Lack of knowledge regarding modern methods.

Many participants were unfamiliar with modern methods and lacked understanding of what they were and how to apply them. A participant with higher secondary education revealed her knowledge of modern methods, leading to widespread fear of potential side effects.

“I don’t understand that much. I haven’t used [modern methods]. Many people talk about Copper-T, but I do not understand them; I do not have a good knowledge about this.” (IDI-9)

Another participant with a primary education stated a similar level of understanding of modern contraceptives. This demonstrates that, despite education levels, women lacked knowledge about modern methods, partly due to their low awareness and partly due to the widespread myth and fear of potential side effects of modern methods, which further prevented them from becoming familiar with these methods.

“Let alone using them, I don’t even know about them [modern methods]. I never thought about using them or learning about them…” (IDI-10)

Providers also reported poor awareness among women regarding modern methods, leading to misconceptions about these methods and the choice of TCM. This emphasizes the pressing need for targeted awareness initiatives to overcome misunderstandings, increase knowledge, and enable women to make informed choices regarding 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.

Fear of adverse effects was a major reason why women in Bangladesh chose TCM. Women who had observed or experienced harmful consequences, such as dizziness, weight gain, and nausea, linked these issues directly to modern methods, prompting them to use TCM, which they believed to be safer. For example, a woman with a higher education level stated that even after knowing modern methods like pills, injectables, and ligation, she preferred not to use them because she was afraid of the risks and side effects.

“I see my sister-in-law having many problems. She uses injections. She has a vision problem; she does not see properly. She has irregular periods every three to four months. She now sees almost nothing. She has become fatter. She had stopped receiving the injections. Pills also deteriorate the body regularly, such as dizziness, vomiting, and other health problems…” (IDI-4)

The providers reported that fear of the adverse side effects of modern methods acted as a barrier to the utilization of modern methods, such as 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. However, their efforts frequently failed to influence women’s beliefs, resulting in the 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 your body. This will take two to three months. There were some changes in the menstrual period. These are hormonal methods; therefore, if they are absorbed in the body, the ability to have children is hindered. This may be the reason why they think something is wrong with their bodies. 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 understanding of TCM, such as the safe-days method or periodic abstinence, confidently identifying the “fertile” and “infertile” days of their cycle.

“I am counting safe days and keeping track of the date of my menstruation. If my period starts on the 10th of the month, I keep track of when it starts… so that’s how I 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 their fertile days. They further highlighted that even educated women were not fully aware of how to use TCM, making them vulnerable to unwanted pregnancies.

“Let me share an experience. A project manager at a reputed organization and his wife followed the [safe period]. The days he thinks are safe are dangerous. This is how they conceived a baby. But we know that it is a dangerous time.” (KII-1)

Perceived effectiveness of traditional methods.

Users of the safe-days method were confident in their ability to calculate safe days because their regular monthly cycles were accurately calculated. The absence of unplanned pregnancies strengthened their satisfaction with the method’s effectiveness, demonstrating a sense of control and confidence in managing their reproductive health. Consequently, they saw no reason to transition to modern methods.

“Yes, it works well; we do it. I believe 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 this divergence, stating that many women had difficulty maintaining correct counts, resulting in a substantial failure rate and unwanted pregnancies. This disparity highlights the discrepancy between individuals’ self-assessed capabilities and professionals’ concerns about the reliability of TCM, underscoring the need for enhanced education and counseling to bridge this gap.

“They can’t do it [count safe days] properly. You must maintain it. However, 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 minimal disruption to their daily tasks. For example, some women did not remember taking pills regularly, while others found it challenging to use condoms 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 women of reproductive age.

“There is no unnecessary trouble (with TCM), like forgetting to take pills, forgetting to take injections, I can’t remember the time, and I can’t always keep an account. There is no hassle. If you consume pills or use any other method, you must stand in line 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 of TCM.

The participants had a low-risk perception of TCM use. They believed that their method was less harmful and had no unintended consequences, such as unplanned pregnancies. They felt safe adopting these methods because they had no firsthand experience with undesirable outcomes or had heard of negative outcomes.

“It seems this is good for my health; there is no risk [of unintended pregnancy]. I believe 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 significant gap in women’s awareness, stating that many were ignorant of the larger health hazards linked to TCM, including sexually transmitted infections (STIs). This assumption regarding TCM’s safety, along with the fear of modern methods, led to 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.

Women from low-income households viewed modern methods as financially inaccessible. They believed that buying contraceptives, such as pills, from local pharmacies or stores, when not available in government health facilities, would be an extra expense for their households. Furthermore, they believed that permanent methods, such as ligation, necessitated expensive surgeries, suggesting their limited understanding of the availability of cost-subsidized, long-acting, and permanent options. This notion was supported by the participants’ inclination toward cost-free TCM, such as recording safe periods, which they believed to be more affordable and appropriate for their socioeconomic situation than 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 of the intervention.

Many women believe that TCM offers fewer health hazards than modern contraception, which they associate with a variety of adverse effects, such as weight gain and other physical discomforts. This perception was supported by individual and family experiences in which older generations used TCM without harmful health impacts, strengthening the view that TCM was safe.

