1 Introduction

Childbirth is socio-culturally recognized as a desired experience for women. Economic and health crises may have significant impact on such experiences, resulting in barriers to deciding to have a baby [1]. Emphasizing health problems, fertility drops dramatically during and after epidemics or pandemics [2,3,4]. This paper focuses particularly on the COVID-19 pandemic and fertility intentions, though both fertility and mortality levels are affected by COVID-19. As a consequence of the COVID-19 pandemic, birth trends are projected to vary according to socioeconomic conditions [2, 16]. Literature shows that in developed countries (e.g. UK, Germany, and Spain), individuals have more or less modified their fertility plans (either planning, postponing, or abandoning) due to the current economic crisis [1]. Few studies also explored COVID-19's impact in either increasing birth rate or unchanged reproductive behaviour [12, 15].

Historically, the fertility rate of Bangladesh has been declining. Declining from nearly seven births per woman in 1975, the total fertility rate (TFR) has declined to about two births (2.04) per woman in 2020 [5, 6]. Currently, Bangladesh is stable or nearer to this birth rate. However, like other countries, Bangladesh has experienced challenging impacts of COVID-19 pandemic-related factors. World Health Organization declared COVID-19 a pandemic on March 11, 2020 [20]. Throughout the pandemic period, childbearing women faced risk factors such as fear of virus exposure, uncertainties in delivery plans, insufficient information, and lack of familial and social support [21,22,23]. These risk factors directed couples to rethink their fertility behaviour during the pandemic [17]. Bangladesh reported the first three COVID-19 cases on March 8, 2020. As of 9 July 2021, 1,000,543 cases were tested positive for COVID-19 and among them, 16,004 individuals died [7]. Sanitary measures included limiting social gatherings, lockdowns, and social distancing directed towards breakdowns in the normal continuation of economic activities, social life and health services. Responses to health emergencies restricted focusing on other routine health services [8]. Emphasizing such similar contexts, many studies show that social and economic changes triggered by pandemics had effects on childbearing intentions and completed fertility, resulting in fewer births for many countries [9, 13, 14, 17].

Now, the literature indicates that COVID-19 had an impact on the childbirth intentions of women. There were intended and unintended childbirth although COVID-19 infection during pregnancy increased with maternal mortality [23]. Further, there were different causes of changing childbirth decisions, resulting in postponing or cancelling their pregnancy plan during the pandemic [17]. But still there were prevalence of childbirths.This study focuses on the rural women's experience of those who conceived babies during the pandemic. Exploring why women conceived babies and  identifying what made their decisions protective from such health and economic crisis are the key areas of discussion in the study. The dynamics of both intentional and unintentional childbirth are analyzed in the following sections of the paper, based on COVID-19-related factors, socioeconomic issues, rural context, and demographic characteristics. To conduct the study, rural areas of Rangpur in Bangladesh were chosen as the study location. Rangpur was one of the severely COVID-19-affected areas in Bangladesh. Being previously vulnerable in terms of poverty and food security [11], COVID-19 influenced this area with probable negative economic outcomes.

2 Methodology

This study’s method is qualitative to explore the direct experience of fertility intentions during the pandemic (childbirth, conception, and decision-making to have a baby).

The field of this study is rural areas of the Rangpur district located in the northern region of Bangladesh (Fig. 1). Five villages were chosen to collect data. In selecting the villages, distance and communication difficulties were taken into consideration. The selected villages were not nearer to the towns (peri-urban areas) so that the study could  ensure an actual rural setting. The provision of contraceptives by community health workers was the popular way of birth control among women in these areas.

Fig. 1
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Study area

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The study followed a non-probability sampling procedure for choosing participants. A total of sixty five rural women were selected for the study who conceived babies during COVID-19 pandemic. This study found this number of participants sufficient when no new findings or new themes emerged. The sufficiency of the sample size in such qualitative study can also be justified by following other studies [21]. The inclusion criteria of participants were: (a) being a woman living in the rural area (b) conceived a baby during the COVID-19 pandemic (Fig. 2).

