By Ilias Mahmud, Sabina Faiz Rashid, Kate Hawkins, Sally Theobald, Rifat Mahfuza, Sadia Chowdhury, Malabika Sarker

The liberation war in Bangladesh ended in December 1971. It has left many legacies, one of which is the provision of Menstrual Regulation services. Some health systems researchers have described the post-conflict moment as a ‘window of opportunity’ when policy makers and practitioners have space within the flux of change to do things differently. In the aftermath of war in Bangladesh many women were pregnant due to rape by war perpetrators. Menstrual Regulation was a medically reliable, politically expedient, culturally acceptable, morally correct, and humane response to this. Menstrual Regulation is essentially the termination of pregnancy of up to 12 weeks gestation sometimes through Menstrual Regulation Medication (misoprostol) or manual vacuum aspiration.

Menstrual Regulation services continue in Bangladesh, providing legal pregnancy termination services, while abortion continues to remain illegal.Nowadays many different women access Menstrual Regulation services. However, younger, married women are more visible because of stigma related to non-normative sexualities (e.g. women who have extra-marital sex; sexually active single women, young working women, divorcees and widows; and older women who continue to have sex past an age deemed appropriate by mainstream society). While access to services is available, the care pathway to these services is by no means straightforward and is mediated by a number of formal and informal health systems actors. Within REACHOUT we have been exploring the role or close-to-community health service providers in improving access to Menstrual Regulation services and using quality improvement methods to see how they could be better supported in this role.

Accessing Menstrual Regulation services: Opportunities and challenges

Bangladesh has a famously complex and plural health system with a range of paid, unpaid, public, private, formal and informal providers – many of whom cross these categories from time to time. As in many other low- and middle-income countries there is also growing urbanisation in Bangladesh. Through acontext analysis in Sylhet and Dhaka and quality improvement process with Marie Stopes and RHSTEP clinics in Dhaka we have gathered useful insights into how access services could be improved.

Women’s choice of health provider is mediated by: availability, accessibility, expenses and perceived quality of care, the latter being shaped by notions of trust, respect, privacy and familiarity. In our study informal providers are usually the first point of contact even for those clients who subsequently access sexual and reproductive health services from formal providers. Despite existing informal interactions between both types of providers and a shared understanding that this can be beneficial for clients, there is no effective link or partnership between these providers for referral, coordination and communication regarding sexual and reproductive health services.

Motivating close-to-community providers, most of whom work for low or no pay, is a perennial problem in many settings. In our study close-to-community providers related that they were motivated by acknowledgement from the community and appreciation from within their organization, their supervisors and bosses. Of course, salary was also a motivating factor. Some said that they felt like ‘invisible men and women’ and there is a perception that if they weren’t there the client would still come to the clinic. This is very hurtful. One of the interventions that we are trialing on our quality improvement cycle is a referral card which ensures that there is documentary proof that someone has been referred and supervisors can see the effort that has been expended on encouraging take up. We are currently analyzing the impact of this.

Close-to-community providers also benefit from supportive supervision in the workplace – as most of us do. We have been working through our quality improvement approach to improve this management relationship and build the skills of supervisors.

So what?

The research that we have done so far has shown that training informal close-to-community providers and developing strategies to enable better links and coordination between this community-embedded cadre and the formal health sector has the potential to reduce service cost and improve availability of quality sexual and reproductive health (and other) care at the community level.

Building these links and better coordination requires evidence – which health systems researchers are ideally placed to gather. We are working with neglected health workers within the system who are laboring on an issue which is profit based, blurred between private and public, contested and tricky. These close-to-community providers require your support. So, as we head towards International Women’s Day we would like to invite further enquiry into this area and that sexual and reproductive health experts and their counterparts in health systems better collaborate for women’s health.

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