In Brief Series 2012, No.3
Menstrual Regulation, Unsafe Abortion And Maternal Health in Bangladesh Key Points Maternal mortality has declined considerably in Bangladesh • Unsafe clandestine abortion persists in over the past few decades. Some of that decline—though Bangladesh. In 2010, some 231,000 led to complications that were treated at health precisely how much cannot be quantified—is likely facilities, but another 341,000 cases were attributable to the country’s menstrual regulation program, not. In all, 572,000 unsafe procedures led to complications that year. which allows women to establish nonpregnancy safely after • Recourse to unsafe abortion can be a missed period and thus avoid recourse to unsafe abortion. avoided by use of the safe, government sanctioned service of menstrual regulation Bangladesh is making solid progress childbirth by improving access to ma- (MR)—establishing nonpregnancy after a toward meeting the Millennium Develop- ternal health care and lowering fertility, missed period, most often using manual vacuum aspiration. In 2010, an estimated ment Goal of reducing maternal mortal- especially births that pose above-average 653,000 women obtained MRs, a rate of ity by three-quarters between 1990 and health risks (e.g., those to high-parity 18 per 1,000 women of reproductive age. 2015.1 According to a commonly used women). What makes the country unique, indicator, the maternal mortality ratio, however, is the potential contribution of • The rate at which MRs result in complica- maternal deaths fell by at least 60% from an authorized procedure—known as tions that are treated in facilities is 1990 to 2010–2011 (Figure 1, page 2).2,3 menstrual regulation, or MR—to “estab- one-third that of the complications The two official government studies of lish nonpregnancy” after a missed period.6 of induced abortions—120 per 1,000 MRs maternal mortality (known as Bangla- vs. 357 per 1,000 induced abortions. The unique contribution of MR to women’s desh Maternal Mortality and Health Care • There is room for improvement in MR health care in Bangladesh dates from the Services Surveys, or BMMS*), which were service provision, however. In 2010, 43% early 1970s. Bangladesh’s current penal conducted in 20014 and 2010,5 offer fur- of the facilities that could potentially code, which dates from 1860, when it ther evidence of this steep decline: Their offer it did not. Moreover, one-third of was a British colony, outlaws all induced findings show a drop in maternal mortality rural primary health care facilities did abortions except those needed to save not provide the service. These are staffed of two-fifths in less than one decade. 7 the life of the pregnant woman. A legal by Family Welfare Visitors, recognized to We know that the country has made great ruling exempted MR from being regulated be the backbone of the MR program. In strides in reducing maternal mortality. by the penal code, and subsequently, the addition, one-quarter of all MR clients were But we know less well which factors, and procedure became part of the national denied the procedure. in what combination, contributed to the family planning program in 1979.8 • To assure that trends toward lower abortion- decline. As in most countries that have MRs are allowed up to 10 weeks after the related morbidity and mortality continue, made similar progress, evidence sug- last menstrual period (LMP) if performed women need expanded access to the means gests that Bangladesh has succeeded in by a physician.9 Family welfare visitors of averting unsafe abortion. To that end, reducing deaths during pregnancy and (FWVs) and paramedics such as sub- the government needs to address barriers to widespread, safe MR services, including assistant community medical officers *The name of this survey has changed over time. women’s limited knowledge of their avail- In 2001, it was Bangladesh Maternal Health Services (SACMOs) are permitted to provide MR ser- and Mortality Survey; in 2010, it was Bangladesh ability, the reasons why facilities do not vices up to eight weeks after the LMP. The Maternal Mortality and Health Care Survey. However, provide MRs or reject women who seek one, the acronym has remained the same. predominantly female FWVs have a mini- and the often poor quality of care. Figure 1 Maternal Mortality governmental criteria and, at and morbidity in Bangladesh. least as of 2012, have been Given the size and scope of the Maternal mortality declined steadily and substantially between 1990 and 2011 in Bangladesh. primarily done using manual MR program, it makes sense to vacuum aspiration (MVA). They assess the relationship between are practiced widely throughout MRs and unsafe abortions, at 1,000 the country at allIHME levels of the both the national and division 900 health system, from primary levels. From existing data on care clinics to tertiary care maternal mortality, we also try 800 BMMS: Sisterhood Method* medical college hospitals and to determine whether MRs have 700 district hospitals. From the late contributed to maternal health BMMS: Household Deaths Method* 1970s through the mid-1990s, and survival. In addition, we 600 the government and interna- discuss new findings on barriers 500 tional donors continuouslyWHO to the provision of MR services
