Clients' expectations and experiences with providers of menstrual regulation: a qualitative study in Bangladesh.

BACKGROUND: Menstrual Regulation (MR) has been legal in Bangladesh since 1979 in an effort to reduce maternal mortality from unsafe abortion care. However, access to high-quality and patient-centered MR care remains a challenge. This analysis aimed to explore what clients know before going into care and the experience itself across a variety of service delivery sites where MR care is available. METHODS: We conducted 26 qualitative semi-structured interviews with MR clients who were recruited from three different service delivery sites in Dhaka, Bangladesh from January to March 2019. Interviews explored client expectations and beliefs about MR care, the experience of the care they received, and their perception of the quality of that care. We conducted a thematic content analysis using a priori and emergent codes. RESULTS: Clients overall lacked knowledge about MR care and held fears about the damage to their bodies after receiving care. Despite their fears, roughly half the clients held positive expectations about the care they would receive. Call center clients felt the most prepared by their provider about what to expect during their MR care. During counseling sessions, providers at in-facility locations reinforced the perception of risk of future fertility as a result of MR and commonly questioned clients on their need for MR services. Some even attempted to dissuade nulliparous women from getting the care. Clients received this type of questioning throughout their time at the facilities, not just from their medical providers. The majority of clients perceived their care as good and rationalized these comments from their providers as coming from a caring place. However, a handful of clients did report bad care and negative feelings about their interactions with providers and other clinical staff. CONCLUSION: Providers and clinical staff can play a key role in shaping the experience of clients accessing MR care. Training on accurate knowledge about the safety and effectiveness of MR, and the importance of client communication could help improve client knowledge and person-centered quality of MR care.

Perceptions and attitudes of Rohingya community stakeholders to pregnancy termination services: a qualitative study in camps of Cox's Bazar, Bangladesh.

BACKGROUND: Rohingya women suffer from inaccessibility to sexual and reproductive health services in Myanmar. After the forcible displacement of the Rohingya from Myanmar to Bangladesh in 2017, pregnancy termination services have been increasingly important and desired, while knowledge gaps and obstacles to access services still exist. The role of community stakeholders is critical as gatekeepers and decision-makers to improve and strengthen pregnancy termination services for women in camps. However, there is paucity of evidence on their perspectives about pregnancy termination. This qualitative study aims to understand the perception and attitudes of Rohingya community stakeholders to pregnancy termination in the camps of Cox's Bazar. METHODS: We used purposive sampling to select 48 participants from the community stakeholders, 12 from each group: majhis (Rohingya leaders), imams (religious leaders), school teachers, and married men. We conducted in-depth interviews of all the participants between May-June 2022 and October-November 2022. Data were coded on Atlas.ti and analysed using a thematic content analysis approach. RESULTS: Multiple socio-cultural and religious factors, gendered norms and stigma associated with pregnancy termination acted as barriers to women seeking services for it. From a religious stance, there was greater acceptance of pregnancy termination in the earlier period than in the later period of pregnancy. We observed that pregnancy termination among community stakeholders in earlier stages of pregnancy than later. However, circumstances, such as a woman's marital status, whether she sought her husband's permission or her ability of childcare capacity, were often framed by community stakeholders as 'acceptable' for pregnancy termination. Health concerns and social and contextual factors can influence community stakeholders supporting pregnancy termination. CONCLUSIONS: The community stakeholders perspectives on barriers and enablers of pregnancy termination were variable with the context. These perspectives may support or impede women's ability to choice to seek pregnancy termination services. To improve women's choice to pregnancy termination, it is critical to consider roles of community stakeholders in creating their supporting attitudes to women's choice and access, and to designing targeted culturally appropriate interventions with communities support and engagement.

Menstrual regulation: examining the incidence, methods, and sources of care of this understudied health practice in three settings using cross-sectional population-based surveys.

BACKGROUND: Menstrual regulation is a practice that may exist within the ambiguity surrounding one's pregnancy status and has been the subject of limited research. The aim of this study is to measure the annual rate of menstrual regulation in Nigeria, Cote d'Ivoire, and Rajasthan, India, overall and by background characteristics and to describe the methods and sources women use to bring back their period. METHODS: Data come from population-based surveys of women aged 15-49 in each setting. In addition to questions on women's background characteristics, reproductive history, and contraceptive experiences, interviewers asked women whether they had ever done something to bring back their period at a time when they were worried they were pregnant, and if so, when it occurred and what methods and source they used. A total of 11,106 reproductive-aged women completed the survey in Nigeria, 2,738 in Cote d'Ivoire, and 5,832 in Rajasthan. We calculated one-year incidence of menstrual regulation overall and by women's background characteristics separately for each context using adjusted Wald tests to assess significant. We then examined the distribution of menstrual regulation methods and sources using univariate analyses. Method categories included surgery, medication abortion pills, other pills (including unknown pills), and traditional or "other" methods. Source categories included public facilities or public mobile outreach, private or non-governmental facilities or doctors, pharmacy or chemist shops, and traditional or "other" sources. RESULTS: Results indicate substantial levels of menstrual regulation in West Africa with a one-year incidence rate of 22.6 per 1,000 women age 15-49 in Nigeria and 20.6 per 1,000 in Cote d'Ivoire; women in Rajasthan reported only 3.3 per 1,000. Menstrual regulations primarily involved traditional or "other" methods in Nigeria (47.8%), Cote d'Ivoire (70.0%), and Rajasthan (37.6%) and traditional or "other" sources (49.4%, 77.2%, and 40.1%, respectively). CONCLUSION: These findings suggest menstrual regulation is not uncommon in these settings and may put women's health at risk given the reported methods and sources used. Results have implications for abortion research and our understanding of how women manage their fertility.