“If I use something else, it will not adjust to my body, she said. Therefore, I use it [safe period]. Our grandmothers, aunts, and mothers used it [safe period] and did not have any problems with it; they are healthy. I have not gained weight. I have remained the same before and after marriage.” (IDI-4)

“I talk to people, but I never hear 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 their choice of TCM.

“They [women] think that it [modern method] can increase their health risks at this age. When they cross 30/40, they may have high blood pressure and diabetes. Therefore, we do not suggest modern methods for patients with diabetes or high blood pressure. Therefore, they are more prone to traditional methods. And they try to avoid modern methods.” (KII-2)

Perceived embarrassment.

The embarrassment associated with modern contraception, such as condoms and injections, underlines longstanding societal beliefs that discourage open family planning discussions. The 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 from in-laws. Similarly, visiting medical facilities for injectables was regarded as publicly reporting their contraceptive use, exposing them to potential scorn and disgrace. The stigma associated with contraceptive use fostered the adoption of TCM, which was viewed as a more discreet alternative.

“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 is about condoms. You must throw it away or dispose of it after use, and I have my family to consider. What if my sisters-in-law and mother-in-law see it while throwing it away? It’s such a shame.” (IDI-2)

Exposure to mass media.

Exposure to mass media plays a critical role in increasing awareness and shaping women’s attitudes toward different contraceptive methods, prompting them to consider modern contraception. The participants admitted to having seen or heard family planning messages on television or radio before; however, they had not encountered many recently. This explains women’s lack of knowledge of modern methods, especially long-acting and permanent ones, leading to the continued use of TCM.

“Yes. I have seen it [family planning messages] on TV, for example, having one child is enough, whether it is a girl or a boy. I remember they used to show dramas on TV as well, but not anymore.” (IDI-9)

Spousal opposition to modern methods of childbearing.

Partner opposition to modern methods was a barrier to their adoption, typically driven by concerns about adverse consequences, including obesity and other health issues. The spouse’s refusal to let his wife choose between pills or injections symbolized a larger sociocultural 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 utilizing Imams to promote the benefits of modern methods, they hoped to leverage their authority to resolve spousal opposition and increase approval.

“The men of the family can be explained by the Imam (who leads the prayers in a mosque). The men will not listen to me, but they accept the words of the Imams. We give them a list of names and ask them to motivate and discuss such things.” (KII-4)

Cooperation is required to use traditional methods.

Most participants reported that their husbands cooperated and supported the use of TCM, especially when they observed that modern methods, such as oral pills, had adverse effects.

“You know, my husband saw that there is a problem with that [pills], and it [safe period] is safe. Therefore, 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 toward TCM facilitated its use among women in Bangladesh. The husbands felt that TCM was more effective, so they supported their wives and encouraged them to use it. This scenario illustrates how partner involvement and mutual satisfaction with TCM led to its continued use, demonstrating the importance of spousal support in reproductive choices. It highlights how partner involvement and mutual satisfaction with TCM contributed to its continued use, underscoring the significance of spousal support in reproductive decision-making.

“My husband says that this [safe period] is good. I feel physically fine. Additionally, we have spent many years in this manner, and he is content with it. He believes there is nothing wrong with it. He also said that I had a problem with pills, but that this one is safer. We are better.” (IDI-1)

Influence of the mother-in-law.

Family members, especially mothers-in-law, play a crucial role in shaping women’s choices and decisions regarding family planning methods. Opposition to modern methods by mothers-in-law 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 a mouth, He will feed them as well… We have not used such useless things. We have raised five or six children; you can do it too. After marriage, my mother-in-law told me not to use these things.” (IDI-1)

However, providers remarked that mothers-in-law’s dominance waned over time, and many no longer opposed 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 and friends, shape the use of TCM among women in Bangladesh. Some participants mentioned their sisters as sources of information and support for the use of TCM. However, even when their peers disapproved, the participants continued to use TCM because of their low-risk perception.

“My elder sister uses this method as well. She advised me to use this method. She also told me that if I follow the rules properly, there will be no problem.” (IDI-8)

Community approval of contraceptive use.

The community’s approval of contraceptive use has grown dramatically, creating a more accepting setting for women to select contraceptive methods that satisfy their requirements, whether modern or traditional.

“I don’t think nowadays anyone has any headache or anything about anyone. People use methods that are beneficial for them or suit their individual needs. No one has discussed this. They use whatever is convenient for them… I see most people are consuming pills. That’s what I hear the most.” (IDI-1)

Even family planning workers, who once faced prejudice and were often disliked by communities, are now welcomed and regarded as trusted, demonstrating a positive shift in community norms. However, 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 because of various reactions. The FWAs could not go home, and people chased 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, have led to the discontinuation of modern methods and a switch to TCM use. These fears and misconceptions were frequently perpetuated and reinforced through community interactions among neighbors and relatives, affecting individual choices to avoid using modern contraceptives.