400 supported the recruitment and in Bangladesh. training of FWVs to perform X 300 MRs.10 Recruitment was stopped Incidence of MR in 199412 and has only recently Obtaining a current, accurate No. of maternal deaths per 100,000 live births 200 X resumed.13 Unfortunately, the picture of the incidence of MRs 100 interruption in recruiting has in Bangladesh is important but challenging. Although MRs are 0 left the program playing catch- 1990 1995 2000 2005 2010 officially authorized, efforts to up in terms of having sufficient97 systematically collect data on World Health Organization numbers of trained FWVs: As of the end of 2011, the total this service suffer from high X BMMS: Household Deaths Method* 15 BMMS: Sisterhood Method* number of health professionals levels of underreporting. Not IHME trained in MR stood at ap- surprisingly, for example, there proximately 10,600 doctors and are no records of procedures Notes: The 2001 Bangladesh Maternal Mortality Survey (BMMS) estimated maternal deaths provided outside of official using two methods, the sisterhood method and the household deaths method, and provided 7,200 paramedics, primarily a retrospective estimate for 1990 using the former. The 2010 BMMS presented estimates for FWVs (and among these, about facilities—or of those that are 2010 using the household deaths method only. Sources: World Health Organization—refer- ence 3; BMMS 2001—reference 4; BMMS 2010—reference 5; and Institute for Health Metrics 4,700 paramedics have received performed in proper facilities X 1991 and Evaluation (IHME)—1994reference 2. 2006 14 but do not conform to govern- 1993 1997 20032002 2011 refresher training). 1992 1996 1998 ment criteria regarding timing 2004 2008 2009 2007 If MRs were universally acces- 16–19 1999 or the training of personel. mum of 10 years of schooling allowing FWVs to provide MRs sible in Bangladesh, they could 2001 Moreover, the last time the and receive at least 18 months’ not only expands access to an greatly reduce the potential incidence of MRs was estimated training in reproductive and essential service but also costs need for women to have an at the national level was in child health services, includ- less; having FWVs be the back- unsafe clandestine abortion. 1995. To assess the incidence of ing training in how to perform bone of the program is a further Currently, a lot of women who these procedures as of 2010, we MRs.10 (SACMOs have similar lev- plus in a predominantly Muslim would like to get an MR face surveyed a nationally represen- els of general schooling as FWVs culture such as Bangladesh barriers to obtaining one; tative sample of 670 public and but take three years of basic where many women—and their many of them resort to unsafe private facilities and collected courses in primary care and re- husbands—feel most comfort- abortion as a result. Because incidence and related data (e.g., productive and child health ser- able when women get care from induced abortions are highly capacity to provide MR and vices.) Given the limited number other women.10 FWVs are posted legally restricted in Bangladesh, indicators of access and barriers of physicians in the country, at primary care facilities across they are often practiced clan- to provision; see Methods box). the country, particularly at destinely in unhygienic settings, Records of MRs performed by union health and family welfare performed by untrained provid- the major nongovernmental *The major NGOs in 2010 were the Re- centres (UH&FWCs). These ers, or both. By averting unsafe organizations (NGOs) involved productive Health Services Training and Education Program (RHSTEP), Associa- facilities are located primarily in abortions and their associated in the MR program* were also tion for Prevention of Septic Abortion, rural areas, where three-quarters health complications, MRs could compiled from records supplied Bangladesh (BAPSA), the Bangladesh 11 have a positive impact on Women’s Health Coalition (BWHC), the of Bangladeshis live. by their head offices. Family Planning Association of Bangla- women’s health and survival. desh (FPAB), the Urban Primary Health MR procedures, which are of- Overall, health facilities in Care Project (UPHCP), Marie Stopes ficially provided by the govern- This issue brief examines the Bangladesh and BRAC Bangladesh. Bangladesh (including NGOs) ment free of charge, are safe relationship between MR, unsafe performed an estimated 653,000 uterine evacuations that meet abortion, and maternal mortality
Menstrual Regulation in Bangladesh 2 Guttmacher Institute Methods no difference in capacity and (accounting for 46%), and other actual performance in public- public-sector facilities such as This report draws on several data sources. Data on both MRs and unsafe sector Mother and Child Welfare district hospitals, MCWCs, UHCs induced abortions were collected through a study conducted by the Association for Prevention of Septic Abortion, Bangladesh (BAPSA) and the Guttmacher Centres (MCWCs) and Upazila and medical college hospi- Institute. The study design and protocols were adapted to the specific situ- Health Complexes (UHCs), as the tals (providing another 17%). ation in Bangladesh from a widely used methodology to indirectly estimate same much-higher-than-average Twenty-eight percent of MRs are abortion incidence, the Abortion Incidence Complications Methodology obtained from NGO clinics and (AICM). The study gathered data through two main sources and a few other proportion (86–87%) were both ancillary sources, described