Fig. 2
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Inclusion and exclusion criteria of respondents

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The study followed face-to-face interviews as data collection tool. To collect data from those women, in-depth interviews were conducted. To get a supportive and overall scenario, seven health workers were chosen for KII who had experience in providing maternal health services during the pandemic. There was hardly any non-participation of the respondents. The interviews were conducted between November and December 2022, by the author and three research assistants. Interviews ranged from 14 to 20 min. Open ended questions were asked to the participants to explore their views and experiences of childbirth intentions and the interview contents gradually evolved into semi-structured interview schedule. The interview protocol was prepared by following the COREQ checklist [24]. The interviews started with how their pregnancy period was during the pandemic and then moved on to how the pandemic made them think about their childbirth decision and how the pandemic didn’t make them feel it as a barrier in a time of such health and economic crisis. Data from interviews were transcribed and then, translated into English. Then, the author wrote a summary of participants' responses about their fertility intentions. Anonymization was carried out during data management by avoiding identifying information of the respondents. Key explanatory variables were considered and themes derived from the interviews were followed in the analysis. And raw statements of the respondents were in the result section. Because, it was necessary to reflect on the in-depth scenario of reproductive norms among the women in Bangladesh.

3 Results

3.1 Demographic characteristics and childbirth during COVID-19 pandemic

As can be seen from Table 1, the largest response group (32) is between the ages of 25 to 34 and the smallest group (6) is 35 or older. In terms of educational level, the majority of respondents have completed primary (24) and secondary education (27) and the smallest group is in higher secondary (10) and honours level (4). Husbands’ occupations of the majority of women were agriculture-related, day labour, rickshaw puller, and driver of three-wheelers (locally named auto bikes). 16 respondents’ family occupation is either any small business, salaried staff in town’s showrooms or shop owner. In terms of family pattern, 38 respondents are of nuclear family and 27 respondents live in extended families. Intentional pregnancy was found among 57 respondents and the rest were found claiming unintentional childbirth.

Table 1 Participants’ Demographic information
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Among the women, 43 expressed a desire to have two children, 16 indicated a preference for just one child, and only 6 respondents expressed a desire for three or more children. In terms of changes in family income during COVID-19, majority of responses were about declining income (55) while only two respondents mentioned that they had lost their jobs due to the pandemic. Reflecting on this data, this study found that COVID-19-related economic difficulties did not have a direct influence on fertility decisions of couples in rural areas.

Among those sixty-five women, about 45% of babies were born as the second child of their parents (Fig. 3). The second largest data are found in the category of being the first child (about 28%). Issues of son preference and accidental pregnancy were perceived key factors among those who had three or more children. This result may be explained by society’s norms and attitudes towards son preference, age at childbirth and government programs on population control and family size. These things may have a direct or indirect effect on the fertility intention during the COVID-19 pandemic.

Fig. 3
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(Born during COVID-19) child position among siblings (source: field data)

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3.2 Factors to intentional childbirth

The study found a higher prevalence of intentional childbirth, during the COVID-19 pandemic, among rural women than unintentional or accidental childbirth Among sixty five women, fifty seven women reported that they had intentional childbirth during the pandemic. It indicates that the majority of the women in rural areas didn’t lower their fertility intentions or the pandemic situations didn’t influence their decisions.

The study explored the factors that made pandemic-related difficulties insignificant in deciding to have a baby. Twenty-seven women directly agreed that they had to bear more costs in pregnancy-related medical treatments than the normal time. In terms of getting maternal care and cesarean section, women found difficulties in getting services. They took more safety measures in fear of virus exposure. Societal values and practices of bearing children overcame the influence of such emerging issues and negative changes in income (stopping, decreasing) and in health care services. The factors in intended childbirth, at the surface level caused by the pandemic, were work from home, enduring stay of husbands at home due to long holidays or out of works of husband, proximity to intimate partners, getting desired support and care of husbands around being pregnant, and perceived opportunities for childbirth. The pandemic, with its stay-at-home measures and fewer external commitments, increased physical contact and intimacy among couples. Couples possibly used the opportunity to actively pursue childbearing in order to take advantage of the conditions. Further, duration of marriage and societal expectations of childbirth, and the desired number of children played significant roles in the couples' decision to have a child. Reflecting on this argument, one quote from a respondent who gave birth to her first child can be mentioned: “COVID-19 is a problem like…health economic difficulties, can’t move when necessary. But two years have passed since we married. In-laws and others also expect to have a baby now. My husband also agreed”.

