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Paper for the conference "Expanding Access: Advancing the Roles of Midlevel Providers in Menstrual Regulation and Elective Abortion Care" South Africa 2 - 6 December 2001. Midlevel Provider in menstrual regulation, Bangladesh experience Halida Hanum Akhter Director, BIRPERHT, Bangladesh Introduction The population of Bangladesh is over 123 million, with an estimated annual growth rate of 1.6% (BBS, 1998). Of the 25 million women of reproductive age, 60% are between 15-29. While 43% of the population is under 15 years, more than 60% of women are married by the age of 15. The median age at first birth is around 18 years (Mitra et al, 1997). Over half (54%) of all couples use contraception and the majority use temporary methods. Although the total fertility rate has declined considerably, it is still high, at 3.3. 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.

Abortion incidence in Bangladesh Induced abortion is restricted by law in Bangladesh which permits abortion only to save life of the pregnant woman. Despite the restrictive nature of the law, "Menstrual /Regulation" services have been available in the Government’s family planning program as a public health measure to reduce high rates of hospitalisation due to complications of induced abortion. 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 Year Measurement: provider registration Annual estimates: Abortion/1000 women aged 15-44 Abortion per 1000 women aged 15-44 1975 1977 1979 1980 1981 1982 1983 1984 1987 1988 1995/96 1997 0.3 0.4 0.6 1.6 2.3 3.1 2.9 3.4 3.5   3.4 3.8*   24                   26-30** 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 Under the Penal Code of 1860,in Bangladesh abortion is permissible only for saving the life of the mother. In all other cases abortion, self-induced or otherwise, is a criminal offence punishable by imprisonment or fines. The draft Bangladesh National Population Policy in 1996 proposed liberalisation of the law on abortion. The draft policy included various measures to increase the accessibility and availability of mother and child health (MCH) services throughout the country. 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) In 1974 the Bangladesh government encouraged introduction of Menstrual Regulation (MR) services in a few isolated family planning clinics. At the early 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. In 1978, a MR Training and Services Program (MRTSP) was initiated in seven government medical colleges and two-government district hospitals. 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. Footnotes: i. Government of Peoples Republic of Bangladesh population control and Family Division Circular No. FP./Misc-26/79/278 (600) issued on 31 May 1979, announced that by 1982 all the headquarters of the country should be equipped with facilities to provide all types of family planning services such as MR, Sterilization, the IUD, and other contraceptive methods. Government of Peoples Republic of Bangladesh PCFPD Memo No. 5-14/MCH-FP/Trg/79 dated 8 December 1979, Subject: MR Program.  ii. Banglasdesh Population Control and Family Planning Division Memo No.5-14//MCH/FR/trg/80, Subject: Guidelines for Menstrual Regulation(MR). This memo provided guidelines to regulate the services and ensure technical standards, including who can perform MR, criteria for MR training, national program support and supervision system iii.Government of Peoples republic of Bangladesh Population Control and Family Planning Division Memo No. 5-14/MCH-FR/Trg/79, National Institute of Population Research and training, Subject: Arrangement for MR training for doctors and FWVs 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 Health care facility Level and number Obstetric care provider Menstrual Regulation services Medical College Hospital District (13) Specialist, MO, Nursing staff MR/ abortion complicationare treated. District Hospital District (59) Specialist, MO, Nursing staff supervise MR services and deal complications if any receive referred complicated cases Maternal Child Welfare Centre (MCWC) District (52) Thana (24) Union (11) MO, FWV, dai nurse FWV FWV Provide MR services and receive referred complicated cases Thana Health Complex (THC) Thana (402) Medical Officer, Nursing staff, FWV provide MR services Health &Family Welfare Centre Union (4,770) FWV, MA provide MR services Community Clinic Village (18,500) FWV, HA, FWA,TTBA do not provideMR services but offer advices and referral to higher level facilities

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 MR training and service facilities were extended in phases and services are now available throughout the country. Currently there are nearly 8,000 doctors and 6,500 paramedics trained on MR who are posted in government clinics at national, district, thana and union levels. Services are also provided privately by doctors and paramedics (Singh 1997,Begum, 1987). out half of the doctors who had MR training, obtained during internship in the medical college hospitals the rest obtained on the job from the facility they were working or form a co-worker who perform MR (Begum,1987). Many private physicians also obtain training from training centers and provide MR services in their private practice. 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 MR program is guided by a National Technical Advisory Committee which is headed by the Director General, Directorate of Family Planning and its members are from the Directorate of Family Planning. Four non-government organizations play a prominent role in providing services and training of MR. 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 Type of provider Total years of pre- professional education Duration of professional medical training Duration of pre-service training in abortion service delivery Duration of in-service training in abortion Duration of apprenticeship / on the job training Training in clinical abortion procedures Training in abortion counseling Training in clinical abortion procedures Training in abortion counseling Training in clinical abortion procedures Training in abortion counseling FWV: Family Welfare Visitors At least 10 years of formal schooling Basic 18 Months of family planning + 3 months of midwifery Clinical observation During basic training Informally during family planning training Two weeks of MR Training at cllinics Two weeks at the time of clinical training (ok) weeks Of refreshers training on MR—lecture and practice sessions, depend on the availability of traing funds Two weeks at the time of refreshers clinical training Doctors MBBS—graduate doctors 12 years of formal schooling Five years of schooling at medical college Two weeks of placement at MR training center during internship Observation and participatory training during the clinical placement come for training if never took training in the past during clinical training Rarely come for Refreshers training as ) during clinical training period Private medical doctors ,MBBS Same Same Same Same Same Same Doctors training depend of the opportunnity for training During clinical training only

Source: FWV training manual and MR training manual used by FWV training institute and MRTSPs.

