable attitudes, such as yelling and neglecting concerns about side effects, further hampered service utilization (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Furthermore, commodity availability issues underscore the urgency for improved supply chain monitoring and greater consistency of consumption estimations with product availability (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBangladesh demonstrated achievements in family planning despite challenges like illiteracy, lower gender equality, and poverty. The 4th Health, Population, and Nutrition Sector Program (HPNSP) 2017-22 targeted raising the CPR from 62\u0026ndash;75% by 2022, focusing on underperforming regions like Sylhet and Chattogram. Bangladesh Family Planning 2030 (FP2030) pledges to expand modern contraceptives' supply, access, and adoption (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). The existing policies, such as the Bangladesh Population Policy 2012, aimed to increase CPR to 72% by 2015 (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). Still, they need to be updated to incorporate the complexity of family planning and the shifting patterns of demographics. These policies emphasize modern methods, which are much more reliable, safer, and effective compared to TCM due to its adverse consequences like unintended pregnancies and sexually transmitted diseases. This underscores the need for a transition beyond a \u0026ldquo;\u003cem\u003eone-size-fits-all\u0026rdquo;\u003c/em\u003e approach to family planning that includes tailored strategies to meet the distinct requirements for the reproductive well-being of Bangladeshi women aged 35\u0026ndash;49.\u003c/p\u003e\n\u003ch3\u003eStrengths and limitations\u003c/h3\u003e\n\u003cp\u003eThe study is one of its kind to specifically explore the traditional contraceptive behavior of older reproductive-age women in Bangladesh using SEM and offer a comprehensive view of the process through which women make their choices for TCM. It has imperative implications for the existing family planning initiatives aimed at the intended demographic group. This study has some limitations, too. Due to time and resource constraints, the study was conducted only in three sub-districts of Khulna district. Nonetheless, it was sufficient to provide a genuine situation of TCM use among older women. In addition, the opinions of the participants' husbands were not explored.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study used the socio-ecological model to explore traditional methods among 35\u0026ndash;49-year-old women. Individual, interpersonal, community, institutional, and policy factors, such as poor knowledge of modern contraceptive methods, perceived ease of use and risk related to the use of TCM, fear of side effects of using modern methods, familial influence, community norms and beliefs, providers\u0026rsquo; attitudes, quality of services, and other health facility related issues such as distance from the house, waiting in queues, unavailability of products, and lack of mass media coverage shaped the TCM use. As a result, family planning services should be strengthened to promote modern methods and address related fears, enhance knowledge, and highlight the risks of TCM through comprehensive counseling. The participation of influential individuals such as husbands, mothers-in-law, and religious figures is critical in disseminating and normalizing modern methods in society. Furthermore, providers should deliver client-oriented services, and policymakers should prioritize improving resources and media outreach to shape women\u0026rsquo;s perception of risk related to TCM use. Reproductive health programs should help women make informed choices and switch from TCM to modern methods, such as long-acting methods. This will improve women's reproductive health and foster gender equity, contributing to sustainable development in the country.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eCPR:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eContraceptive Prevalence Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eIDIs:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIn-depth Interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eKIIs:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eKey Informant Interviews\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSDGs:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSustainable Development Goals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSEM:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSocio-Ecological Model\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTCM:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTraditional Contraceptive Method\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Department of Population Sciences, University of Dhaka. The study participants were provided with information about the purpose of the research, the kind of questions to be asked, and their freedom to refuse or cancel the interview at any moment during the process. Before each interview, they were asked if they agreed to participate and allowed the session to be recorded while maintaining confidentiality and anonymity. People who did not provide approval were immediately omitted from the sample. All transcripts and excerpts in the findings section contain anonymous identifiers to protect participants\u0026apos; identities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting this study\u0026apos;s findings are not publicly available due to restrictions that were applied to them. However, the authors will make the data available upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research did not receive any funding from any sources.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMA and MBH conceptualized and designed the study. MA collected and analyzed the data while MBH supervised MA. Both authors contributed to interpreting the results, drafted and edited the manuscript, and finally approved it for submission.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eNational Institute of Population Research and Training (NIPORT) and ICF. Bangladesh Demographic and Health Survey 2022: Key Indicators Report. Dhaka, Bangladesh, and Rockville, Maryland, USA; 2023.\u003c/li\u003e\n \u003cli\u003eBangladesh Bureau of Statistics. Population \u0026amp; Housing Census 2022: Preliminary Report. Dhaka, Bangladesh; 2022.\u003c/li\u003e\n \u003cli\u003eNoor F, Rahman M, Rob U, Bellows B. Unintended pregnancy among rural women in Bangladesh. 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Factors influencing contraception choice and use globally: A synthesis of systematic reviews. Eur J Contracept Reprod Heal Care. 2022;0(0):1\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eRakhi J, Sumathi M. Contraceptive methods: Needs, options and utilization. J Obstet Gynecol India. 