Menstrual regulation, or bringing back a late period, is an understudied practice that women may use when they are worried they are pregnant but that may be viewed as distinct from abortion. This study seeks to measure the frequency of menstrual regulation in Nigeria, Cote d'Ivoire, and Rajasthan, India, overall and by women's characteristics and to describe the methods and sources women use. We used data from representative surveys of women aged 15­49 years old in each study setting. We asked women whether they had ever done something to bring back a late period at a time when they were worried they were pregnant, and if so, what methods and sources they used. Results indicate that menstrual regulation may be a common practice, particularly in West Africa; the observed one-year rates were 22.6 menstrual regulations per 1,000 women aged 15­49 in Nigeria and 20.6 menstrual regulations per 1000 women in Cote d'Ivoire; women in Rajasthan only reported 3.3 menstrual regulations per 1000 women per year. Menstrual regulations primarily involved traditional or "other" methods in Nigeria (47.8%), Cote d'Ivoire (70.0%), and Rajasthan (37.6%) and traditional or "other" sources (49.4%, 77.2%, and 40.1%, respectively). These findings suggest menstrual regulation is not uncommon and may put women's health at risk given the reported methods and sources used. Results have implications for abortion research and our understanding of how women manage their fertility.

Factors influencing menstrual regulation and its socioeconomic inequalities among ever-married women in Bangladesh: Findings from a nationwide cross-sectional survey.

Despite a significant drop in maternal mortality in Bangladesh, unsafe abortion remains a critical maternal health issue that could be reduced by promoting menstrual regulation (MR). This study aimed to investigate the prevalence and determinants of MR use among ever-married women as well as to identify the socioeconomic inequalities in MR use in Bangladesh. The latest Bangladesh Demographic and Health Survey (BDHS) 2017-18 data were used in this study. We used a sub-sample of 12,586 ever-married women aged 15 to 49 years for this study. To identify the determinants of MR, multilevel (mixed-effect) binary logistic regression analysis was used while accounting for potential between-clusters variations. The weighted prevalence of MR was 7.64% (95% CI: 7.19 - 8.12). Women of aged 20-29 years (AOR: 2.50, 95% CI: 1.46, 4.30) and ≥ 30 years (AOR: 4.17, 95% CI: 2.39, 7.26), from urban areas (AOR: 1.24, 95% CI: 1.04, 1.47), having one or two children (AOR: 1.96, 95% CI: 1.25, 3.09) and ≥ 3 children (AOR: 2.26, 95% CI: 1.40, 3.65), who used traditional contraceptive method (AOR: 1.39, 95% CI: 1.12, 1.73), and from Barishal division (AOR: 1.44, 95% CI: 1.08, 1.93) were more likely to have MR. Women were less likely to have MR if they were from Chittagong (AOR: 0.62, 95% CI: 0.46, 0.84) and Mymensingh (AOR: 0.51, 95% CI: 0.36, 0.73) divisions. MR use was found to be higher among higher socioeconomic status (SES) groups as the concentration index (CIX) value was positive and the Lorenz curve lay below the line of equality (CIX: 0.095, p<0.001). Health policy and intervention design should prioritize minimizing socioeconomic inequities concerning MR services.

The association between intimate partner violence and self-managed abortion: a cross-sectional study among women in urban Bangladesh.

