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Paper for the conference "Expanding Access: Advancing the Roles of Midlevel Providers in Menstrual Regulation and Elective Abortion Care" Midlevel Provider in menstrual regulation, Bangladesh experience
Paper for the conference "Expanding Access: Advancing the Roles of Midlevel Providers in Menstrual Regulation and Elective Abortion Care"
Midlevel Provider in menstrual regulation, Bangladesh experience
Halida Hanum Akhter
Director, BIRPERHT, Bangladesh
The maternal mortality rate of 420 per 100,000 live births (BBS, 1997) is a major concern. This high rate is a result of poor availability of obstetric servicesas well as low utilisation of pregnancy related services and over all due to a general lack of access to information. About one quarter of these maternal deaths are due to complications of unsafe abortion. The low status of women is a major determining factor for the high mortality and morbidity burden women face.
Table 1: selected population characteristics
Abortion incidence in Bangladesh
The menstrual regulation procedure can be performed, within six weeks of gestation, on an out-patient basis, by a trained paramedic. Menstrual Regulation by vacuum aspiration is not regulated by the code and is considered to be "an interim method for establishing non pregnancy"(Akhter, 1988). Table 2 presents the incidence of abortion or MR procedures nationally. The rates derived form various sources shown below the table.
Table 2: National incidence of abortion /MR in Bangladesh
Source (for1975-1988 data came from: provider registration ): The Population Policy data Bank maintained by the Population Division of the Department of International Economic and social Affairs of the United Nations secretariat, in Abortion Policies: A global Review, Vol. 1, Afganistan to France, United Nations New York, 1992
*World abortion policies 1999, UN population division , department of economic and social affairs
**Singh et al 1997
MR is allowed up to 8 weeks by a paramedic and up to 10 week by a physician. However,the providers sometimes perform the procedures beyond the allowable duration of gestation (BAPSA, 1996).
Each year about 2.8% of all pregnancies undergo MR and about 1.5% undergo induced abortion. A significant number are conducted in public facilities, but under unsafe conditions (HPSP, PIP,1998).In Bangladesh 71,800 women are hospitalised each year due to complications from unsafe procedures and this rate is 2.8 per thousand women of 15- 44 years (Singh,1997).
Accurate estimates of the annual number of MR procedures performed in the country are not available. This may be primarily due to the tendency of MR performers to under-report the performance, as they also perform, in their private practice. Estimates of induced procedures based on the interviews with the practitioners are in the range of 400,000-500,000 (Singh, 1998). The number of MRs officially reported to the Directorate of Family Planning is approximately 120,000 in 1998-99. But MRs are also performed privately by doctors, female paramedics (FWVs) , by other medical personnel and such others as unauthorized or unskilled providers including indigenous practitioners without formal training .
About 12,000 doctors and paramedics have received formal training in MR(BAPSA, 1996, Begum,1987 ), however, and due to availability of MR procedures the rate of hospitalisation due to complications and side effects have been reduced over time(Begum, 1991), unsafe termination of pregnancies continues to occur due to inadequately trained personnel and inadequate logistic support. In addition, many women do not know of a provider or are not aware of time limits.
Access to legal MR services is also poorer in rural areas than urban areas (Begum,1984). In spite of the restricted abortion law, through the delivery of menstrual regulation (MR) services, many women in Bangladesh have nevertheless enjoyed access to a way to avoid unwanted pregnancies(BAPSA , MR 1996 newsletter.
Laws and Policies
The policy also proposed Menstrual Regulation by a qualified medical practitioner within 12 weeks of pregnancy would not be punishable, provided that the woman, with the consent of her husband or legal guardian, voluntarily submits for the procedure for socio-economic or medical reasons.
For the purposes of the law, socio-economic reasons would include unintentional pregnancy, rape, desertion by husband or extreme penury. Medical reasons would include risk of life or grave danger to the physical and mental health of the women or risk that the child be born with congenital abnormality.
Introduction of Menstrual Regulation (MR)
The Bangladesh government’s Population Control and Family Planning Division (PCFPD) circular states that MR is included in the official policy and that a necessary logistic support for MR services and training will be provided by the Division.(i) It permits that MR can be performed by an MR-trained registered medical practitioner and by an FWV who has specific training in MR.(ii) It also specifies that an FWV should perform MR only up to eight weeks from the last menstrual period, that is, four weeks from the missed menstrual period under supervision of a physician. (iii) Any case with a longer duration must be referred to a trained doctor. In many government-supported clinics the procedure is performed by paramedics.
