CONTRIBUTORS
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Noushin Islam
Introduction
Unsafe clandestine abortion persists in Bangladesh. In 2010 in Bangladesh, 646,600 induced abortions were performed (Singh et al., 2012) where 572,000 were unsafe abortions that led to complications; among those two-third were not treated at the health facilities. In the same year, 43% of the facilities did not offer and one-third of rural health care facilities did not provide the Menstrual Regulation (MR) service (Hossain et al., 2012).
In Bangladesh in 2010, for an annual rate of 18 abortions per 1,000 women aged 15–44. The treatment rate for MR complications was 53% higher in 2010 than in 1995 (1.1 vs 0.7 women per 1000) while that for abortion complications rose by 59% (4.3 vs 2.7) (Singh et al 2012). The overall rate if treatment for induced abortion complications was quite high in 2010: An estimated 6.5 women per 1000 aged 15-44 were treated each year, a rate comparable with those in a number of other developing countries where abortion is highly legally restricted and MR services do not exist. 13% of overall maternal mortality in Bangladesh is due to these unsafe abortion practices[1]. It is estimated that 25% of all clients presenting themselves at the MR clinics are refused services for various reasons, consequently pushing these women to resort to illegal and unsafe back-alley abortion clinics (Singh et al., 1997). However, this is a minimum estimate because some women in this situation would not have obtained treatment. This rate is much higher than that found when the procedure is performed by trained personal in hygiene settings and is an indicator of the extent to which unsafe MR is taking place (Singh et al 2012). Thus it is important to address the existing MR/abortion policy gaps regarding service provisions.
Background
Abortion is illegal in Bangladesh except to save a woman’s life. Despite the legal restrictions on abortion, menstrual regulation, or the evacuation of the uterus of a woman at risk of being pregnant to ensure a state of non-pregnancy, is sanctioned by the government and provided by public sector clinicians at all levels of the healthcare system. These uterine evacuation services are offered under the Bangladesh Menstrual Regulation (MR) program and succeed in providing women much needed care.
The MR program was sanctioned by the Bangladeshi government in 1979 and evolved as part of the country’s population program as part of the family planning method. Today the focus of the program has been incorporated within a reproductive health and rights agenda and provides services through a nationwide primary care level program.2 Since the 1970s, paramedics, called Family Welfare Visitors (FWVs), have been trained in MR service delivery and play an important role in communities, particularly in areas with few qualified physicians. FWVs are now central to the success of the MR program. The MR Program is designed to make MR services available throughout the country through public and some NGO and private-sector health facilities. FWVs are the main providers of MR at approximately 4,770 Health and Family Welfare Centres (HFWCs) at the union level, 402 Upazila Health Complexes, and 87 Maternal and Child Welfare Centres (MCWCs).2 NGOs, including BAPSA, BRAC, BWHC, FPAB, MSCS, and RHSTEP also offer MR services, particularly in urban areas where the government facilities do not operate.
Source: Singh et al., 2012
Problem description
Socio-cultural, religious and economic factors are strong determinants for abortion related policy; ‘time limits’ on terminating pregnancy and practices related to that are the major contributing factors for unsafe abortion in Bangladesh. Strong ‘patriarchal biases’ encourage women to handle abortion related matter with top secrecy. Women perceive abortion as ‘illegal’, ‘sinful’, ‘guilt’ and ‘shameful’. The unmarried, widowed and separated women are subjected to social exclusion for pregnancy and abortion. Health system factors like poor training of providers, inadequate supplies, high cost (including transport, under the table payment), lack of privacy and substandard quality of care also contribute to resort to unsafe care from unqualified traditional abortionists who often use harmful and dangerous methods. In Bangladesh, adolescent girls and women likely have little decision-making power within families that also deter use of safe abortion care services from formal health sector.
Unique laws and service provision do not necessarily translate into safer MR/abortion choices and service utilization from a formal health MR/abortion health care providers. Socio-cultural and religious factors along with health systems’ constraints can create formidable barriers in service utilization. Interventions needed on knowledge awareness programs regarding time limits for MR procedure ; service cost related information ; monitoring of quality of MR service both public and private facilities, monitoring of record keeping system in MR and post abortion care needed.
Solution
Women who are living in Bangladesh should have access to affordable quality of MR/abortion care service by 2015.
Revising the existing MR/abortion service provision so safe abortion sometimes not accessible because of additional requirement of spousal consent or laws that restrict the gestational time (>10 weeks experience refusal from formal service providers) for MR/abortion.
Need to develop a fixed MR/abortion service charge document for the MR/abortion service recipients and distribute in both public and private facilities. This should monitor regularly through public-private partnership approach.
Argument 1
In Bangladesh, early marriage and childbearing has led to an adolescent fertility rate that is among the highest in the world. The average age of marriage for girls is 14-15 years and 1 in 5 births to girls aged 15-19 years were unintended, with the overwhelming majority of these unintended births being mistimed (wanted later) rather than being unwanted (not wanted at all)[2]. 14.1% of currently married girls aged 15-19 years have an unmet need for contraception, and 3 out of 4 girls in the same age group know of MR services, while only 1.3% has ever used them. Adolescent girls are vulnerable in regards to their age, knowledge of MR/abortion service, decision making power, lack of autonomy and stigma associated with safe MR/abortion care in Bangladesh.
Argument 2
In the existence policy if a woman wants to abort her child, the service providers asked for the consent from the guardian or from her husband. Why women are asked for consent from a guardian or husband for the MR/abortion procedure if she is <18 years old?
Argument 3
Lack of dialogues has been conducted on the exiting MR/abortion policy. Existing data suggest that there has been very little policy dialogue regarding MR and abortions which could have had huge impact in designing relevant policies. These works revealed two significant reasons behind scant policy dialogue: 1) there is unwillingness to discuss reproductive matters in public (stigma/shame) and giving women reproductive freedom is thought to promote promiscuity, and 2) perceived conservatism (WHO/UNFPA/UNICEF/World Bank, 2003).
Policy recommendations:
Revised MR/abortion service provision policy (remove 6-10 weeks gestational time limit and spousal consent) and develop revised guideline to distribute in the registered MR/abortion facilities for better and extended service.
Develop a fixed MR/abortion service charge (equitable and affordable) document for the MR/abortion service recipients that will be application both public and private facilities.
Build formal partnership among public-private MR/abortion service providers and mass media to change the MR/abortion care seeking pattern through KAP approach.
Call to action
Health Minister will coordinate and collaborate with Line Director of Family Planning (national level) under the Ministry of Health and Family Welfare, district level Family planning personal (Director of FP), international donors, ministry of finance, media and communication wing under the Ministry of Family Planning, leading NGOs representatives, civil society representatives, Lawyers and Religious leaders through research Institution.
Health Minister will coordinate and collaborate with Line Director of Family Planning (national level) under the Ministry of Health and Family Welfare, international donors, leading NGO representatives, quality control and service monitoring regulatory team and research institution.
Line Director of Family Planning (national level) under the Ministry of Health and Family Welfare regulatory team for monitoring the service charge periodically and local mass media, international donors, ministry of finance, media and communication wing under the Ministry of Family Planning, leading NGOs representatives, civil society representatives, community and religious leaders through research Institutions.
By Noushin Islam, Research Investigator at icddr,b-Bangladesh