Influence of the husband’s return migration at home as a cause of intended childbirth was found among three couples. Husbands’ works at distant places in capital cities or foreign countries were interrupted by the pandemic and their return to home became unexpected benefits for the women in taking decision for pregnancy (Fig. 4).

Fig. 4
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Causes and assumptions about intended childbirth (source: field data)

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Following the findings above, beyond social values about the time of conceiving a baby, the key aspect of COVID-19-related fertility intention is that the pandemic was perceived as an unexpected benefit among many rural women. The pandemic allowed more time for bonding among couples, and better care during the pregnancy period appeared as an incentives for the women. These factors caused women to be distracted from the fear of pandemic-related suffering.

3.3 Unintentional childbirth during COVID-19

By using ‘unintentional childbirth’, the study focused on COVID-19-related factors on conceiving a baby unexpectedly or unwanted pregnancy. From study data, eight cases were found as unintended childbirth. Due to lockdown, fear of virus exposure and distance maintenance during COVID-19, the movements of people were restricted and access to medical services was uncertain, the study found. The rural health care providers had difficulties in accessing their pre-pandemic service consumers, the women. A quote from a health practitioner can perfectly explain the scenario of restricted access faced by  those health practitioners:

“Women were not comfortable in meeting with us. Many of them were afraid of the virus exposure because they thought we might be the bearer of the virus since we had to visit many homes in the villages. Another thing I would say, women were not comfortable sharing their reproductive health needs. They felt uneasy talking to us and taking contraceptives since the lockdown and other issues made male family members stay at home. Hence, they didn’t get the privacy that they needed. We had managed in many different ways. But some families were hard to manage.”

The statement of the health worker indicates the reproductive health practices in rural areas and related pandemic-induced difficulties. Another key aspect is that due to the confinement of the family members at home, women found it difficult for private talks with the health workers. Within such situations, husbands of those women who used pregnancy control pills/ injections from health workers were reluctant to collect contraceptives from the pharmacies. Particularly, injected contraceptives were found difficult to manage by those women. A 43-year-old woman stated, “What could I do? I told my husband many times to bring the injection from pharmacies. He didn’t hear me. Besides, certainly, Allah has wanted it to happen so.” Two issues evolve from the statement. Firstly, women in rural areas are dependent on husbands and health workers to get access to contraceptives. Discontinuity in such access may cause unintentional childbirth. Secondly, the cultural belief that deciding on childbirth is not confined only to the couple’s choice. Such belief reflected acceptance of unintentional childbirth, to some extent, and a favourable opportunity to negotiate among those couples (Fig. 5).

Fig. 5
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Factors to unintentional childbirth (source: Field data)

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Shutting down pharmacies within the restricted time was claimed as the cause of unintentional pregnancy by one respondent who worked in a factory for ten to twelve hours daily. She stated, “I couldn’t manage time to collect contraceptive pills from pharmacies. Pharmacies were closed earlier. I found it closed after finishing my working time. My husband also didn’t care about the situation.”This may, directly and indirectly, have impacts on unwanted pregnancies during COVID-19 in rural areas.

