DHAKA — Bangladesh and the United Nations Population Fund (UNFPA) have agreed to cooperate on providing contraception to Rohingya refugees from Myanmar as the estimated population of the camps housing them has now passed 1 million.
An agreement between the Bangladesh Family Planning Directorate (DGFP) and the UN agency signed on April 17 lays out 13 “areas of cooperation” in providing reproductive health and family planning information and services to the “Rohingya refugees and host communities in Cox’s Bazar district without discrimination and with dignity and respect.”
According to a copy of the agreement seen by The Irrawaddy, the agencies will adopt policies and guidelines for providing both short- and long-acting reversible contraceptive services, maternal health services, and record keeping and reporting, and will strengthen coordination and collaboration with agencies working with the host communities and refugees in Cox’s Bazar to ensure culturally sensitive quality healthcare information and services are provided without “discrimination, and with dignity and respect.”
According to the bilateral agreement, the UNFPA will procure and supply long-acting reversible contraceptives, including intrauterine devices (IUDs) and implants, to the DGFP based on the needs of the Rohingya refugees.
“We have already procured 8,600 implants and 600 other IUDs following the agreement,” Abu Sayed Hasan, a family planning specialist at the UNFPA, told The Irrawaddy.
He said the agencies had decided to include long-acting methods of contraceptives because the dropout rate for short-acting methods including pills and condoms was high.
DGFP chief Kazi Mustafa Sarwar said many Rohingya are reluctant to use condoms and pills, adding that “they threw the condoms away when our staff supplied them with the items.”
“Many of them have been given short-acting injectable [contraceptives] with three-months’ effectiveness, but we want to introduce long-acting methods that last three years and 10 years,” Mustafa said.
Between October 2017 and mid-May, Cox’s Bazar family planning officials said the displaced Rohingya population was administered only 3,223 condoms, compared to 15,500 short-acting injectable contraceptives.
A total of 19,456 strips of oral contraceptive pills were also distributed, according to the district family planning office.
In September and October 2017, 1,000 condoms and 3,000 strips of pills were distributed and 3,900 women were given birth control injections.
The DGFP has permitted other NGOs employing trained providers to offer long-acting reversible contraceptives as long as they obtain prior permission from the DGFP, the Bangladeshi officials said.
The DGFP, with financial support from the UNFPA, will recruit two full-time doctors to provide sexual reproductive health services in Rohingya camps in Cox’s Bazar. Once the doctors are recruited DGFP plans to withdraw its seven mobile medical teams from the refugee camps.
The DGFP chief said the funding for this came from the UNFPA and there would be additional funding from the World Bank.
According to the Bangladesh National Institute of Population Research and Training, better known as NIPORT, Bangladesh’s maternal mortality ratio (the annual number of female pregnancy-related deaths per 100,000 live births) declined by 40 percent from 322 in 2001 to 194 in 2010.
According to their latest statistics, the total fertility rate (TFR) in Bangladesh declined from 2.7 in 2007 to 2.3 in 2014. According to the World Health Organization (WHO), TFR “refers to the total number of children born or likely to be born to a woman in her life time if she were subject to the prevailing rate of age-specific fertility in the population.”
“But,” said family planning specialist Hasan, “we have conducted a survey in [Rohingya] camps and found that their rate is higher than the host community.”
Since Aug. 25, 2017, nearly 700,000 Rohingya have fled across the border from Myanmar into Cox’s Bazar. Bangladesh has so far completed registration of 1.1 million Rohingya, including some who have been living in Cox’s Bazar for several decades.
According to the Bangladesh Refugee Relief and Repatriation Commission, 35,355 Rohingya were already registered in two official camps in Cox’s Bazar district by June 2014. The number had risen to 38,455 by August 2017.
According to NIPORT, the contraceptive prevalence rate in Bangladesh increased from 56 percent in 2007 to 62 percent in 2014, while the use of modern contraceptive methods increased from 48 percent to 54 percent in the same period.
In mid-May, the United Nations Children’s Emergency Fund said in a statement that more than 16,000 Rohingya babies had been born in camps and informal settlements in Cox’s Bazar in the previous nine months.
About 100,000 Rohingya children are expected to be born in Bangladesh in 2018, according to a projection by the WHO.
Religious Beliefs Pose a Challenge
Family planning is a sensitive subject in Muslim Rohingya communities, according to both Bangladeshi and UNFPA officials.