below. capable of providing MRs and did the remaining 9% from private clinics. The proportion of all • Health Facilities Survey. We collected information on the number of MRs so in 2010. provided and the number of women treated for complications of unsafe MRs that each type of facil- abortion through a nationally representative survey of 670 public- and When we look at the specific ity provides varies widely by private-sector health facilities. Data on other variables, including qual- types of facilities, all MCWCs administrative division (six at ity of care, were also collected. The survey was fielded in May through provided the service, as did November of 2010. the time of the study but now 83% of UHCs (not shown); both seven; Table 1), likely reflect- • MR service data from NGOs. As NGO facilities account for a large number of these facility types are staffed ing variations in the availability MR procedures and, to a lesser extent, postabortion care cases, we com- by doctors, nurses and para- piled data from the head offices of all the major NGOs that provide MR or of and access to UH&FWCs and postabortion care in Bangladesh. Each provided data, at the division level, medics. However, only about the extent to which NGOs are on the number of MR procedures performed and the number of women two-thirds of UH&FWCs—small actively working to increase ac- treated for abortion complications in 2010 at all of their facilities. public clinics staffed by FWVs, cess in underserved areas. • Other data sources. We relied on data from several Bangladesh Demographic who are envisioned as the and Health Surveys, including those conducted in 1999–2000, 2007 and backbone of the MR program— Possible impact of MRs on 2011. We also used data from the 2010 Household Income and Expen- trends in abortion-related diture Survey, which provides information on household and per capita provided MRs. Once we include income, and from the 2001 and 2010 BMMS, which provide information on these clinics, the proportion of mortality maternal mortality and its causes in Bangladesh. The report also draws on all facilities providing MRs rises Given the widespread use of the existing body of prior research carried out in Bangladesh. to 57%, and among all public MRs—and the large increase sector facilities it is 66%. in the absolute numbers of procedures in recent years— MR procedures in 2010, which private-sector clinics: Only about In terms of the sources of the an important policy question translates into a rate of 18 MRs one-third of these facilities pro- country’s MRs, almost two-thirds is whether MR has helped to per 1,000 women aged 15–44 vided MRs in 2010, even though are provided by the public sec- reduce maternal mortality in years (Table 1).*20 This rate 60% have both the equipment tor (Figure 2, page 4). Making Bangladesh. We can infer the is identical to the 18 MRs per and trained staff to do so. On up this 63% are the most com- procedure’s impact on maternal 1,000 estimated in the mid- the other hand, there is virtually mon single source, UH&FWCs deaths by assessing the extent 1990s.21 The absolute number of procedures, on the other hand, Table 1 increased by 39%, largely be- MR Procedures and Where They Are Performed cause of growth in the popula- Estimated number of MR procedures, percentage distribution by type of facility, and annual MR rate, by tion of women of reproductive division, Bangladesh, 2010 age. However, different method- Division Total no. % distribution Annual MR ologies were used to estimate of MRs rate (MRs UH&FWCs Other public- Private NGOs Total incidence, so trends should be per 1,000 sector facilities* clinics women 15–44) interpreted with caution. Bangladesh 653,078 46.2 17.1 9.1 27.6 100.0 18.3 Nationwide, two-thirds (67%) of all facilities that are poten- Barisal 42,740 42.0 28.7 3.2 26.1 100.0 20.0 tial providers of MR excluding Chittagong 99,494 42.3 19.4 3.4 34.9 100.0 15.1 UH&FWCs had both functional Dhaka 223,569 42.3 13.0 14.9 29.8 100.0 20.1 MVA equipment and a staff mem- Khulna 61,833 30.4 13.3 20.8 35.4 100.0 13.7 ber trained in MVA, the procedure Rajshahi† 197,148 60.2 18.8 4.2 16.8 100.0 22.0 generally used for MR (Table 2, Sylhet 28,294 33.7 19.6 2.0 44.7 100.0 12.3 22 page 4). Yet only 48% actually *District hospitals, Mother and Child Welfare Centres (MCWCs), Upazila Health Complexes (UHCs) and all medical college hospitals, both provided MRs in 2010. Moreover, public and private. We group public and private medical college hospitals together because they are similar in terms of cost and access. †In early 2010, the eight northerly districts of Rajshahi Division (about half the population of Rajshahi) were split into a new administrative division, the gap between being able to Rangpur. Rates are presented here for the old Rajshahi Division. Notes: These data have been adjusted for underreporting by facilities; see provide MRs and actually doing methodology in reference 20. MR=menstrual regulation. UH&FWC=Union Health and Family Welfare Centre. NGO=nongovernmental organiza- tion. Source: reference 20. so is especially wide among