Table 5. Organization of abortion care Level of Health Care System Provider types Abortion methods provided Maximum gestation for abortion Management of complications Monetary cost of specific services provided Treatment Referral To individual (specify amount) To health care system (specify amount if data available) Community FWV: family welfare visitor Manual Vacuum Aspiraton,MVA Upto six weeks, Up to eight weeks from LMP Same provider/if supervisor physician is available To thana helath complex or to a large hospital On an average 50 –100 taka( pr 1-2 do;;ar) Modest Primary   FWV under direct supervision of a doctor MVA Up to six weeks Same provider if it is a doctor. If the Provider is FWV then it is a supervisor doctor To a Doctor or referred to a higher facility, Like district hospital   Hospital cost data not available District/First Referral Doctors or Ob/gyn specialist MVA or electric suction and/or D&C 10-12 weeks Same facilty or referred to medical colleges Same facility indoor or to medical college hospital Taka 700.00 on an average(DAC study)++++these are officially free of charge Official data is not available Secondary and Tertiary Doctors or Oob/gyn specialist MVA or electric suction And/ or D&C 10-12 at MR training centers Ob/gyn unit specialists Same facility at the indoor for surgery or other treatment Taka 700.00 on an average(DAC study)++++ Some sudy data are available as indirect estimates

Utilization of MR services: unmet need In spite of the widespread availability of MR services, utilization remains low, especially by those who need it most . There could be a number of reasons for this. Due to religious and political reasons, MR related messages are not published. 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 The government memorandum issued on 31 May 1979, 8th December 1979 and 1980 states that MR is part of official policy and that the necessary logistic support for MR services and training will be provided by the Population Division. Another memorandum of 1980 states that MR can be performed by an MR-trained registered medical practitioner or by a Family Welfare Visitor (FWV) who has specific training in MR. It also specifies that an FWV should perform MR only up to eight weeks from the last menstrual period, and must do so under supervision of a physician. Any case with a longer duration must be referred to a trained doctor. 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. International assistance In the mid-1970s funding and technical assistance from Family Health International, an organisation situated in North Carolina, USA, supported research, such as clinical trials on contraceptives and in the clinic. The first clinic where MR was initiated was funded by Pathfinder Fund under the auspices of the Ministry of Health. 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 Type of procedure Offered by this level of provider (Y/N)? If "yes" specify method. Method(s) of pain management used Type of supervision required when performing the procedure On-site Remote MR Yes / MVA Usually nothing independently Doctor at health ccomplex Medical abortion (specify different regimens used) Do not perform NA NA NA 1st trimester surgical Do not perform NA NA NA 2nd trimester surgical Do not perform NA NA NA Emergency treatment of abortion complication Stabilization May try to treat the condition by MVA       Uterine evacuation Refer to hospital or to clinics       Management of spontaneous abortion Stabilization Try at home if fail then refer to hospital or clinic       Uterine evacuation Yes       Postabortion contraception Counseling yes       Services yes

Utilisation of MR services and lack of knowledge The Bangladesh Demographic and Health Survey of 1996/97( Mitra, 1997) shows that almost four in five of all women who have ever been married know about MR, while levels of knowledge about MR is low among currently married men. On average, 3-4% of women reported that they ever had undergone MR at some point. This is widely acknowledged to be a substantial underestimate. The proportion of those who have had MR is highest among married women with children and are currently in their late 20s and 30s. 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 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 government 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. 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. Rejected MR In the training centres, MR is performed during the 6-8 week LMP period by FWVs and doctors using MVA. In the 8-10 week period, it is performed by doctors using electric vacuum aspiration. A study in 1990 (Kamal et al, 1990) found that nearly one-third of women seeking MR services were rejected. Most of the rejections were due to pregnancy durations longer than eight weeks. 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 The complications of illegal abortion affect not only individual women and their families, but also medical institutions and society as a whole. Treating these complications consumes substantial quantities of scarce resources such as hospital beds, blood for transfusion, costly medicines, and the time of medical personnel which could be better utilised treating other medical conditions. Studies showed that the mean duration of a hospital stay for post-abortion care is about six nights (Khan et al., 1984). 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 It has been found that women seeking induced abortion had to spend about 700 taka for their incomplete abortion procedures. The median amount of payment given to a physician was taka 370, to a nurse was taka 425 and to a FP worker was taka 435.For induced abortion , among the providers 23 percent of physicians, 8 percent of nurses and 11 percent of FP workers received payments. Payment for Menstrual services Some MR acceptors have to pay for services at health complexes. Total costs include medications and payment to the persons involved with the service provision. The amount spent at the clinic was on an average taka 100(Akhter,1998). Transport costs are additional. The effect of MR services on abortion seeking practices and consequences An examination of the types of methods used, providers, complications and fatality rates over a period of 17 years reflects some changes in the pattern of unsafe induced abortion and related consequences. This conclusion draws on three studies (Begum,1977, Khan,1984, Begum,1991, Akhter,1994) to describe the patterns. The studies show that even in recent years, about one third of unsafe abortions are done by inserting solid objects into the uterus. 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. References Akhter,HH.,Zahniser,C, Ahmed, G.,Rochat, R. and Mandel, M.,Can Paramedics In Bangladesh Perform Menstrual regulation safely and Efectively? Presented in Epidemic Intelligence Services (EIS) Conference at Center for Disease Controle(CDC), Atlantaa .Georgia in 1982. Akhter HH. Abortion in Bangladesh, International Handbook on Abortion edited by Paul Sachdev, 1988, Greenwood Press. 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