2011;61(6):626\u0026ndash;34.\u003c/li\u003e\n \u003cli\u003eAkamike IC, Okedo-Alex IN, Eze II, Ezeanosike OB, Uneke CJ. Why does uptake of family planning services remain sub-optimal among Nigerian women? A systematic review of challenges and implications for policy. Contracept Reprod Med. 2020;5(1):30.\u003c/li\u003e\n \u003cli\u003eAjayi AI, Adeniyi OV, Akpan W. Use of traditional and modern contraceptives among childbearing women : findings from a mixed methods study in two southwestern Nigerian states. BMC Public Health. 2018;18(604):1\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eKamal N, Saha UR, Ali Khan M, Bairagi R. Use of periodic abstinence in Bangladesh: Do they really understand? 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Glob Heal Sci Pract. 2022 Oct;10(5).\u003c/li\u003e\n \u003cli\u003eNosaka A, Bairagi R. Traditional roles, modern behavior: Intergenerational intervention and contraception in rural Bangladesh. Hum Organ. 2008 Feb 17;67(4):407\u0026ndash;16.\u003c/li\u003e\n \u003cli\u003eAgha S. Intentions to use contraceptives in Pakistan: Implications for behavior change campaigns. BMC Public Health. 2010;10.\u003c/li\u003e\n \u003cli\u003ePradhan MR, Mondal S. Examining the influence of mother-in-law on family planning use in South Asia: Insights from Bangladesh, India, Nepal, and Pakistan. BMC Womens Health. 2023;23(1):418.\u003c/li\u003e\n \u003cli\u003eIslam MS. Social networks and their effects on the choice of contraceptive use and method in Bangladesh. Int J Hum Rights Healthc. 2020;13(1):58\u0026ndash;71.\u003c/li\u003e\n \u003cli\u003eCalhoun LM, Mirzoyants A, Thuku S, Benova L, Delvaux T, van den Akker T, et al. 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Qualitative study of reasons for discontinuation of injectable contraceptives among users and salient reference groups in Kenya. Afr J Reprod Health. 2011 Jun;15(2):67\u0026ndash;78.\u003c/li\u003e\n \u003cli\u003eMushy SE, Tarimo EAM, Fredrick Massae A, Horiuchi S. Barriers to the uptake of modern family planning methods among female youth of Temeke District in Dar es Salaam, Tanzania: A qualitative study. Sex Reprod Healthc. 2020;24:100499.\u003c/li\u003e\n \u003cli\u003eOkenyoru DS, Matoke V, Odhiambo F, Salima R, Anyika D, Ogutu G. Social-cultural factors influencing modern contraceptive uptake among women of the reproductive age in Turkana County, Kenya. Int J Community Med Public Heal. 2023 Dec 30;11(1 SE-Original Research Articles):51\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eAyanore MA, Pavlova M, Groot W. Unmet reproductive health needs among women in some West African countries: A systematic review of outcome measures and determinants. Reprod Health. 2016;13(1):5.\u003c/li\u003e\n \u003cli\u003eTessema GA, Streak Gomersall J, Mahmood MA, Laurence CO. Factors determining quality of care in family planning services in Africa: A systematic review of mixed evidence. PLoS One. 2016 Nov 3;11(11):e0165627.\u003c/li\u003e\n \u003cli\u003eSilumbwe A, Nkole T, Munakampe MN, Milford C, Cordero JP, Kriel Y, et al. Community and health systems barriers and enablers to family planning and contraceptive services provision and use in Kabwe District, Zambia. BMC Health Serv Res. 2018 May;18(1):390.\u003c/li\u003e\n \u003cli\u003eDaff BM, Seck C, Belkhayat H, Sutton P. Informed push distribution of contraceptives in Senegal reduces stockouts and improves quality of family planning services. Glob Heal Sci Pract. 2014 May;2(2):245\u0026ndash;52.\u003c/li\u003e\n \u003cli\u003eFP2030. Bangladesh FP2030 Country Commitment. Family Planning 2030. 2022.\u003c/li\u003e\n \u003cli\u003eMinistry of Health and Family Welfare (MoHFW). Bangladesh Population Policy 2012. Dhaka, Bangladesh; 2012.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Background Characteristics of Women\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"627\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eID\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (Years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Living Children\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eContraceptive Use\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003eIDI-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eSafe Period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eOral Pills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eClass 8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003eIDI-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eSafe Period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eOral Pills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eClass 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003eIDI-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eSafe Period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eOral Pills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eClass 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003eIDI-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eSafe Period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eMasters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003eIDI-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eWithdrawal, Safe Period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eOral Pills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eMasters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eHindu\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003eIDI-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eSafe Period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eOral Pills, Injection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eClass 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003eIDI-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eSafe Period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eOral Pills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eClass 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003eIDI-8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eSafe Period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eOral Pills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eClass 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003eIDI-9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eSafe Period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eClass 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003eIDI-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003eSafe Period\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eFolk Method\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eClass 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Information of the Key Informant