Guttmacher Institute 3 Menstrual Regulation in Bangladesh Table 2 MR Services and Capacity than was previously used. The clandestine abortions to MRs 2010 BMMS shows a further drop was roughly two to one in Measures of MR services and availability of MVA equipment and 1989.24 trained staff in all facilities excluding UH&FWCs, 2010. in the proportion of maternal By 2008, however, for deaths related to abortion, every clandestine abortion there 5 Measure All Private- Public-sector facilities to just 1% in 2008–2010. Of were five MRs. This important facilities sector course, given that all surveys increase in MRs relative to excluding clinics Hospitals* Other UH&FWCs facilities† of maternal mortality—and of clandestine abortions over % providing MR services 47.8 35.6 37.0 86.4 abortion-related mortality in the years is likely contribut- % having: particular—suffer from recall ing to the sustained declines Functional MVA kits 70.3 64.6 67.7 87.6 bias and high levels of under- in abortion-related maternal 3 At least one staff member reporting, these results should mortality in the same area: The trained to perform MVA 72.8 67.5 71.0 88.9 be interpreted with caution. proportion of maternal deaths Both 67.0 60.0 62.0 87.0 related to induced abortion in Despite this uncertainty, how- the comparison Matlab area fell *District hospitals and all medical college hospitals, both public and private. We group public ever, the large relative decline and private medical college hospitals together because they are similar in terms of cost and from 16% in 1986–1990 to 9% in abortion-related maternal access. †Mother and Child Welfare Centres (MCWCs) and Upazila Health Complexes (UHCs). in 2001–2005.16,25,26 Notes: Because UH&FWCs were not asked questions about capacity, they are excluded from deaths from 1978–1979 to the capacity and availability measures in this table. MR=menstrual regulation. MVA=manual vacuum aspiration. Source: reference 22. 1998–2001 is likely indicative Even if the slightly different of real change. To what extent time periods prevent us from to which it averts unsafe abor- unsafe abortion played a role in could MR have played a role? lining up the decline in tions. The available data sug- 26% of maternal deaths.23 The The 2001 BMMS notes anecdotal abortion-related mortality to gest that sustained declines in next most recent national-level evidence supporting the “dra- the increase in the ratio of abortion-related deaths were an estimates of abortion’s role in matic decline” in deaths from MRs to clandestine abortions important driver of the decline maternal mortality date from incomplete and septic abor- mentioned in the previous tion as “presumably due to the paragraph, the trends are robust in maternal mortality over the 1998–2001, the reference period expanded provision of safer and enough to show a clear impact past few decades. for the first of the country’s two more accessible MR services.”4 of MRs on declining mortality. maternal mortality studies— For example, during the 1970s Indeed, another study conducted the 2001 BMMS.4 That assess- The availability of longitudinal and 1980s, before the wide- in Matlab arrived at similar data from the well-studied Mat- spread availability of MR, ment indicated that just 5% of conclusions.27 That study cited lab area allows us to examine unsafe abortion was a major maternal deaths were related to as evidence of MR’s role in avert- trends in abortion-related mor- cause of maternal mortality induced abortion, a considerable ing abortion-related deaths the tality, albeit not at the national in Bangladesh. A 1978–1979 decline from the 26% measured paradoxical decline in the rate of level. The Matlab Demographic study conducted in nearly 800 in 1978–1979—even though abortion-related mortality even Surveillance System has been facilities throughout the country the latter study used a differ- as the ratio of abortions (defined tracking the annual numbers of found that complications from ent, less rigorous methodology as both MRs and induced abor- MRs and clandestine abortions tions) to live births increased since 1989 (with the excep- Figure 2 over roughly the same period. Distribution of MRs by Source tion of 2001) in both an area that receives enhanced family The public sector provides nearly two-thirds of all MRs. Persistence of unsafe planning services and a com- abortion parison area that does not.24 Despite the documented decline 28% These data allow us to chart the in abortion-related maternal UH&FWCs 46% relationship of MRs to clandes- mortality and a decrease in the Other public sector tine abortions over time in the most dangerous methods of facilities* comparison area, which does clandestinely inducing abortion, Private clinics 9% not receive enhanced family unsafe abortion remains wide- NGO providers planning services and thus is spread. Even if unsafe abortions the more likely of the two areas do not result in death, they can 17% to be representative (or the cause injury and suffering that Percent distribution of MRs, Bangladesh, 2010 “best estimate”10) of the country can have lifelong consequences. as a whole. Unfortunately, morbidity from *District hospitals, Mother and Child Welfare Centres (MCWCs), Upazila Health Complexes (UHCs) and all medical college hospitals, both public and private. We group public and unsafe abortion remains com- According to data for the Matlab private medical college hospitals together because they are similar in terms of cost and mon, despite the availability of access. Notes: MR=menstrual regulation. UH&FWC=Union Health and Family Welfare Centre comparison area, the ratio of NGO=nongovernmental organization. Source: reference 22.