Bangladesh’s top family planning official Kazi Mustafa Sarwar told The Irrawaddy that motivating Rohingya people to use contraception is a big challenge.
“We plan to recruit eight interpreters who can provide counseling to convince them [about the benefits of family planning services]. It’s our main challenge, as we have yet to make them convinced [that they would benefit from receiving the services]. Many of them were not at all aware of family planning in Myanmar.”
Regarding the beliefs of Rohingya people, he said, “They are conservative in their religious beliefs. Many of them are madrassa educated.” A madrassa is an Islamic religious school.
In fact, views in the camps toward contraception are somewhat mixed, with a spectrum of cultural and religious beliefs apparent among refugees.
Aminul Islam, a religious teacher based in Bangladesh’s Rajshahi district, believed any temporary method of contraception that protects a woman’s health is acceptable, but that permanent birth control procedures were in conflict with the faith.
Hafez Abdul Wahab, 43, came to Bangladesh 27 years ago and is a registered refugee in the Kutupalang camp. He and his wife have 11 children.
Wahab said on Friday that in the past he had been reluctant to use birth control, describing the process as “difficult”. However, he is now in poor health and said he would be willing to follow family planning methods if the government or an agency approached him about it.
“Of course religious belief is an issue… Some Rohingya also believe that they need large families if they are to survive,” said another family planning officer in Dhaka who did not want to be named as he is not authorized to speak to the media.
Hasan, the UN family planning specialist, said the size of the average family in the camps was 5 to 6 members.
The UNFPA plans to recruit 40 more midwives and deploy 10 paramedics to provide family planning counseling in the Rohingya camps, taking the total to 100 in the Rohingya-populated Ukhia and Teknaf sub-districts of Cox’s Bazar. The UN agency in partnership with NGOs will also recruit 100 community volunteers to build awareness of the need for family planning, maternal health and safe delivery procedures among the Rohingya refugees.
Under the agreement between Dhaka and the UN, Pintu Kanti Bhattacharjee, the head of the family planning office in Cox’s Bazar district, will supervise and coordinate the areas of cooperation on behalf of the Bangladesh government.
Pintu criticized NGOs operating in the area for focusing too much on financial and infrastructure assistance to Rohingya and neglecting the issue of birth control.
He said his office had held a series of meetings with donors and charity agencies to discuss ways of increasing coordination and bringing the population of the camps under control.
“Now, we are hopeful about our progress,” said Pintu, adding that a voluntary sterilization plan was also being considered as a way of tackling the high birth rate among the Rohingya.
The U.S. Embassy in Dhaka announced on March 28 that in response to a request from the Bangladesh Health and Family Welfare Ministry, the U.S. Agency for International Development (USAID) had on March 25 supplied 622,800 doses of injectable contraceptives to Bangladesh, bringing the total contribution from the U.S. to nearly 1 million doses.
USAID mission director Janina Jaruzelski said that “USAID remains committed to helping the most vulnerable Rohingya refugees gain access to essential and life-saving health commodities.”
A family planning official in Dhaka said last week that a report by Agence France-Presse on the possible introduction of voluntary sterilization in the camp had resulted in a delay in the approval of the introduction of long-term contraceptive methods, as the government feared the report cast its assistance activities for the Rohingya people and others in a bad light.
In October, the AFP reported that Bangladesh was planning to introduce voluntary sterilization in its overcrowded Rohingya camps after efforts to encourage birth control failed.
Many of the refugees interviewed for that report told AFP they believed a large family would help them survive in the camps, where access to food and water remains a daily battle and children are often sent out to fetch and carry supplies. Others had been told that contraception was against the tenets of Islam.
Bangladesh has for years run a successful domestic sterilization program, offering 2,300 taka ($28) and a traditional lungi garment to each man who agrees to undergo the procedure.
Every month 250 people undergo sterilization in the border town of Cox’s Bazar.
But performing the permanent procedure on non-Bangladeshi nationals requires final approval from a committee headed by the health minister, according to the AFP report.
“But, we finally got approval,” the family-planning official in Dhaka said. Bangladeshi officials believe sterilization of males is the best way to control the population, as it permanently removes a man’s ability to reproduce, regardless of how many wives he has.
An official at an Ukhiya-based NGO working on gender-based violence told The Irrawaddy that many Rohingya males have multiple wives in various camps, adding that once a wife becomes pregnant the male often goes to stay with another for sexual relations.