Editor's note: A shorter version of this story appeared on The Guardian Global Development.
MATLAB, Bangladesh – Wearing sandals and a dark blue sari, Aparajita Chakraborty glides into the cluster of hilltop homes with the self-assurance of someone who has been making house calls for a long time.
Indeed, she has. For more than 30 years, Dr. Aparajita, as she is known here, has been visiting this extended family, doing checkups and dispensing advice.
But Chakraborty is no doctor. She’s a community health worker dispatched by the local hospital that has won the trust and gratitude of the surrounding community by saving lives – mainly from cholera and other debilitating diarrheal diseases.
With all of the men away, either working in the rice fields or jobs in the city, Chakraborty quickly gets down to business in the family compound of a half-dozen homes. She and a colleague conduct a group interview, asking four women the most personal of questions: When was their last menstrual cycle? Are they taking the pill? Using another method of family planning?
One woman explains that she stopped taking the pill while her husband was working in Chittagong, a city that’s a day’s journey away. She started up again immediately after his surprise visit. Too late. She’s now pregnant, again, with their third child.
Another woman says she’s not using any form of contraception. Chakraborty, who has been tapping information with a stylus into a hand-held electronic device, looks up. They exchange a knowing look and fleeting smile of those who share a secret. She goes back to tapping on her device.
It turns out the woman’s husband agreed to a vasectomy, after their fourth child. But he doesn’t want his brothers—or his neighbors—to know, for fear they will think him impotent or less of a man. So it’s a secret, albeit it one that’s documented by the hospital staff, along with every birth, death, marriage, divorce and other vital statistics of 225,000 people in the region.
Chakraborty knows more intimate details of the community she canvases than they know themselves. Discretion is paramount, she said. “I keep what I hear to myself. I feel like I’m part of the family.”
She’s part of an all-woman cadre of community health workers who fan out across this portion of Bangladesh’s low-lying delta, carefully maintaining one of the longest running health and population data sets in the developing world.
The Matlab hospital that dispatched her has grown extensively since it arrived in 1963 as a cholera research station atop a barge that had been floated downriver from Dhaka. It was set up by the International Center for Diarrheal Disease Research, Bangladesh.
A half-century later, this innovative center for child and maternal health is widely credited for demonstrating how poor, Muslim women with little or no education can plan their families. The ideas taken root here have spread throughout Bangladesh, helping this densely populated, poverty-stricken nation put the breaks on its rapid population growth.
Only about a dozen years ago, demographers at the United Nations were projecting that this small country of 160 million—a bigger population than Russia’s—would soar to 265 million by mid-century. With a steep decline in birthrates, the latest projections show Bangladesh will reach slightly more than 200 million by mid-century and peak about 10 years later at 203 million before beginning to drift lower.
“Matlab showed us the way,” said Ubaidur Rob, the Population Council’s country director in Bangladesh. “Women were employed as field workers in the 1970s, when fertility was very high and female employment was virtually zero. This is where change began.”
The well-chronicled successes have made Matlab something akin to a mecca for public health researchers. Initially, researchers were drawn to this isolated, undeveloped area at the confluence of major rivers because it was relatively close to Dhaka (a two-hour speed boat ride away) and suffered from regular cholera epidemics.
Now, the lure is the database of population and health statistics, with a workforce in place to measure ongoing changes that would reflect the success or failure of a drug trial or health intervention.
In the mid-1970s, family planning advocates from USAID the Population Council thought this was an ideal place to test whether poor women in a religiously conservative area would adopt the use contraceptives, if they were made available.
To set up the experiment, researchers divided 149 villages into two areas. About half of the villages had access only to health care provided by the Bangladesh government, acting as a comparison area. The other half would receive the benefits of contraceptives and other maternal and child healthcare provided by the Matlab Health Research Center.
Otherwise the areas were identical: Poor Bangladeshi families subsisting on farming or fishing, living in bamboo houses, some with tins roofs, in villages with little or no electricity, running water or sewer systems. Most had dirt floors and cooked over a fire of wood, rice chaff and cow dung.
The odds of success were long. Contraception was opposed by Islamic clerics, who were influential in this area that was 88 percent Muslim. Most households practiced “purdah,” segregating the sexes by secluding women in the house and allowing them out only if properly covered and escorted by a male family member.
Health researchers learned that it was not enough just to make available birth control pills, condoms, IUDs and other contraceptives, said Dr. Mohammad Yunus, who ran the Matlab Health Center for nearly 40 years. Instead, he said, the formula for success was a comprehensive doorstep service with women health workers making regularly follow-up visits. They helped mothers pick what type of contraception was right for them, treated any side effects and provided basic maternal and child healthcare.
The Matlab Health Center was careful to select health workers from influential families in the villages inside the service area. The women had at least a sixth grade education, were married with children and had personal experience taking birth control pills or using other forms of contraceptives. They were trained how to give hormone shots of Depo-Provera, and treat common ailments such as fever, diarrhea, skin infections and parasites such as hookworm.