Menstrual Regulation in Bangladesh 4 Guttmacher Institute safe MR services. As of 2010, this financial burden into per- that do have adequately trained and then directly address these Bangladeshi women risked their spective, the average monthly staff and the requisite equip- reasons. health by having clandestine per capita income in rural ment are still not offering this abortions at a rate of 18 per regions of Bangladesh is roughly government-sanctioned service. Rejection by MR providers 1,000 women each year.20 In 2,000 taka.29 Prices for clan- The persistence of such gaps Many women are unable to that same year, an estimated destine abortions are estimated greatly reduces women’s access, obtain an MR because they are 231,000 women received treat- to be even higher in urban and gaps are especially wide in turned away for one. Our study ment at a health facility for areas, with a physician-provided private-sector clinics. found that more than one- complications of unsafe abor- abortion costing 900–2,100 quarter of all clients requesting tion. Moreover, according to the taka in areas where the average The reasons behind this an MR, or 166,000 women, were perceptions of respondents to monthly per capita income is untapped potential were denied the procedure in 2010.20 our survey of health profession- 3,741 taka.29 hinted at in the responses to When facilities were asked why als in 2010 (see methodology in a supplemental question asked they rejected requests for MRs, reference 20), only about 40% Overcoming barriers to MR of UH&FWCs only. Among staff nearly all said that one of their of all women who needed treat- Why do Bangladeshi women surveyed at UH&FWCs that did reasons for doing so was because ment for abortion complications continue to unnecessarily risk not offer MR services, 43% cited women were above the maximum actually received it. This means their health and life by having a religious or social reasons for permitted weeks since their LMP that an additional 341,000 clandestine abortion when safe not doing so, 37% mentioned (Figure 3, page 6). This reason is and affordable MR procedures women developed complications that beliefs related to their understandable given regulations are available? Below we examine but did not obtain care, indicat- own health prevent them from on LMP limits. Similarly, medical some of the obstacles women ing that all told, an estimated offering the service, and 24% reasons (i.e., a client’s preexist- may encounter when trying to 572,000 Bangladeshi women simply said they do not like to ing medical condition), cited by obtain an MR. We also look at suffered complications from perform the procedure. In addi- roughly half of facilities, may be constraints within the program unsafe abortions in 2010. tion, roughly 10% each pointed understandable as well, although that may be limiting women’s to inadequate MR training, specifics are unavailable. Unfor- That MRs are relatively safe, access to, and timely use of, the insufficient MR supplies, lack tunately, several other reasons compared with unsafe abortions, service. is clear when we compare their of space and the absence of for turning away MR clients, outcomes. For example, the rate Limited provision support staff. That roughly four though cited by smaller propor- at which MR complications are One-third of facilities that in 10 FWCs—the facility type tions of facilities, are culture treated in a health facility is are potential providers of MR providing the highest percent- based and thus go beyond any just one-third that of clandes- services cannot offer them be- age of all MRs—cited “social or guidelines or requirements. tine abortion complications (2.2 cause they lack either the basic religious” reasons or personal These include a woman not yet vs. 6.5 cases treated per 1,000 equipment or trained staff, or preference for not offering MRs having any children (cited by women aged 15–44 years; Table both (Table 2). Perhaps even is an important indication of 20%) and considering a woman 3). Moreover, whereas for every more troubling, many facilities the need to better understand to be too young (by 12%). 1,000 MRs that are performed each year, roughly 120 result in Table 3 complications that are treated Treated Complications in health facilities, the compa- Measures of treated morbidity from MRs and unsafe induced abortions, by division, Bangladesh, 2010. rable ratio for clandestine abor- tions is about 360 per 1,000 Division MRs, no. of cases of complications treated Unsafe induced abortions, no. of cases of complications treated abortions. Total Per 1,000 Per 1,000 MR Total Per 1,000 Per 1,000 induced In addition to the health women 15–44 procedures women 15–44 abortions consequences of clandestine Bangladesh 78,061 2.2 120 231,367 6.5 358 abortions, their monetary costs Barisal 3,707 1.7 87 4,942 2.3 344 are also substantial. Experts interviewed in the 2010 Health Chittagong 8,742 1.3 88 29,228 4.4 369 Professionals Survey estimated Dhaka 28,087 2.5 126 60,868 5.5 299 that in rural areas, the safest Khulna 18,265 4.1 295 53,980 12.0 490 clandestine abortions—those Rajshahi* 13,932 1.6 71 65,849 7.3 334 provided by medical doctors— Sylhet 5,328 2.3 188 16,500 7.2 397 cost 500–1,100 taka.28 To put *In early 2010, the eight northerly districts of Rajshahi Division (about half the population of Rajshahi) were split into a new administrative divi- sion, Rangpur. Rates are presented here for the old Rajshahi Division. Note: MR=menstrual regulation. Sources: references 20 and 22.