In Bangladesh, abortion is illegal, except to save a woman's life. However, menstrual regulation (MR) to induce menstruation up to 12 weeks from the last menstrual period is permitted. Although safe and legal MR services are available, many women choose to self-manage their abortions. The prevalence of intimate partner violence (IPV) in Bangladesh is high. Whether IPV is associated with self-managed abortion is unknown. Between January and December 2019 we administered cross-sectional surveys to women presenting for MR or post-abortion care (PAC) services at facilities in six cities in Bangladesh assessing if women had ever experienced IPV and if they attempted to self-manage their abortion. We used multivariable logistic regression to assess the association between IPV and self-managed abortion and multinomial logistic regression to the association between IPV by type: (none, any physical, any sexual, or both) and self-managed abortion. Among 2679 women who presented for MR or PAC care and participated in the survey, 473 (17.7%) had previously attempted to self-manage abortion. Women who had ever experienced any IPV were more likely to attempt self-managed abortion prior to presenting for MR or PAC (adjusted odds ratio (aOR) = 1.52, 95% CI 1.24, 1.87). Women who ever experienced physical IPV were more likely to attempt self-managed abortion (adjusted relative risk ratio (aRRR) = 1.62, 95% CI 1.30, 2.03). Women who have ever experienced physical IPV may be more likely to attempt a self-managed abortion because they seek more covert ways of ending a pregnancy out of fear for their safety, or because of limited mobility or lack of resources. Interventions to support women to safely self-manage abortion should focus on populations with higher rates of IPV.

'Of course, women will adopt it!': A qualitative study on the acceptability of medical menstrual regulation in Senegal.

OBJECTIVE: Medical menstrual regulation (MMR) may offer a promising way to reach Senegalese women and girls in need of fertility management, especially in rural contexts. To assess the feasibility of introducing a MMR service in Senegal, the study aimed to (1) understand how women and girls manage their menses and fertility, and (2) document acceptability of MMR among women, youth, and health providers. METHODS: Six focus group discussions and 34 in-depth interviews were conducted with women, youth, and health providers in Kaolack, Mbour, and Thiès, Senegal. RESULTS: All participants characterized the pubescent period by a lack of sexual education, familial support, and access to reproductive health services. Reproductive health service utilization in Senegal was portrayed as highly stigmatized, creating barriers to contraception and reliable information on family planning. Unwanted pregnancy and clandestine abortion were depicted as common occurrences among many participants. Senegalese women and youth perceived MMR services as an acceptable method to manage a missed period with discretion, rid of moral and legal ramifications - and framed MMR as a needed mechanism to prevent abortion and avoid undesired pregnancies. The majority of health providers, with the exception of female health volunteers, were reluctant to endorse the service, comparing MMR to abortion. CONCLUSIONS: In a context fraught with restrictive abortion laws and limited uptake of modern contraception, MMR is an acceptable among potential service users. Nonetheless, introduction and implementation of MMR will be feasible in Senegal only if policymakers approve and support the service and health provider buy-in is achieved.

Efficacy of myo-inositol in improving pregnancy rate and regulation of menstrual cycle for patients with polycystic ovarian syndrome: A systematic review and meta-analysis

Background@#Polycystic ovarian syndrome (PCOS) is a common, reproductive endocrinopathy associated with ovarian dysfunction, cardiovascular disorders, obesity, and infertility. Myo-inositol is a novel treatment for women with PCOS that claimed to have improved fertility rate in this population. This systematic review and meta-analysis examined the effect of myo-inositol on pregnancy rate, menstrual cycle, and adverse effects from randomized controlled trials (RCTs). @*Methods@#RCTs that evaluated the efficacy of myo-inositol in improving pregnancy rate and regulation of menstrual cycle in women with PCOS. Electronic databases were searched and studies published up to October 24, 2021 were included in the systematic review and meta-analysis. Study selection and assessment of quality were conducted independently by two review authors. @*Results@#Seven studies with 729 patients treated with myo-inositol and 677 patients treated with placebo and/or metformin were included in the analysis. The research groups did not diverge significantly in terms of basic characteristics, such as age, adnexal or uterine pathology, body mass index, and duration of infertility. In the myo-inositol group, regulation of the normal menstrual cycle is at 20%, significantly higher than the metformin group at 12%, (p<0.001). However, there is no significant difference in the pregnancy rate between myoinositol and placebo (p=0.42) and/or metformin (p=0.17). @*Conclusion@#This systematic review and meta-analysis showed that myo-inositol can be an alternative treatment for PCOS in terms of regulation of menses and may improve the success of spontaneous pregnancies. However, additional randomized, double-blind controlled trials with larger sample sizes, low heterogeneity, and uniform inclusion criteria are recommended to establish the effects of myo-inositol on PCOS treatment and pregnancy rate.

A mixed-methods study exploring women's perceptions of terminology surrounding fertility and menstrual regulation in Côte d'Ivoire and Nigeria.