4 Discussion and conclusions

To explore dynamics related to fertility intentions, this study explored rural women’s situations through face-to-face interviews. To sum up, the results indicated that 87.7% of reported childbirths were intentional, while 12.3% were unintended childbirth. Stay-at-home measures during the pandemic led to an increase in the active pursuit of childbearing, either directly or indirectly. The challenges and uncertainty caused by the pandemic may have influenced husbands to be more supportive and caring towards their partners, leading to increased confidence in handling motherhood responsibilities. In terms of unintentional childbirth, lockdown restrictions and limited access to medical services led to a lack of birth control strategies. Facing difficulties in accessing health workers due to social distancing measures, resulting in limited access to contraceptive options, women conceived babies during the pandemic. Further, earlier shutting down pharmacies influenced couples not to access contraceptives, particularly for working women. Another aspect is desired family size that might encouraged women to conceive babies. During the pandemic, babies were born as either the first or second child of parents and this may be influenced by societal practices and attitudes towards desired family size which was quite different a few decades ago in Bangladesh.

Then, the study tries to address why couples decided to have babies during such pandemic-induced economic and health crises. Cultural beliefs about family, parenting, and chldbirths may have a more significant impact on reproductive decisions among the families. These standards might place a strong emphasis on the value of procreation and maintaining the family tree. As a result, despite the severity of pandemic crisis, despite the majority of respondents claiming that their income declined, the economic crisis was unable to alter these firmly set societal standards around childbearing. In short, the economic crisis failed to cultural norms. Personal and social narratives of having children are more significant than the uncertainties like COVID-19.

The study claims that a decline in income didn’t significantly influence decision to conceive a baby among rural women while other studies found income loss an important factor in preventing women from bearing children during the pandemic [25, 27]. Economic pressure didn’t emerge as a significant influencing factor for those families. Family members’ suggestions for having a child and their support to care for children have an impact on the pandemic being less important for pregnancy decisions which is also supported by other studies [26]. This reflects the rural family life of Bangladesh society where the couple’s decisions are influenced by other family members and acquaintances. Further, limited access to contraceptives was a cause of unintended childbirth in rural areas which was also predicted by Aassve et al. (2020) that rural and urban areas would have differential impact on access to family planning services [28]. This data supports other studies claiming that, by limiting women’s access to family planning and other reproductive health services, the COVID-19 pandemic increased the burden of unintended pregnancy [29]. Restricted access of local health care providers to the women and the unavailable access to pharmacies prevailed in such a vacuum of services. These issues are also evident in other studies [18, 19]. It is noteworthy that, at the beginning of COVID-19 in 2020, there was a noticeable decline in the adoption of certain methods of contraception compared to the corresponding period in 2019 [30]. Specifically, the utilization of contraceptives decreased. Along with emphasizing availability of the contraceptives, this finding indicates the importance of women’s exposure to awareness and education about reproductive health services. It also indicates the importance of making rural women independent and empowered in accessing contraceptives. Making communication with health care providers easier can be another way to reduce unintended pregnancy. Since the study is about context-specific pregnant women, there might be an underrepresentation of unintended pregnancy. In larger-scale data, the scenario might be more alarming.

Bangladesh is one of those developing countries where COVID-19 has a severe impact on economic and social life. Considering the influence of this pandemic on people's plans to have children is important to prevent sudden shifts in Bangladesh's population makeup. According to the latest SVRS report, the Crude Birth Rate (18.1) is declining but the Crude Death Rate (5.1) is higher than in the previous year [5]. Contraceptive Prevalence Rate is more (63.9) than before (62.3 in 2016) [10] which, coupled with other protective policies and family planning strategies, might be a sign indicating  an impact on the declining birth rate in future [18]. Hence, this study may contribute to rethink pandemic-related birth intentions of women and to make policy initiatives by the relevant stakeholders to ensure a balanced demographic structure in future Bangladesh.

The study has some limitations. Firstly, the study focuses specifically on the Rangpur region of Bangladesh. Focusing on context-specific insights may limit the scope of generalizability. However the in-depth analysis and ensuring the characteristics of rural settings in the study may overcome the limitations in many cases. Secondly, the limited time frame of the study may not capture long-term impact on fertility intention. However this study could be a reference for further studies and research insights. This research may be thought of as incomplete, but this could be a source of information on pandemic-related childbirth trends.