Guttmacher Institute 5 Menstrual Regulation in Bangladesh Figure 3 31 MR Rejection the richest women (8–11%). bidity and mortality. Below we Furthermore, very little is known offer a few strategies to achieve Providers mainly reject women seeking MRs because of exceeded LMP limits, but many also do so for reasons outside of official requirements. regarding unmarried women’s wider use of MR. knowledge about MR; these women have the most to lose Educate women about 100 97 should they become pregnant, MR’s availability given strong taboos against Given that the MR program has been in place for three decades, 80 sex and childbearing outside of marriage.6 detailed knowledge about the service should be nearly univer- 60 The information that many sal by now. That many women 49 women do have is often inac- are unable to clearly distinguish 40 curate. Qualitative research from MR from unsafe abortion18 is the mid-1990s demonstrates indicative of the need for better 20 widespread confusion about information, especially since 20 12 the distinction between safe missing the opportunity for an 7 8 5 MR services and clandestine MR can lead directly to hav- 32 % of all public and private facilities citing reason 0 abortions. A 2012 qualitative ing an unsafe abortion, which Exceeded Medical Has not Client No consent Client Other† LMP limits* reasons had a too from not study found that, even now, presents far higher health and child young husband married many women do not understand monetary costs to women. The Reason for rejection‡ the difference between trained dangers of unsafe abortion and untrained providers,18 which need to be publicized so women *Family welfare visitors and other paramedics are allowed to provide MR services up to eight weeks after LMP, and physicians are allowed to provide MR services up to 10 weeks after LMP. is unsurprising given the wide clearly understand that an †”Other” includes client cannot afford fee, supplies unavailable, doctor is absent, doctor is not range of people providing MRs. confident in procedure, client refused post-MR contraception, client had many previous MRs authorized, safe alternative is and religious reasons. ‡Multiple responses were permitted. Notes: MR=menstrual regulation. For women who want to keep officially available and that it is LMP=last menstrual period. Source: reference 22. their MR a secret, nonmedical free of charge. Efforts to engage facility staff, including ayahs fieldworkers who are already Poor quality of care paid their provider, with the (female domestic workers), are visiting households or com- Despite the relative safety of amount averaging 44 taka.30 often a preferred option because munity clinics33 to disseminate the procedure, many MRs— Such charges—whose amounts they perform the procedure information about MR may prove 78,000 in 2010—still lead are unknown until the woman discreetly after hours in the effective, especially for reach- to complications (Table 3), arrives at a clinic—can be an facility, or in their or the ing illiterate women and those probably because of systemic important deterrent to getting woman’s home. These nonpro- who live in rural areas.34 FWVs’ flaws in MR service provision. needed services.18 In addition, fessionals use MVA but are not encouraging women who have Studies have found a number evidence suggests that illicit properly trained in the tech- already had an MR to talk about of shortcomings, including brokers prey on women who nique, so their procedures have their experience with others is improper MVA technique, lack of have been rejected for an MR to a high likelihood of complica- another potentially effective sterilization of MVA equipment, steer them, for a fee, to unof- tions, which is further increased strategy.30 unhygienic conditions, nonuse ficial providers who arbitrarily by the unhygienic settings in of pain relief during procedures set a price according to such which the procedures are often Increase availability of and use of a single MVA syringe factors as weeks since their LMP carried out. MR services more than the recommended and “adding” pain relievers to Overall, 43% of the nation’s number of times.18,19 the procedure.16 Recommendations facilities that could potentially Although much needs to be offer MR services did not provide In addition, according to a Women’s limited knowledge done to improve maternal health them in 2010. MR services need nationwide 2002 assessment of The MR program’s reach is in Bangladesh—including mak- to be made more widely avail- the government’s MR program, constrained by the extent to ing childbirth safer by increas- able, especially in facilities that unofficial payments are com- which women know about it. ing the number and proportion provide primary care and are monly made for a service that is As of 2007, nearly one-fifth of of deliveries attended by skilled most accessible to women living supposed to be free.19 Indeed, married Bangladeshi women had personnel and expanding emer- in rural communities, who likely in one of the few studies that still never heard of MR;9 this gency obstetric services—more live far from hospitals. Indeed, collected information on pay- proportion is higher among the widespread use of the existing the finding that one-third of ments for MR services (from least-educated and the poorest MR program has the potential to rural-based UH&FWCs were not the mid-1990s), one-third of women (25–26%), compared avert unsafe abortions and thus even providing the service in the women who had an MR with the most educated and further reduce maternal mor- 2010 is potentially troubling,