BACKGROUND: Women use various terms when discussing the management of their fertility and menstrual irregularities and may interpret the experience of ending a possible pregnancy in nuanced ways, especially when their pregnancy status is ambiguous. Our study aims to understand the terminology used to refer to abortion-like experiences (specifically menstrual regulation and pregnancy removal), and the specific scenarios that these practices encompass among women who reported doing something to bring back a late period or ending a pregnancy in Nigeria and Côte d'Ivoire. METHODS: Our analysis draws upon surveys with women in Nigeria (n = 1114) and Cote d'Ivoire (n = 352). We also draw upon qualitative in-depth interviews with a subset of survey respondents in Anambra and Kaduna States in Nigeria, and Abidjan, Cote d'Ivoire (n = 30 in both countries). We examine survey and interview questions that explored women's knowledge of terminology pertaining to ending a pregnancy or bringing back a late period. Survey data were analyzed descriptively and weighted, and interview data were analyzed using inductive thematic analysis. RESULTS: We find that the majority (71% in Nigeria and 70% in Côte d'Ivoire) of women perceive menstrual regulation to be a distinct concept from pregnancy removal, yet there is considerable variability in whether specific scenarios are interpreted as referring to menstrual regulation or pregnancy removal. Menstrual regulation is generally considered to be more ambiguous and not dependent on pregnancy confirmation in comparison to pregnancy removal, which is consistently interpreted as voluntary termination of pregnancy. CONCLUSIONS: Overall, menstrual regulation and pregnancy removal are seen as distinct experiences in both settings. These findings have relevance for researchers aiming to document abortion incidence and experiences, and practitioners seeking to address women's reproductive health needs.

Women use various words and phrases to describe their experiences managing their fertility and menstrual irregularities, and may interpret the experience of ending a possible pregnancy in nuanced ways, especially when their pregnancy status is ambiguous. Our study aims to understand the terminology women use to refer to abortion-like experiences (specifically menstrual regulation, which refers to actions taken to regulate a menstrual cycle, and pregnancy removal), and the specific scenarios that these practices encompass among women who reported having had an abortion in Côte d'Ivoire and Nigeria. Our analysis draws upon data from surveys and qualitative interviews conducted in both countries. We find that the majority (71% in Nigeria and 70% in Côte d'Ivoire) of women perceive menstrual regulation to be a distinct concept from pregnancy removal, yet there is considerable variability in whether specific scenarios are interpreted as referring to menstrual regulation or pregnancy removal. Menstrual regulation is generally considered to be more ambiguous and not dependent on pregnancy confirmation in comparison to pregnancy removal, which is consistently interpreted as voluntary termination of pregnancy. These findings have relevance for researchers aiming to document abortion incidence and experiences, and practitioners seeking to address women's reproductive health needs.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: Lack of standardization among providers of MR gestational age cutoffs may affect patient care and MR access, causing some patients to be inappropriately turned away. Providers in urban tertiary care facilities in Bangladesh see primarily the complicated MR/PAC cases, which may impact their negative attitude, and the safety of out-of-clinic/self-managed abortion is unknown. MR safety may be improved by eliminating brokers. A harm reduction approach to improve counseling about MR/abortion care in pharmacies may improve safety and access. Policy makers should consider increasing training of frontline health workers, such as Family Welfare Visitors to provide evidence-based information about Mifepristone/Misoprostol.

A qualitative study on health care providers' experiences of providing comprehensive abortion care in Cox's Bazar, Bangladesh.

BACKGROUND: Humanitarian settings are characterised by limited access to comprehensive abortion care. At the same time, humanitarian settings can increase the vulnerability of women and girls to unintended pregnancies and unsafe abortions. Humanitarian actors and health care providers can play important roles in ensuring the availability and accessibility of abortion-related care. This study explores health care providers' perceptions and experiences of providing comprehensive abortion care in a humanitarian setting in Cox's Bazar, Bangladesh and identifies barriers and facilitators in service provision. METHOD: In-depth interviews (n = 24) were conducted with health care providers (n = 19) providing comprehensive abortion care to Rohingya refugee women and with key informants (n = 5), who were employed by an organisation involved in the humanitarian response. Data were analysed using an inductive content analysis approach. RESULTS: The national menstrual regulation policy provided a favourable legal environment and facilitated the provision of comprehensive abortion care, while the Mexico City policy created organisational barriers since it made organisations unable or unwilling to provide the full comprehensive abortion care package. Supplies were available, but a lack of space created a barrier to service provision. Although training from organisations had made the health care providers confident and competent and had facilitated the provision of services, their knowledge of the national abortion law and menstrual regulation policy was limited and created a barrier to comprehensive abortion services. Even though the health care providers were willing to provide comprehensive abortion care and had acquired skills and applied strategies to communicate with and provide care to Rohingya women, their personal beliefs and their perceptions of Rohingya women influenced their provision of care. CONCLUSION: The availability and accessibility of comprehensive abortion care was limited by unfavourable abortion policies, a lack of privacy, a lack of knowledge of abortion laws and policies, health care providers' personal beliefs and a lack of cultural safety. To ensure the accessibility and availability of quality services, a comprehensive approach to sexual and reproductive health and rights is needed. Organisations must ensure that health care providers have knowledge of abortion policies and the ability to provide quality care that is woman-centred and non-judgmental.