Differences showed up almost immediately away in participating villages and expanded over the decades. More married women began using contraceptives right away. Over time they had, on average, 1.5 fewer children than their counterparts in the comparison area. Their children were healthier. Fewer women died of pregnancy-related causes. Child mortality dropped.
Families covered by the program grew wealthier, too, according to socio-economic surveys. With fewer children to support, the parents accumulated more assets over their lifetimes, including more farmland, more valuable homes and were more likely to gain access to running water. Their children stayed in school longer and the incomes of women climbed considerably higher.
The striking results made the case for international health researchers that family planning is one of the most cost-effective ways to improve the health of poor people and help lift them out of poverty. And, they maintain, it showed that higher wealth and education don’t have to happen before fertility begins to fall—if contraception is made available in a culturally appropriate way.
More importantly to Bangladesh, the Matlab program drew the attention of top government officials, who have long mustered a national family planning program to slow the growth of a large population squeezed into a flood-prone country slightly smaller in size than Iowa.
Yet officials were skeptical that Matlab’s program could be replicated, believing it was successful because it was such an intensive program supported by international health experts and donors.
Still, government officials were willing to explore it, Yunus said, and they picked two other poor areas to match the experiment. “Can you show us?” Yunus recalled them asking. Matlab workers trained government employees in the door-to-door approach and those areas quickly saw a similar jump in women using contraceptives. By the early 1980s, the government had adopted the Matlab model and began to train tens of thousands of female health workers.
“Over the next five years, it was phased in across the whole country,” said Yunus, who now works in the diarrheal disease research center headquarters in Dhaka. “Bangladesh became a success story for family planning and reducing infant mortality.”
Indeed, fertility in Bangladesh dropped from six children per woman on average to slightly more than two –- the so-called “replacement fertility,” which over time will level off the country’s population. Bangaldesh is one of a half-dozen developing countries that have already met the U. N. Millennium Development Goal of reducing child mortality by two thirds. Deaths of Bangladeshi children under age 5 have fallen by 72 percent since 1990.
At Matlab, where much of this started, the rhythms of village life include the regular visits by community health workers, like Kaniz Fatema. This no-nonsense, middle-aged woman runs a clinic four days a month, vaccinating children, giving shots of Depo Provera, dispensing contraceptives and other medicine.
The rest of the her time, she makes the rounds in her neighborhood — as she has for 36 years — challenging women to stand up for themselves and take control of their lives. She locates a newly married teenage girl and greets her in the doorway.
“You’ve been married seven months. What’s your plan, do you plan to make babies?” Fatema asked. “Have you spoken to your husband about this? What does he say?”
The girl remains quiet, backs up a step. Fatema steps forward. “You are a child yourself. If you take the pill, if you wait to have children, it will be better for you. You can go out with your husband and have fun. That’s also important for a family life.”
The girl remains silent.
“You are not saying anything to me today. Your husband wants a child, but how about you? What do you want?”
The girl finally speaks, in barely a whisper. “I’ll let you know after I speak to my husband.” She tightens the scarf that covers her head and frames her face.
“Please talk to your husband,” Fatema said. “If you take a pill, if you postpone, it won’t hurt your chances of having a child later.”
The Islamic clerics in the area no longer voice their opposition to contraceptives. Mohammad Ali Akkas Khan, a local imam, said he worries more about Bangladesh’s poverty and how a small country can take care of so many. He said he remains quiet when men ask him for guidance on various types of contraceptives, giving silent consent that they do not violate the tenets of Islam.
“There was a saying from the Koran, our prophet mentioned long ago, you should chose a woman who is more fertile – so that the followers of Islam would increase. But that’s not true. You are not supposed to have more children, if you cannot provide for them.”
That view is filtering into society, including a crowded multi-generational household in the village of Dhanarpar, with grandmother Fatema, as the surviving head of the household.
She said she learned of birth control shortly after she gave birth to her first of six children.
“But I didn’t trust it,” said Fatema, 67, who like many in this region goes by just one name. “If I had, I wouldn’t have had so many children.” She now wishes she had only three.
When Shahanara married one of her sons and moved in with her, Fatema suggested her daughter-in-law go on the pill. “There was no need to have children right away, or have so many,” Fatema said.
Shahanara followed her advice until she suffered a kidney ailment, prompting a doctor to warn her away from taking hormones. Over the years, she had five children.
Now, a new daughter-in-law has arrived at the house, one of three clustered atop a mud embankment, elevated above the rice paddies to avoid being flooded during the wet season.
At age 17, Hafsa, with large eyes framed by striking eyebrows, has two generations of older women advising her to break the tradition of large families that now crowd into these of wood-framed houses with corrugated metal roof and walls.
Although the older women supported Hafsa’s underage marriage—the legal age is 18—they have instructed her to put off childbearing. Take contraceptive pills, they tell her. Stay in school.
“We made mistakes, but those days are gone,” Shahanara said. “There is no space for many more mistakes. If God wills it, two children are good for her. If it doesn’t happen, one is fine.”