Menstrual Regulation in Bangladesh 6 Guttmacher Institute given the program’s emphasis Standards of patient care also side effects.18 This implies that 5. NIPORT, Bangladesh Maternal on their staff (FWVs) as essen- were shown to be weak. Hav- providers need to both facili- Mortality and Health Care Survey tial MR providers. The country ing to pay unauthorized fees tate method-switching should 2010, Summary of Key Findings and Implications, Dhaka, Bangladesh: only recently reinitiated efforts can make MRs unaffordable to women become dissatisfied with NIPORT, 2011. to recruit new FWVs.10 Because women—many of whom go on their current method and im- 6. Akhter H, Abortion in Bangladesh, many of these new recruits may to have an unsafe abortion. This prove the quality of counseling in: Sachdev P, ed., International lack confidence in their MR practice is especially egregious on consistent and correct use. Handbook on Abortion, New York: skills, on-site mentoring could given that MR is supposed to be In addition, as part of com- Greenwood Press, 1988. be combined with supportive a free government service. Other prehensive reproductive health 7. Penal Code, 1860, as adopted by supervision to expand the aspects of poor care include care, contraceptive methods and the Bangladesh Laws Revision and number of competent provid- inadequate pain relief, lack of counseling should be offered Declaration Act of 1973. ers of the procedure. Improved privacy and being subjected to to women when they come 8. Government of the People’s availability of MRs not only providers’ judgmental and puni- into the system for postpartum Republic of Bangladesh, Memo No. 5-14/MCH-FP/Trg.79, Dhaka, would benefit women’s health, tive attitudes. To avoid these visits, postabortion care and MR Bangladesh: Population Control and but also would save money: In resolvable problems, increased services. Family Planning Division, 1979. 2008, the hospital per-case cost supervision is needed along The better able Bangladeshi 9. NIPORT, Mitra and Associates and of providing an MR was 27–40% with improved basic training women are to avoid unintended Macro International, Bangladesh of the hospital cost of treating and repeat refresher training. Demographic and Health Survey, pregnancy and the need to moderate abortion complica- Much of the inappropriate pro- 2007, Dhaka, Bangladesh: NIPORT resort to unsafe abortion, the tions, and 13% of the hospital vider behavior and poor clinical and Mitra and Associates; and lower the burden of abortion- Calverton, MD, USA: Macro per-case cost of treating severe practices could be addressed related maternal illness and International, 2009. abortion complications.17 if the MR guidelines currently death. Making safe MRs more 10. Johnston H et al., Scaled up and being developed by the govern- widely accessible will further marginalized: a review of Bangladesh’s Improve the quality of ment36 were to be finalized and menstrual regulation programme and reduce complications related MR care broadly implemented. its impact, in: Blas E, Sommerfeld J The level of complications from to unsafe MRs and avert unsafe and Karup A, eds., Social Determinants MR procedures suggests a great Conclusions abortions and their negative Approaches to Public Health: From need to improve their safety. Of course, the most direct way impact on women’s health. Concept to Practice, Geneva: WHO, 2011, pp. 9–24. One avenue currently being to safeguard women’s health studied is to offer MR performed and lower the number of unsafe References 11. Department of Economic and Social Affairs, United Nations, World with medication (mifepris- 1. United Nations, 2015 Millennium abortions is to prevent unin- Urbanization Prospects, the 2011 tone plus misoprostol), which tended pregnancies. Bangladesh Development Goals: a gateway to the UN system’s work on the MDGs, revision, no date,