Task-sharing in menstrual regulation services: Implementation efforts and lessons learned in Bangladesh.

OBJECTIVE: To explore the strategies undertaken to decentralize menstrual regulation services and implement task-sharing, including barriers and facilitators, with nonphysician providers in Bangladesh. METHODS: We conducted a desk review of relevant policies and health service information from grey and published literature on task-sharing in menstrual regulation services, plus stakeholder interviews with 19 representatives of relevant health organizations to investigate facilitators for and barriers to the implementation of task-sharing of these services. RESULTS: Task-sharing in menstrual regulation began in 1979 as part of the national family planning program. The Ministry of Health and Family Welfare has guidelines for menstrual regulation services provided by a wide range of healthcare workers using manual vacuum aspiration and the medications misoprostol and mifepristone. Despite government approval, implementation of task-sharing is challenging owing to lack of skilled providers, lack of facility readiness, and unmet need for family planning. CONCLUSION: The government needs to implement effective planning for skills building of nonphysician providers and ensuring facility readiness for provision of menstrual regulation services to reduce unsafe abortion in Bangladesh.

Exploring potential interest in missed period pills in two US states.

OBJECTIVE: Missed period pills (MPP) are uterine evacuation medications used for treatment of delayed menses without prior pregnancy confirmation. This study explores potential interest in missed period pills in two US states. STUDY DESIGN: We enrolled people seeking pregnancy test services at nine health centers in two US states between June 2015 and October 2017. Participants completed an anonymous questionnaire containing closed- and open-ended questions about background characteristics, reproductive practices, pregnancy feelings and intentions, abortion attitudes, and MPP interest. We used ordered logistic regression to identify factors associated with MPP interest and inductive content analysis to identify recurring qualitative themes related to MPP interest or disinterest. RESULTS: In all, 678 people completed the survey and 286/678 (42%) indicated interest in missed period pills. Interest was greatest (129/185 or 70%) among those who would be unhappy if pregnant. Variables associated with interest in the multivariate analyses were age ≥ 35, nulliparity, prior abortion and contraceptive use, recent use of emergency contraception, pregnancy feelings and intentions, and abortion attitudes (p < .05). Variables not associated with interest included state of residence, educational attainment, ethnicity, religious affiliation, and frequency of religious attendance. Key reasons for interest were to prevent, avoid or terminate pregnancy; and psychological or emotional benefits, including management of abortion stigma. Reasons for non-interest included concerns about safety or side effects, desire to be pregnant or have a baby, and not wanting to abort or hurt the fetus/baby. CONCLUSION: If missed period pills were available in the United States, demand might be substantial and wide-ranging across demographic groups. IMPLICATIONS: Our findings suggest that some people with missed periods do not desire pregnancy confirmation before taking medications that might disrupt a pregnancy. As a result, provision of missed period pills in the United States would expand reproductive service options and could improve the delivery of patient-centered care.

Navigating the crisis landscape: engaging the ministry of health and United Nations agencies to make abortion care available to Rohingya refugees.

BACKGROUND: Unintended and unwanted pregnancies likely increase during displacement, making the need for sexual and reproductive health (SRH) services, especially safe abortion, even greater. Attention is growing around barriers to safe abortion care for displaced women as donor, non-governmental and civil society actors become more convinced of this need and reports of systematic sexual violence against women are more widely documented around the world. Yet a reluctance to truly change practice remains tied to some commonly reported reasons: 1) There is no need; 2) Abortion is illegal in the setting; 3) Donors do not fund abortion services, and; 4) Abortion is too complicated during acute emergencies. While there is global progress towards acknowledging the deficit of attention and evidence on abortion services in humanitarian settings, improvements in actual services have yet to follow. CASE PRESENTATION: In August 2017, over 700,000 Rohingya refugees fled Myanmar for Bangladesh. Women and girls fled homes and communities - many experienced terrible violence - and arrived at camps in Bangladesh with SRH needs, including unwanted pregnancies. With funding from UNFPA and others, Ipas trained providers and established safe induced abortion (called menstrual regulation (MR) in Bangladesh) and contraception services in October 2017.Ipas Bangladesh initiated the trainings in coordination with the government's health system and international aid agencies. Training approaches were modified so that providers could be trained quickly with minimal disruption to their ability to provide care. Within one month of the arrival of refugees, MR services had been established in eight facilities, for the first time during an acute emergency. By mid-2019, over 300 health workers from 37 health facilities had attended training in MR, postabortion care (PAC), and contraception. Over 8000 Rohingya refugees have received abortion-related care, more than three-quarters of which were MR procedures; over 26,000 women and girls have received contraception at these facilities. CONCLUSIONS: This study demonstrates demand for abortion care exists among refugees. It also illustrates that these needs could have been easily overlooked in the complex environment of competing priorities during an emergency. When safe abortion services were made available, with relative ease and institutional support, women sought assistance, saving them from complications of unsafe abortions.