The Health and Population Sectoral Program (HPSP) for 1998 to 2003 has included menstrual regulation and unsafe abortion as one of the components of the reproductive health care package. Population Sector Program (HPSP) 1998-2003 of Ministry of Health and Family Welfare in its National Program Implementation Plan (PIP) has included one paragraph "Menstrual Regulation (MR) and Unsafe Abortion" as one of its Reproductive Health Care Package. As its component the reproductive health care package contains: Safe Motherhood, Family Planning, Prevention and Control of RTI/STD/AIDS, Maternal Nutrition, Menstrual Regulation and Unsafe Abortion, Adolescent care, Infertility and Neonatal care.
‘Safe abortion services’ is included as one of the interventions to reduce infertility. The HPSP document (1998-2003) incorporates the following articulation to incorporate issues of Menstrual regulation and unsafe abortion: "Menstrual Regulation (MR) and Unsafe Abortion: Existing information suggests that each year about 2.8% of all pregnancies undergo MR and about 1.5% undergoes induced abortion. A significant amount of these are conducted in the public facilities, but under unsafe conditions.
Although significant number of doctors and paramedics (about 12,000) received formal training in MR, and rate of complications and side effects have been reduced over time, still unsafe termination of pregnancies mostly occurs due to inadequate trained personnel and logistic support. In addition many women do not know of a provider or are not aware of time limits and access to legal MR services is poorer in rural areas than urban areas. These also contributed to the factors related to unsafe abortion and MR causing avoidable morbidity and mortality.
Adequate training and supplies has been ensured to minimise unsafe abortion or MR. MR activities will also play an important role in lowering the number of septic abortions with low complication rate and thus reducing morbidity and mortality due to illegal abortion." (HPSP PIP 1998).
Table 3: Existing infrastructure: Location of Family Welfare Visitor
The table 3 shows the infrastructure for the delivery of health and family planning services which have been developed over three Decades. Maternal health services are provided at community and facility levels through a network of domiciliary field workers, `satellite’ clinics, health clinics and hospitals.
At community level, female family welfare assistants (FWAs), provide mostly domiciliary family planning services and some maternal health care to household level women in the villages. male health assistants (HAs) also provide domiciliary services, including distribution of vitamin A capsules, immunization, detection of malaria, and prevention and treatment of diarroheal diseases, among others. The FWVs and male health assistants having ten years’ education are recruited locally . The population served by each FWA and HA is approximately 5,000-6,000.
Family welfare visitors (FWVs) mostly are based at the union level and twice a week organize satellite clinics to provide antenatal care, immunization and family planning services to a cluster of villages covering ninety-one percent of the women as they live in communities where a satellite clinic is available.
Midlevel providers, their training and services
The FWVs are an important provider of MR services both in government facilities and in their private capacity, especially in the rural areas. The FWVs have at least ten years of formal schooling prior to their 18-month course in family planning and MCH. They learn to insert IUDs during their course. MR techniques are taught through additional training in fresher and refresher courses.
At present several programs, including one government and several non-government, provide training to the government health personnel (doctors and FWVs) on the MR procedure. he MR training and service organisations use three standardised training protocol and curricula: first time training for doctors, first time training for FWVs, and refresher training for FWVs.
To be certified, every doctor trainee has to perform at least 20 MR cases independently and counsel 20 clients, every new FWV trainee has to perform at least 25 MR cases independently and counsel 25 clients and every refresher FWV trainee has to perform ten MR cases independently and counsel ten clients. ( There is no specific interval when FWV must obtain a refreshers course. It depended in the past on the availability of funds to the organization responsible for arranging the refreshers training.)
MR training covers counselling and infection prevention. Films on contraceptives and menstrual regulation are shown during training. A lecture on safety and comfort is included in the curriculum.
In addition to MR services, most trained FWVs provide counselling and follow up to their clients although some FWVs are found not to provide MR services because of their personal reasons. FWVs are posted in almost all rural health centers including Thana Health Complexes (460) and all the Family Welfare Centres (4500) each of which services a population of 20,000 and 25,000. Given their roles nd privileges the FWVs are vital in minimising the rate of rejection, because they come in contact not only with the women demanding clinical services but also with others who visit the satellite clinics.