Interviewees\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eID Number\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 450px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccupation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eKII-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eAssistant Director, FP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eKII-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eAssistant Director, FP\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eKII-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eUpazila Family Planning Officer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eKII-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eFamily Welfare Visitor\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eKII-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eMedical Officer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eKII-6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eFamily Welfare Visitor\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003eKII-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 450px;\"\u003e\n \u003cp\u003eFamily Welfare Assistant\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Main Findings of the Study\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eIndividual Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cul\u003e\n \u003cli\u003eLack of Knowledge\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eabout Modern Methods\u003c/li\u003e\n \u003cli\u003eFear of Side-effects of Modern Methods\u003c/li\u003e\n \u003cli\u003eKnowledge of Traditional Methods\u003c/li\u003e\n \u003cli\u003ePerceived Effectiveness of Traditional Methods\u003c/li\u003e\n \u003cli\u003ePerceived Ease of Using Traditional Methods\u003c/li\u003e\n \u003cli\u003ePerceived Low Risk of Traditional Methods\u003c/li\u003e\n \u003cli\u003ePerceived Cost of Modern Methods\u003c/li\u003e\n \u003cli\u003ePerceived Health Benefits\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePerceived Embarrassment\u003c/li\u003e\n \u003cli\u003eExposure to Mass Media\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eInterpersonal Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003col\u003e\n \u003cli\u003e\u003cstrong\u003eSpousal Influence\u003c/strong\u003e\n \u003cul\u003e\n \u003cli\u003eOpposition to Modern Methods\u003c/li\u003e\n \u003cli\u003eCooperation to use Traditional Methods\u003c/li\u003e\n \u003cli\u003eSpousal Attitude\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eInfluence of Mother-in-Law\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePeer Influence\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eCommunity Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003col\u003e\n \u003cli\u003e\u003cstrong\u003eCommunity Approval of Contraceptive Use\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCommon Fear of Medical Complication\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eReligious Beliefs\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003eInstitutional Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003col\u003e\n \u003cli\u003e\u003cstrong\u003eProviders\u0026rsquo; Attitude\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIrregular Visits\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eQuality of Service\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHealthcare Center-related Issues\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003ePolicy Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003col\u003e\n \u003cli\u003e\u003cstrong\u003eLack of Updated Policy\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Traditional contraceptive methods, older reproductive-age women, Bangladesh","lastPublishedDoi":"10.21203/rs.3.rs-5868830/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5868830/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The continued use of traditional contraceptive methods (TCM) among older reproductive-aged women (aged 35–49 years) in Bangladesh poses a significant public health issue. Existing research in Bangladesh suggests that women of this age use TCM more than their younger counterparts do. However, the reason why TCM use is higher among Bangladeshi older reproductive-age women is yet to be explored. The current study attempted to understand the use of TCM among Bangladeshi women aged 35 years or older.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This qualitative study used purposive sampling from the Khulna district to conduct ten in-depth interviews among women aged 15-49 years and seven key informant interviews among family planning service providers. The socio-ecological model was adopted in this study. Data was collected in January 2024. The interviews were audio-recorded and transcribed verbatims afterward. Thematic data analysis was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The study found that women’s poor knowledge and fear of the side effects of modern contraceptive methods and perceptions related to the effectiveness, risk and benefits, ease of use, and cost shaped the use of TCM at the individual level. The interpersonal factors included the influence of spouses, mothers-in-law, and peer groups. Community norms and beliefs were pivotal as well. Institutional-level factors included providers’ attitudes, health facility-related issues such as distance from the house, waiting in queues, and unavailability of products, and policy-level influences such as lack of updated policy molded the TCM use among older reproductive age women in Bangladesh.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e A complex interplay of various level factors shapes the use of TCM in Bangladesh. As a result, comprehensive reproductive health education programs should be considered so that women can make informed choices about the use of contraceptives and switch from traditional to modern contraceptive methods, such as long-acting methods. This will ultimately lead to better reproductive health outcomes in Bangladesh.\u003c/p\u003e","manuscriptTitle":"Qualitative Understandings of the Persistent Use of Traditional Contraceptive Methods Using Socio-Ecological Model among Older Reproductive-age Women in Bangladesh","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-06 05:06:01","doi":"10.21203/rs.3.rs-5868830/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c86c546e-ba04-4b8e-8191-89d192dbb30d","owner":[],"postedDate":"February 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-06T05:06:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-06 05:06:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5868830","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5868830","identity":"rs-5868830","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}