“If you undergo an operation such as ligation, you must undergo many cuts. What if the cut is not well stitched? 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 they must be cut off as well. So, I am scared. My neighbor told me not to do it.” (IDI-1)

Health professionals acknowledged the existence of preconceptions about modern methods among women, thus recognizing the need to create tailored educational programs to overcome these misunderstandings.

“Many people think IUDs mix with blood and heart, go inside, and they fear that it will be displaced.” (KII-6)

Religious beliefs.

Religion plays an important role in the use of TCM and the non-use of modern methods among older women of reproductive age in rural areas. Only one participant was Hindu, while the rest were Muslim. According to Muslim women, modern methods such as injectables, implants, and ligation were heinous and prohibited because they involved alterations to the body that were regarded as inconsistent with religious teachings. Therefore, they rejected modern methods in favor of traditional ones to ensure religious observance.

“According to my religion, it is not right to take any pills or anything. Using a condom or a pill is a 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 aspects of modern religious methods. They believed that TCM, such as the safe period method, was natural, acceptable, and non-sinful, and aligned better with their beliefs than Western methods. Thus, it was legitimate to use it according to 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 reasons for women’s opposition to the use of modern methods, such as divine punishment and retribution in the afterlife. As a result, they attempt to cope by enlisting spiritual figures, such as imams, to clarify myths and advocate 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]

Providers’ attitude.

The participants expressed mixed feelings about the behaviors of their healthcare providers. Some women found them accommodating, but others mentioned feeling angry if they ignored the providers’ advice. The inconsistency in professional attitudes led to a loss of faith and poor experiences for women, particularly when healthcare workers encouraged them to adopt specific methods, such as implants or 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 furiously told me, “What are you doing? You don’t want to take the pill? You don’t want to perform ligation? What is this? You have two children.” They behave so strangely, do not explain properly, do not come to us regularly, but still get angry!” (IDI-1)

In response, program managers believed that they delivered thorough training to improve their communication skills and foster good rapport and trust, especially at the grassroots level. They emphasized the use of Behavior Change Communication (BCC) to develop the skills necessary to address individual issues, convey accurate information, and provide respectful and patient-friendly care.

“We have BCC [Behavioral Change Communication] strategies. We train them to communicate effectively with others. However, more training is needed because they repeatedly perform the same tasks. That’s why sometimes we give them refresher training, so their work is better.” (KII-3)

Irregular FWAs visits.

Some participants reported receiving inadequate and irregular home visits from Family Welfare Assistants (FWAs). FWAs are grassroots healthcare workers who provide reproductive and maternal health services to communities in their designated locations, including contraceptive distribution, counseling, and, if necessary, referrals to higher-level healthcare professionals. They serve as a critical link between women and the larger health system, and irregular attendance can result in missed opportunities for education, contraception, and prompt referrals. Consequently, the women felt less supported, which contributed to their 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 at health centers. Fear of encountering practitioners’ harsh attitudes and satisfaction with TCM prompted women to avoid healthcare centers entirely. This finding demonstrates that strengthening interpersonal care components is critical for women’s use of 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 in higher positions. I am afraid of how they will behave toward me. And I am satisfied with my method [safe period], so I do not go.” (IDI-1)

Healthcare center-related issues.

Women reported issues at the healthcare center, such as the distance from their homes, waiting in lengthy queues, and product unavailability, which led to frustration and contributed to the non-use of modern methods of menstrual hygiene management. 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…. They often claim that no more products are 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, providers emphasized patient-friendly care by creating an enabling, courteous, and individualized atmosphere that focused on the well-being of those receiving healthcare, making them feel at ease, valued, and adequately cared for.

“Our union-based healthcare centers work as a team. Those who go to the field are always in contact with those at the centers. They also considered whether any complications were associated with the use of any method. If any complications arise after using a family planning method, the government will cover the associated costs. This is how we have been able to create a patient-friendly environment.” (KII-1)

The key informants further explained how they ensured that women who sought family planning services at health centers had full access to them. They outlined the financial considerations for long-acting and permanent methods of contraception services provided to women, as per government instructions.

“If someone comes to get clinical services in that FWC (Family Welfare Center) … we pay a transportation cost. Once 60 Taka is given to them, it is used for follow-up. Three follow-ups were performed monthly. The amount for the three months is also provided. They are informed when the FWV (Family Welfare Visitor) motivates them to undergo the procedure. And it is mentioned in the citizen charter.” (KII-1)

Lack of updated policy.

Family planning initiatives in Bangladesh have emphasized the promotion of modern contraceptive methods to combat the growing population and promote the well-being of mothers and children. Traditional methods have been a part of the general family planning scenario but are rarely promoted in mainstream policy because of high failure rates, often resulting in unintended pregnancies.

“In fact, according to 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 ongoing initiatives to revise national policy, including consultations with stakeholders to accommodate varied family planning needs, doorstep care, and greater knowledge of women’s needs. Given the number of older reproductive-aged women using TCM in Bangladesh, instead of sidelining traditional methods in policy discourse, it is imperative to adopt an inclusive approach and raise awareness of 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 are expected to be completed this year. Family planning activities have been incorporated into national policy through 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)