Menstrual Regulation in the Public and Private Sectors
The government provides considerable support in the form of clinic space, salaries, and equipment for MR training and services. Until 1983, external funds were available from USAID, the Pathfinder Fund, and the Population Crisis Committee. In 1983-84 almost all non-government programs supported by USAID stopped providing MR services due to the U.S. government stance on abortion.
Table 4 Providers of abortion services and training background
Source:FWV training manual and MR training manual used by FWV training institute and MRTSPs.
Table 5. Organization of abortion care
Utilization of MR services: unmet need
The target population are reached mostly by the word of mouth communication through the MCH-FP field workers, primarily the Family Welfare Assistants (FWAs). The FWAs are supposed to visit each household and educate the eligible women on MCH-FP. FWAs are working as a regular staff for every 800 couples in the country where there are a total of about 23,500 FWAs.
In spite of the restricted abortion law, through the delivery of menstrual regulation(MR) services, many women in Bangladesh have nevertheless enjoyed access to a way to avoid unwanted pregnancies. Although about 14500 doctors and paramedics have received formal training in MR, and the rate of complications and side effects have been reduced over time, unsafe termination of pregnancies continues to occur due to inadequately trained personnel and inadequate logistic support. In addition, many women do not know of a provider or are not aware of time limits. Access to legal MR services is also poorer in rural areas than urban areas
Government support for midlevel provider of MR
An Important justification of the provision of menstrual as a public health measure has been high rates of hospitalisation due to complication of induced abortion and the high levels of maternal mortality resulting from septic abortion. A substantial proportion of admissions to gynaecology units of large hospitals are due to complications of illegally induced abortion. It has been estimated that about 15.4% of maternal deaths are due to unsafe abortion (Fauveau,1989).
The MR programme involving the paramedics encountered virtually no resistance from physians or their professional societies. The MR programme was located in the family planning division of the Ministry of Health and these paramedics belonged to the same division while the the Health Division mostly concentrated on curative health services in addition to providing primary health care. The female paramedics involved initially were family planning paramedics named Lady Family Planning Visitors (LFPV). Their name was later changed to FWVs and they were given additional midwifery training.
Several studies were conducted in Matlab and other clinics to compare the performance of MR by paramedics and physicians concluded that Female paramedics can provide MR services as safely as physicians if they are properly trained(Akhter,1982).It was also found that with the provision of appropriate medical supervision and back up they can perform MRs on women with somewhat higher gestations than allowed seven weeks (Bhatia,1980).
There were basically no oppositions from the obstetricians and gynaecologists to this govt strategy. Rather there were referrals of MR cases from the obstetricians and gynaecologists to the MR centres. The specialists who were at that time performing abortions in their private practice were doing it through D&C, and not by MVA technique. so, they were rather happy to have the paramedics perform MR ( personal opinion) and some of them were leading organizations where paramedics were predominantly responsible for performing MR procedures.
In about 1974, experts involved in the development of manual vacuum aspiration (MVA) with a plastic cannula came to Bangladesh under the auspices of the US Agency for International Development. The experts delivered lectures and practically demonstrated the use of MVA at the clinic.
Table 6 : Midlevel provider; their scope of abortion practice
Utilisation of MR services and lack of knowledge
In spite of the widespread availability of MR services, utilisation of MR basically remains low, especially among high parity, less educated rural woman. There could be a number of reasons. Firstly, MR is not well publicised. Women learn about MR services mainly through word of mouth communication, through the family planning field workers, FWAs, traditional birth attendants (TBAs) and through other women. The FWAs are a particularly important source of information. They visit households and educate women on mother and child health and family planning. One FWA covers about 800 households, and there are a about 23,500 FWAs in the country.
A second reason for under-utilisation is that women are not well informed that MR is available only up to 8 weeks LMP.This is to be mentioned that MR beyond eight weeks is done by doctors in relatively larger centres at district level and thus this service is less accessible to rural women. The majority of rural women are illiterate, and do not have access to written materials. Surveys show that even those who have had MR, do not know what it is(Akhter,1998). The different languages in the country complicates communication.
Inappropriate use of MVA equipment
The highest proportion of abortion complications is reported when providers are FWVs, Kabiraj and self induced. Dais, ayas, and village doctors are another group of providers for whom complications are reported.
