Challenges and barriers in accessing Menstrual Regulation services in Bangladesh
By Raafat Hassan, Farzana Islam, Mohammad Riaz Hossain, Sushama Kanan, Malabika Sarker, Sabina Faiz Rashid
Being pregnant is a happy and welcome experience for many women. Yet some women may have to decide to discontinue their pregnancy at some point because of economic factors, health issues, or the need to maintain one’s dignity in within our gendered society.
Terminating a pregnancy is a critical process and an essential maternal health issue as well as a sexual and reproductive right. This process requires trained health professionals and facilities with appropriate equipment for providing a quality service. Lack of these facilities can lead to a woman encountering health related complications which can turn to life threatening hazards.
The REACHOUT Bangladesh team is working towards strengthening the capacity of close-to-community (CTC) providers to enable a strong referral network to ensure women have easy access to safe Menstrual Regulation (MR) services at local health facilities.
MR has been a fundamental part of the family planning programme in Bangladesh since 1979. A range of MR service providers co-exist in Bangladesh. Government and NGOs have made the services available even at the union level facilities and in urban slums; still there are several barriers to building a strong referral network for women so they can access safe MR services.
In 2014, almost half of all pregnancies were unplanned and almost three-fifths of those pregnancies ended through MR and unsafe abortion. Unsafe MR services from clandestine operators can create complications such as hemorrhage, incomplete abortion, shock, uterine perforation, and sepsis.
MR is still stigmatized as a matter of shame and sin, and frowned upon in society. Some even consider it an act against god. A CTC provider who used to refer MR clients to a nearby local facility had stopped referring clients because of her religious beliefs. She said:
“…I do not refer MR clients anymore, because it is a sin and I don’t want to be associated with any of it.”
This kind of belief in society is one of the major reasons behind maintaining secrecy. Women who visit a facility for MR raise a lot of questions within her family and community. Visiting a clandestine provider is seen to safeguard confidentiality.
Older women can be stigmatized for being sexually active. A 43-year-old client who had taken MR services mentioned:
“…I got pregnant in this age. I was very ashamed and could not tell anyone. My elder daughter scolded me for being so careless.”
Women in Bangladesh do not always have the authority to make decisions regarding getting pregnant and pregnancy continuation or termination, because many women in Bangladesh are not socially, culturally, or economically empowered. Women have to depend on their husbands and families for the permission about the decision to seek MR services; and are usually forced to act according to the wishes of others. One 17-year-old client who had taken MR services mentioned:
“…I had to terminate the pregnancy because my mother-in-law told me that it might get suspicious if I get pregnant so early after the wedding.”
In fact, some of the clients did not even tell their husbands about using MR services; because they might be forced to continue with the pregnancy. One client said:
“…My husband lied to me about having vasectomy and told me not to take any precautions as he wanted me to get pregnant. He wants me to get pregnant only because I go outside for work and he suspects men can be interested about me. That is why when I was pregnant I did not tell him and had the pregnancy terminated.”
Clients are also being persuaded by brokers/dalals to use untrained clandestine providers. These brokers/dalals disregard the risks and consequences of their client’s health; they only serve their own financial interests.
In 2014 the government made some policy changes to improve the quality of MR services and to make the access easier. In addition, the government approved ‘mifepristone’ and ‘misoprostol’ known as MRM (MR with medicine). The recent availability of over the counter MR medication in local pharmacies has made it easier for women to access MR services and creates an opportunity for women to maintain secrecy and allow them to take the pregnancy termination decision on their own. Therefore, women prefer having MRM at home rather than visiting facilities to have MR services. However, due to information gaps and lack of proper instructions for administration of the medicines, sometimes women face further health complications such as hemorrhage, incomplete abortion, shock, uterine perforation and sepsis. One of the Clinic Managers mentioned:
“…Nowadays, we receive Post Abortion Care (PAC) clients more than regular MR clients. Because nowadays women tend to perform MR at home using medicines. As most of the time, they do not follow the proper instructions, they face complications like hemorrhage and terrible stomach pains because of incomplete pregnancy termination. Therefore, they come to us for PAC.”
The drug sellers who sell these medicines cannot always provide proper guidance/instructions. There have been several cases where clients were taken to hospitals/clinics because of complications. A local drug seller who had stopped selling MR medicines for this reason explained:
“…I have stopped selling MR medicines. Because one of my customers had a massive hemorrhage. Afterwards, her husband came and blamed me for it. Finally, she had to be taken to Sohorwardi Hospital (A public hospital in Bangladesh).”
Besides these, there are also other barriers in access to MR services, such as the high cost, a general lack of information regarding available services, and distances to facilities. Moreover, there are provider-related constraints as well; such as inadequate training of providers, staff turnover and logistical insufficiency.
In Bangladesh, both the public and private sectors should take necessary steps to address these barriers. Extensive awareness building outreach activities on safe MR services at the community level will help to reduce the social stigma and sensitivity around it gradually. Regular follow up with the clients as part of the outreach programs by the CTC providers can also make clients more aware of the role and impact of clandestine operators and their brokers/dalals. Moreover, focused and informative outreach activities about the complications of improper administration of ‘over the counter MRM’ medicines are necessary to reduce complications. Building a strong referral network and dissemination of proper information will gradually allow women to have their own voice in the decision making process regarding pregnancy termination and access safe MR services.
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This project is funded by the European Union.