Abortion service provision in South Asia: A comparative study of four countries.

OBJECTIVES: Nationally representative evidence on abortion service provision is scarce in South Asia. To inform improvements in service provision, this paper assesses the availability of facility-based postabortion services in Nepal, India (six states), Bangladesh and Pakistan, and legal abortion services in India and Nepal and Bangladesh (where the official term used is menstrual regulation or MR). STUDY DESIGN: The paper presents comparable indicators on three aspects of abortion service provision from representative surveys of public and private sector facilities, conducted over 2012-2015. Indicators cover three areas: (a) need for abortion-related care (total number of abortions and percent of abortions that are legal and the postabortion treatment rate); (b) availability and accessibility of facility-based abortion-related services (percent of facilities offering only one of the two services, percent which are public and percent located in rural areas); (c) quality of facility-based abortion care (percent of legal abortions using procedures not recommended by WHO and percent of women turned away when seeking abortion or MR services). RESULTS: The proportion of all abortions that are illegal ranges from 58% to almost 78% in the three countries where abortion is permitted under broad criteria. The annual treatment rate for abortion complications ranges from about 4 to 26 per 1000 women ages 15-49 across the countries and states covered. In India and Nepal, less than 40% of public sector facilities that are permitted to provide abortion services do so; in Bangladesh, the situation is somewhat better, at 53% providing MR. Across the six Indian states, 4-43% of facilities that offer abortion care are located in rural areas, disproportionately lower than the proportion of women living in rural areas (49-87%). About 30-60% of facilities offered only postabortion care and did not offer legal services in the three countries where legal services are permitted (with the sole exception of Tamil Nadu where this proportion was only 11%); of the remaining facilities, the large majority offered both services. Medication abortion is offered by the large majority of facilities that provide induced abortion and accounts for 40-45%, of facility-based abortions in Nepal and four of the states of India; in Assam and Bihar, this proportion was much lower (13% and 27% respectively). Invasive procedures that are not recommended by WHO are more widely used in India (up to 25-37% of facility-based abortions are D&C procedures; the large majority of this group are D&C, and a small proportion may be D&E, a WHO-recommended abortion procedure, that could not be separated out in this study because providers use the two labels interchangeably); by comparison, the proportion is much smaller in Nepal (5%). Between 22% to a little over half of facilities turned away some women who would otherwise be eligible for an abortion or MR procedure in Nepal, the six Indian states, and Bangladesh. CONCLUSIONS: There is an urgent need to increase access to abortion, MR and postabortion services, especially for rural women. Greater access to legal abortion/MR services in the three countries that permit these procedures would increase the proportion of abortions that are legal and safe, reduce morbidity and the need for facility-based treatment for complications. Broadening the legal criteria under which abortion is permitted in Pakistan, and implementing access under such broader criteria, is needed to achieve the same improvements in Pakistan. Ensuring that these services are of high quality and comprehensive-meeting WHO-recommended standards-is essential to protect women's reproductive health and rights. IMPLICATIONS: To improve access to abortion, MR and postabortion care in South Asia, all facilities (public and private) permitted to provide these services should do so, and should include medication abortion. Improvements in quality of care are critical: invasive procedures (D&C) should be eliminated through adherence to WHO's standards of safe abortion care and women seeking abortions should not be turned away because of providers' biases.

Understanding reproductive health challenges during a flood: insights from Belkuchi Upazila, Bangladesh.

Background: Bangladesh is exposed to natural hazards such as floods, cyclones and droughts. As such, its health systems and health infrastructure are exposed to recurrent disasters. Research studying the impacts of natural disasters on reproductive health in particular is lacking. This research contributes to this knowledge gap by studying the challenges related to menstrual regulation and post-abortion care at both the facility and community levels, and the care-seeking patterns of pregnant women during the 2016 flood in Belkuchi, Bangladesh. Methods: Six government-run primary health care facilities were assessed using a structured assessment tool prior to the flood of 2016. In total, 370 structured interviews were conducted with women in three unions of Belkuchi (Belkuchi Sadar, Daulatpur and Bhangabari) 4 months after the 2016 flood. Results: The main challenges at the facility level are a lack of services and a shortage of medicines, equipment and trained health workers. The main challenges at the community level are displacement, high rates of self-diagnosed spontaneous abortion and a lack of treatment for post-abortion complications. A majority of the interviewed women (48%) sought menstrual regulation from the residence of a nurse or family welfare visitor. In total, 73.2% of the women who experienced post-abortion complications sought medical care. Conclusion: To overcome the challenges at the facility level, it is important to construct flood-resistant health infrastructure and train health workers in menstrual regulation and post-abortion care, so that these services can be made available during a flood. At the community level, more research is required to understand the reasons for spontaneous abortions so that these, and the subsequent chronic conditions/complications women experience, may be avoided. Context specific interventions that can overcome local challenges (both at the community and facility levels) are required to promote disaster resilience at primary health care facilities.

