Understanding the low uptake of long-acting reversible and permanent contraceptive methods in rural Bangladesh: A qualitative socio-ecological approach

BACKGROUND: Long-acting reversible and permanent contraception methods (LARC/PM) are safe and highly efficacious; yet their uptake remains persistently low in Bangladesh. The current study sought to explore factors constraining LARC/PM uptake among married women and men of reproductive age in rural Bangladesh. METHODS: This qualitative study employed purposive sampling to carry out twenty-eight in-depth interviews with married women and men, and nine key informant interviews involving family planning service providers and a religious leader in two rural communities in Cumilla district, Bangladesh. Data were analyzed thematically, guided by the socio-ecological model, to identify multilevel influences on LARC/PM uptake. RESULTS: The findings revealed profound knowledge gaps, embodied side-effect concerns, and factual misconceptions pertaining to LARC/PM at the individual level, including fears of infertility, organ removal, and device migration, coupled with method-specific beliefs such as vasectomy-related impotence and restriction of tubal ligation to caesarean sections, largely shaped by anecdotal narratives. Interpersonal dynamics included male-dominated decision-making, spousal opposition, and pronatalist gatekeeping by female relatives. Resistance is further exacerbated by male child preference norms, stigma and myths attached to permanent methods, religious interpretations, and spousal migration at the community level. At the institutional level, provider bias, brief counselling, privacy deficits, and coercive or non-consensual practices undermined rights-based contraceptive service delivery. These were compounded by health system factors, including workforce shortages and inadequate remuneration, contributing to persistently low LARC/PM uptake. CONCLUSION: Low LARC/PM uptake in rural Bangladesh is shaped by a complex interplay of multilevel barriers that constrain women's reproductive autonomy. Addressing these barriers is critical for facilitating voluntary, informed access to a full contraceptive method mix, thereby advancing reproductive health outcomes and gender equity.