Guttmacher Institute 7 Menstrual Regulation in Bangladesh (BAPSA), M.R. training and services Bangladesh: a 30-year cohort study, 37. NIPORT, Mitra and Associates, status, M.R. Newsletter: Working Lancet, 2007, 370(9595):1320– and ORC Macro, Bangladesh Together to Improve Women’s Lives, 1328. Demographic and Health Survey, Dhaka, Bangladesh: BAPSA, Twenty- 26. Chowdhury ME et al., Causes of 1999–2000, Dhaka, Bangladesh: first year, No. 2, 2005, p. 3. maternal mortality decline in Matlab, NIPORT and Mitra and Associates; 16. Oliveras E et al., Situation Bangladesh, Journal of Health, and Calverton, MD, USA: ORC Macro, Analysis of Unsafe Abortion and Population and Nutrition, 2009, 2001. Menstrual Regulation in Bangladesh, 27(2):108–123. Dhaka, Bangladesh: International 27. ICDDR,B, Increasing levels of Centre for Diarrhoeal Disease abortion and decreasing abortion- CREDITS Research, Bangladesh (ICDDR,B), related mortality, Health and Science This In Brief was written by Altaf 2008. Bulletin, 2007, 9(2):1–6. Hossain, Association for Preven- 17. Johnston H et al., Health 28. Unpublished data from the tion of Septic Abortion, Bangladesh system costs of menstrual Health Professionals Survey, (BAPSA); Isaac Maddow-Zimet regulation and care for abortion Bangladesh, 2010. and Susheela Singh, both of the complications in Bangladesh, Guttmacher Institute; and Lisa International Perspectives on Sexual 29. Bangladesh Bureau of Statistics Remez, independent consultant. and Reproductive Health, 2010, (BBS), Report of the Household It was edited by Susan London, 36(4):197–204. Income and Expenditure Survey, independent consultant. The authors 2010, Dhaka, Bangladesh: BBS, are grateful for comments on drafts 18. Hashemi A, Rashid S and 2012. Rashid M, Where do women go and provided by Saifuddin Ahmed, Johns why? Understanding the barriers 30. Akhter H et al., A Study Hopkins Bloomberg School of Public to safe MR services in Bangladesh, to Assess the Determinants and Health; Ahmed Al-Sabir, freelance unpublished manuscript, Dhaka, Consequences of Abortion in consultant and former director of Bangladesh: James P. Grant School Bangladesh, Dhaka, Bangladesh: research, NIPORT; Ferdousi Begum, of Public Health, BRAC University, Development Assistance Council Associate Professor of Obstetrics and 2012. and Bangladesh Institute of Gynecology and former secretary Research for Promotion of Essential general, Obstetrical and Gynaecologi- 19. Chowdhury SN and Moni & Reproductive Health and cal Society of Bangladesh; Halida D, A situation analysis of the Technologies (BIRPERHT), 1998. Hanum Akhter and Elizabeth Oliveras, menstrual regulation programme both at Pathfinder International; 31. Special tabulations of data from in Bangladesh, Reproductive Mohammed Sharif, Director, Maternal the 2007 Bangladesh Demographic Health Matters, 2004, 12(24 and Child Health Services and Line and Health Survey. Suppl.):95–104. Director, Maternal, Child, Reproduc- Association for Prevention of 32. Caldwell B et al., Pregnancy tive and Adolescent Health (MCRAH); 20. Singh S et al., The incidence Septic Abortion, Bangladesh of menstrual regulation procedures termination in a rural subdistrict Heidi Bart Johnston, Swiss Tropical of Bangladesh: a microstudy, and Public Health Institute and and abortion in Bangladesh, House #71, Block–C International Family Planning University of Basel; Reena Yasmin, International Perspectives on Sexual Avenue–5, Section–6 Perspectives, 1999, 25(1):34–37 Marie Stopes Bangladesh; and Laura and Reproductive Health, 2012 Mirpur, Dhaka–1216 (forthcoming). & 43. Reichenbach, ICDDR,B. The authors acknowledge the contributions of Bangladesh 21. Singh S et al., Estimating the 33. NIPORT, Mitra and Associates, Hadayeat Ullah Bhuiyan, BAPSA, and [email protected] level of abortion in the Philippines and Measure DHS, ICF International, the following Guttmacher colleagues: and Bangladesh, International Bangladesh Demographic and Health Patricia Donovan, Rubina Hussain, Family Planning Perspectives, 1997, Survey, 2011: Preliminary Report, Gustavo Suárez and Michael Vlassoff. 23(3):100–107 & 144. Dhaka, Bangladesh: NIPORT and Mitra and Associates; and Calverton, This publication was supported by 22. Unpublished data from the MD, USA: Measure DHS, 2012. grants from the Dutch Ministry of Health Facilities Survey, Bangladesh, Foreign Affairs and the UK Depart- 2010. 34. Islam M, Rob U and Chakraborty ment for International Development. N, Menstrual regulation practices 23. Rochat RW et al., Maternal in Bangladesh: an unrecognized Suggested citation: Hossain A et al., and abortion related deaths form of contraception, Asia-Pacific Menstrual regulation, unsafe abortion in Bangladesh, 1978–1979, Population Journal, 2004, 19(4): and maternal health in Bangladesh, International Journal of Gynaecology 75–99. In Brief, New York: Guttmacher Advancing sexual and & Obstetrics, 1981, 19(2):155–164. Institute, 2012, No. 3. 35. ICDDR,B and Maternal Health reproductive health worldwide 24. DaVanzo J and Rahman M, Safe through research, policy analysis Task Force, Menstrual Regulation © Guttmacher Institute, 2012 vs. unsafe pregnancy termination Using Medication Is Acceptable and public education in Matlab Bangladesh: trends and and Feasible in NGO Settings in correlates, paper presented at the Bangladesh, Dhaka, Bangladesh: annual meeting of the Population 125 Maiden Lane Center for Reproductive Health, New York, NY 10038, USA Association of America, San 2011. Francisco, CA, USA, May 3–5, 2012. Tel: 212.248.1111 36. Bhuiyan HU, BAPSA, [email protected] 25. Chowdhury ME et al., Dhaka, Bangladesh, personal Determinants of reduction in communication, July 13, 2012. www.guttmacher.org maternal mortality in Matlab,
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