Using a Call Center to Reduce Harm From Self-Administration of Reproductive Health Medicines in Bangladesh: Interrupted Time-Series.

BACKGROUND: Annually, there are approximately 25 million unsafe abortions, and this remains a leading cause of maternal morbidity and mortality. In settings where abortion is restricted, women are increasingly able to self-manage abortions by purchasing abortion medications such as misoprostol and mifepristone (RU-486) from pharmacies or other drug sellers. Better availability of these drugs has been shown to be associated with reductions in complications from unsafe abortions. In Bangladesh, abortion is restricted; however, menstrual regulation (MR) was introduced in the 1970s as an interim method of preventing pregnancy. Pharmacy provision of medications for MR is widespread, but customers purchasing these drugs from pharmacies often do not have access to quality information on dosage and potential complications. OBJECTIVE: This study aimed to describe a call center intervention in Bangladesh, and assess call center use over time and how this changed when a new MR product (combined mifepristone-misoprostol) was introduced into the market. METHODS: In 2010, Marie Stopes Bangladesh established a care provider-assisted call center to reduce potential harm from self-administration of MR medications. The call center number was advertised widely in pharmacies and on MR product packaging. We conducted a secondary analysis of routine data collected by call center workers between July 2012 and August 2016. We investigated the reported types of callers, the reason for call, and reported usage of MR products before and after November 2014. We used an interrupted time series (ITS) analysis to formally assess levels of change in caller characteristics and reasons for calling. RESULTS: Over the 4-year period, 287,095 calls about MR were received and the number of users steadily increased over time. The most common callers (of 287,042 callers) were MR users (67,438, 23.49%), their husbands (65,999, 22.99%), pharmacy workers (65,828, 22.93%), and village doctors (56,036, 19.52%). Most MR calls were about misoprostol, but after November 2014, a growing proportion of calls were about the mifepristone-misoprostol regimen. The most common reasons (of 287,042 reasons) for calling were to obtain information about the regimen (208,605, 72.66%), to obtain information about side effects (208,267, 72.54%), or to report side effects (49,930, 17.39%). The ITS analyses showed that after November 2014, an increasing number of calls were from MR users who had taken the complete regimen (P=.02 and who were calling to discuss reported side effects (P=.01) and pain medication (P=.01), and there were fewer calls asking about dosages (P<.001). CONCLUSIONS: The high call volume suggests that this call center intervention addressed an unmet demand for information about MR medications from both MR users and health care providers. Call center interventions may improve the quality of information available by providing information directly to MR users and drug sellers, and thus reducing the potential harm from self-management of MR medications.

Prevalence and determinants of menstrual regulation among ever-married women in Bangladesh: evidence from a national survey.

BACKGROUND: Despite the remarkable reduction of maternal mortality, unsafe and untimely menstrual regulation (MR) remains a major maternal health problem in Bangladesh. This study aimed to determine the prevalence and identify determinants of MR among ever-married women in Bangladesh. METHODS: Data for this study have been extracted from Bangladesh Demographic and Health Survey (BDHS) 2014. The survey followed a two-stage stratified sampling procedure and the study used a sub-sample of 8084 ever-married women aged 15 to 49 years extracted from survey sample of 17,863. Univariate and multivariate mixed-effect logistic regression analyses were used to identify risk factors for MR accounting for potential between-clusters variations. RESULTS: The weighted prevalence of MR was 12.3% (95% CI: 11.1-13.4%) among (991/8084) ever-married women. Women were less likely to have MR if they were from Chittagong (AOR 0.74, 95% CI: 0.57-0.96; p = 0.026) and Sylhet (AOR 0.53, 95% CI: 0.36-0.77; p = 0.001) divisions. Women were more likely to have MR if they were from high (AOR 1.47, 95% CI: 1.18-1.83; p = 0.001) and the highest (AOR 1.62, 95% CI: 1.27-2.05; p < 0.001) socioeconomic status (SES) group; being employed (AOR 1.35, 95% CI: 1.16-1.56; p < 0.001), having one or two children (AOR 1.73, 95% CI: 1.24-2.40: p = 0.001) and ≥ 3 children (AOR 2.56, 95% CI: 1.82-3.58; p < 0.001), and having membership of non-government organization (NGO) (AOR 1.18, 95% CI: 1.02-1.38; p = 0.030). CONCLUSION: MR is prevalent among Bangladeshi women and independently associated with geographic location, SES, parity, employment and NGO membership status. Health policy should prioritize in reducing spatial and socioeconomic inequalities in relation to MR services by ensuring accessibility and availability of MR services, especially in suburban divisions. Furthermore, abortion should be legalized in Bangladesh that will ultimately reduce the morbidity and mortality associated with unsafe abortion.

