healthmedicinet

Globally, slow progress has been made toward Millennium Development Goal 5 (MDG 5)
of reducing maternal mortality ratio by 75.0 % between 1990 and 2015. Many countries,
particularly those with low resources, have not met the necessary 5.5 % annual decline
necessary to be on track for the 2015 deadline 1]. Nonetheless, in Bangladesh, maternal mortality ratio has decreased by 66.0 % in
the last 20 years, from an estimated 574 to 194 per 100,000 live births between 1990
and 2010 2]. The annual abortion-related deaths per 100,000 women of reproductive age decreased
by 87.0 % from an average of 17 in the years 1976–1985 to an average of 2 for the
years 1996–2005 in Matlab, a rural area of Bangladesh 3]. The Bangladesh Maternal Mortality Surveys from 2001 to 2010 recorded that abortion-related
mortality as a percent of all maternal deaths fell from 5 to 1 % 2]. Longitudinal data suggest that reductions in abortion-related mortality – a cause
of 13 % of maternal mortality globally – may have contributed to this decline 4]. With its current annual rate of decline in maternal mortality of 5.5 %, Bangladesh
appears to be one of the few countries on track to meet the primary target of MDG
5 2]. Yet women who do not want to become pregnant and do not have access to contraception
are at risk of unplanned pregnancy and unsafe abortion 5]. This result in complications arising from MR procedures and unsafe abortion continue
to cause deleterious health, economic and social consequences not only for the women
but also for the society as a whole, both in the short term and in the long run 6].

Abortion is illegal in Bangladesh except only to save the life of the woman. Since
the 1970s, Bangladesh has maintained a menstrual regulation (MR) program, which is
defined as an interim method of establishing non-pregnancy in women at risk of being
pregnant 7]. MR has an advantage in countries where abortion is legally banned because it can
be conducted without a confirmatory pregnancy test, within 10 weeks of the beginning
of the last menstrual period by family welfare visitors (health service providers
having at least ten years of formal schooling and 18 months of training in family
planning and maternal and child health care, and additional training specifically
in MR) and within 12 weeks of a missed menstrual period by medical doctors 8], 9]. Although MR services have been decentralized, estimates showed that the incidence
of induced abortion was the same as that of MR in 2010, (647,000 and 653,000 respectively)
which implies that the demand for MR services are not being met 10]. Also there were 231,400 women treated for complications of induced abortions in
the same year and another 341,000 complicated cases did not get any medical care 10]. Additionally, an estimated 78,000 complications from MR were found which indicate
that the quality of clinical services needs to be strengthened 10].

Over the last decade, a set of tools and indicators have been used to monitor emergency
obstetric care (EmOC) interventions for reducing maternal deaths. These UN EmOC indicators
include treatment of abortion complications 5], 11]. However, essential preventive means to reduce unsafe abortion are not represented.
A recent study in Bangladesh showed that in the public sector, a system for collecting
data on MR and PAC exists, but underreporting is common, while in the private sector,
there is limited or no data 6]. Although this study gave estimates for MR and PAC in one point in time, it pointed
out that having consistent and comparable data on a continuous basis would help the
government in identifying gaps in the health system that influence provision of MR
and abortion for legal indications 6].

As for the health system in Bangladesh, in the public sector, the largest health service
provider of the country is the Ministry of Health Family Welfare (MoHFW). There
are two major implementation wings under the MoHFW- the Directorate General of Health
Services (DGHS) and the Directorate General of Family Planning (DGFP). The DGHS is
responsible for implementation of all public health programmes in the country including
emergency preparedness and response (EPR) programme. The DGFP is responsible for implementing
family planning (FP) programmes and providing FP related technical assistance to the
MoHFW 12], 13].

To address the gap on consistent and continuous data on MR and PAC, we conducted this
study to adapt and implement a set of process indicators, based on the safe abortion
care (SAC) model, developed by Ipas, a reproductive rights non-profit organization
based in the US, specifically to supplement the tools and indicators for monitoring
emergency obstetric care interventions. In this study, The SAC model was validated
and adapted as the safe menstrual regulation and abortion care (SMRAC) model 9], 14] with the objective of assessing the feasibility, acceptability and utility of the
SMRAC model in Jessore district of Bangladesh. We also documented the availability,
utilization, and quality of MR and abortion services over time, and highlighted elements
of care in need of quality improvement.