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.