Clinical efficacy of laser combined with menstrual regulation in the treatment of female melasma: a retrospective study.

The aim of this study was to evaluate the clinical efficacy of using a Medlite C6 Q-switch Nd:YAG laser combined with menstrual regulation-based traditional Chinese medicine (TCM) in the treatment of female melasma. Forty cases of female patients with melasma, who were treated between December 2013 and December 2015 at the Jiangsu Provincial Hospital of Traditional Chinese Medicine, were reviewed retrospectively. Twenty patients received Q-switch Nd:YAG 1064 nm laser treatments combined with menstrual regulation treatments (experimental group), and 20 patients were treated only with the laser (control group). All treatments lasted for 6 months. The patients' faces were photographed before, immediately, and 6 months after treatment. The therapeutic efficacy was assessed by the reduction in the Melasma Area and Severity Index (MASI) score and the total skin damage score, and this was then compared between the two groups. Immediately and 6 months after the treatment, both the MASI and total skin damage scores in the experimental group were significantly lower compared to those in the control group (P < 0.001). The experimental group had significantly higher basic recovery and effectiveness rates than the control group (P = 0.020 and P = 0.008, respectively) and had a significantly lower invalidity rate (P < 0.001). Results from Medlite C6 Q-switch Nd:YAG laser treatment combined with menstrual regulation are superior than those obtained using only a laser for the treatment of female melasma.

Feasibility of assessing the safety and effectiveness of menstrual regulation medications purchased from pharmacies in Bangladesh: a prospective cohort study.

OBJECTIVE: To assess the feasibility of following up women who purchase mifepristone+misoprostol or misoprostol-only from pharmacies in order to measure the safety and effectiveness of self-administration of menstrual regulation. STUDY DESIGN: A prospective cohort study followed women purchasing mifepristone+misoprostol or misoprostol-only from pharmacies in Bangladesh. Participants were recruited by pharmacy workers either in person or indirectly via the purchaser of the drugs. End users were contacted by phone 2 weeks after recruitment, screened and interviewed. RESULTS: Study recruitment rates by pharmacy workers were low (30%, 109 of 642 women informed about the study), but 2-week follow-up rates were high (87%). Of the 109 end users interviewed, 87 purchased mifepristone+misoprostol and 20 misoprostol-only, while 2 women did not know what drugs they had purchased. Mean self-reported number of weeks of pregnancy was 5.7 weeks. Information provision by pharmacy workers was inadequate (40.4% received none, 8.7% received written information or pictures). A total of 80.5% of mifepristone+misoprostol users were sold the correct regimen versus 9 out of 20 misoprostol-only users. A total of 68.8% did not report experiencing any complications (70.0% misoprostol-only; 69.0% mifepristone+misoprostol users, p=1.0). A total of 94.3% of mifepristone+misoprostol users and 75% of misoprostol-only users reported that they were not pregnant at day 15 (p=.020). However, 7.3% of all users sought additional treatment. CONCLUSIONS: Challenges in assessing outcomes of self-managed menstrual regulation medications purchased from pharmacies must be overcome through further development of this methodology. Interventions are urgently needed to ensure that women have access to correct dosages, accurate information and necessary referrals. IMPLICATIONS: This paper assesses the outcomes of women who self-manage menstrual regulation medications purchased from pharmacies. The methodology requires further development, but our study provides preliminary positive evidence on the safety and effectiveness of self-management despite low information provision from pharmacy workers.

Mifepristone-misoprostol for menstrual regulation in public sector facilities in Bangladesh.

OBJECTIVE: To examine the use of mifepristone and misoprostol for menstrual regulation among Bangladeshi women attending public sector facilities. METHODS: In a prospective study, women (aged ≥18 years) with up to 9 weeks of amenorrhea were enrolled at 24 government health facilities in Bangladesh from November 2012 to June 2015. Paramedics or female welfare visitors provided most menstrual regulation care. Participants took 200 mg mifepristone followed by 800 µg buccal misoprostol after 24 hours, and were asked to return to the clinic 10-14 days later for clinical assessment and an exit interview. The primary outcome was successful evacuation of the uterus without need for surgical intervention. Women who completed follow-up were included in analyses for the primary outcome. RESULTS: Among 1744 enrolled participants, 1738 completed follow-up. Most (1674, 96.3%) had a successful uterine evacuation without the need for surgical intervention. A successful outcome was significantly more common in primary (724/744, 97.3%) and secondary facilities (861/895, 96.2%) than in the specialty hospital (89/99, 89.9%; P<0.001 and P=0.004, respectively). CONCLUSION: Menstrual regulation with mifepristone and misoprostol can be provided effectively in public sector facilities in Bangladesh. CLINICALTRIALS.GOV: NCT01798017.