Inappropriate use of MVA equipment can yield complications. In a study it has been reported thatas MR syringes are used by paramedics beyond 8 weeks LMP. The paramedics start the abortion, then refer the woman to a hospital where she gets treatment by D&C. The guidelines state that the MR syringe can be used for a uterus of less than eight weeks’ size and that the appropriate cannula should be used beyond this date. Research shows that the use of the MR syringe beyond nine weeks’ gestation results in complications, and especially incomplete abortions.
There is, however, a positive side to this situation. In the pre-MR period these women would go to indigenous provider who would put sticks inside the uterus. This would often result in infection and death. The trained paramedic uses a method which is approved, but beyond the recommended period. Thus women have access to a facility where her life can be saved through early access to a hospital and lessened risk of the complications of induced abortion.
Reporting to the clinics at a pregnancy duration of more than 10 weeks was found to be the most common reason for rejection for MR. Many of the rejected MR clients resort to dangerous indigenous methods of abortions. About one-fifth of maternal mortality is attributed to traditional unsafe abortions.
Drainage of hospital and family resources
Another study of 452 admitted induced abortion complication cases had mean duration of 5.4 nights for those with no surgery, 5.2 nights for those needing D&C and 11.2 nights for those who had associated surgeries (Akhter, 1998).
Payment for abortion services
Payment for Menstrual services
The effect of MR services on abortion seeking practices and consequences
Use of MR equipment to induce abortion was not reported in the 1977, maybe because at that time the equipment was not widely available in the country. In 1984, MR equipment was used in 9% of cases, while the 1994 study found the proportion to be 37%. D&C was reported by 2% of patients with complications in 1977, and 5% in 1991. In 1994, D&C was not reported at all by patients with abortion complications as a method of induction.
In terms of providers, non-medical providers were used by 49% of the women with complications in 1977 and 38% in 1994 study. In 1977, physicians induced in 2% of cases. In 1984 the proportion was 15%, and ten years later it was 16%. If we combine all medically trained persons, including doctors, nurses and FWVs, the proportion of abortions conducted by them in 1977 was 26%, in 1984 it was 43%, and in 1994 it was 46%. These figures indicate a clear transition from non-medical abortionists to personnel with some medical training. This should have contributed to saving women's lives and minimising suffering from morbidity.
Since the introduction of MR services and training, the proportion of severe infection spread beyond the uterus has reduced from 29% in 1977 to 18% in 1994. The fatality rate from unsafe abortion has decreased from 5% in 1977 to 0.2% in 1994.( Akhter,1998) This is coincident with an increase in MR.
In 1985 bans were imposed on using USAID funds for MR. Several organisations who were receiving USAID funds stopped providing services. Nevertheless the procedure continued to be offered within the government service network where there were people trained and willing to perform the procedure.
When USAID money stopped, Ford Foundation provided some bridging funds. The Swedish International Development Cooperation Agency (SIDA) then started providing funds for the NGO network to support FWV refresher training and research. The SIDA support continues until today. USAID now provides support for post abortion care. The Health and Population Sector Programme for 1998 to 2003 of the Ministry of Health and Family Welfare includes menstrual regulation as part of the Reproductive Health Care Package.
In a country like Bangladesh there could be several reasons for lack of resistance to MR service delivery. In general, health NGOs were sensitised about women's health care needs and some NGOs were interested in providing MR services. This provided a fertile ground for the government-NGO collaboration that characterises the programme.
Both the NGOs and government feel that if they talk loudly about abortion, there could be problems. It is more important for them that services are being provided, that services are provided through government clinics, and that government trained personnel, both doctors and paramedics, perform the procedure to a decentralized level. Further, both pre- and post-counselling is given on MR as well as post MR contraceptive use. The service thus constitutes a good ‘package’.
Since none of the available contraceptives were foolproof in protecting women from unwanted pregnancy , MR was used as a back up to contraceptive failure. It was made clear that MR is not a contraceptive method, it is rather a backup for ineffective use of contraceptives. The impetus for its introduction thus came from scientists, government and international leadership rather than from those concerned with women’s rights.
In Bangladesh significant access to termination of pregnancy has been achieved despite illiberal laws. In Bangladesh, a legal solution for abortion was never seriously on the agenda once MR had been introduced. Most actors and advocates of MR are content with the current MR regulations. Improved quality and accessibility are the issues to be addressed rather than legality of abortion services. Currently, paramedics are providing services, government provides logistics, and NGOs do the training. The programme thus represents good networking government and NGOs. There is widespread support for protecting and promoting the programme.
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