Out-of-clinic and self-managed abortion in Bangladesh: menstrual regulation provider perspectives

• Published in: Reproductive health 2021-03, Vol.18 (1), p.69-69, Article 69
• Main Authors: Crouthamel, Bonnie, Pearson, Erin, Tilford, Sarah, Hurst, Samantha, Paul, Dipika, Aqtar, Fahima, Silverman, Jay, Averbach, Sarah
• Format: Article
• Language: English
• Subjects: Abortifacients; Abortion; Care and treatment; Curettage, Vacuum; Drug stores; Family planning; Hospitals; Interviews; Maternal mortality; Medical schools; Menstrual regulation; Menstruation; Methods; Nurses; Obstetricians; Pharmacy; Physicians; Reproductive health; Surveys; Womens health
• ISSN: 1742-4755; 1742-4755
• DOI: 10.1186/s12978-021-01123-w

In Bangladesh, abortion is illegal except to save a woman's life, though menstrual regulation (MR) is permitted. MR involves the use of manual uterine aspiration or Misoprostol (with or without Mifepristone) to induce menstruation up to 10-12 weeks from the last menstrual period. Despite the availability of safe and legal MR services, abortions still occur in informal setttings and are associated with high complication rates, causing women to then seek post abortion care (PAC). The objective of this study is to contextualize MR in Bangladesh and understand systemic barriers to seeking care in formal settings and faciltators to seeking care in informal settings via the perspective of MR providers in an effort to inform interventions to improve MR safety. Qualitative individual semi-structured interviews were conducted with 25 trained MR providers (doctors and nurses) from urban tertiary care facilities in six different cities in Bangladesh from April to July, 2018. Interviews explored providers' knowledge of MR and abortion in Bangladesh, knowledge/experience with informal MR providers, knowledge/experience with patients attempting self-managed abortion, personal attitudes and moral perspectives of MR/abortion in general, and barriers to formal MR. Team based coding and a directed content analysis approach was performed by three researchers. There were three predominant yet overlapping themes: (i) logistics of obtaining MR/PAC/abortion, (ii) provider attitudes, and (iii) overcoming barriers to safe MR. With regards to logistics, lack of consensus among providers revealed challenges with defining MR/abortion gestational age cutoffs. Increasing PAC services may be due to patients purchasing Mifepristone/Misoprostol from pharmacists who do not provide adequate instruction about use, but are logistically easier to access. Patients may be directed to untrained providers by brokers, who intercept patients entering the hospitals/clinics and receive a commission from informal clinics for bringing patients. Provider attitudes and biases about MR can impact who receives care, creating barriers to formal MR for certain patients. Attitudes to MR in informal settings was overwhelmingly negative, which may contribute to delays in care-seeking and complications which endanger patients. Perceived barriers to accessing formal MR include distance, family influence, brokers, and lack of knowledge. Lack of standardization among providers of MR gestational age cutoffs may affec