(This blog was originally published on the REACHOUT Consortium Blog.)
In Bangladesh, poor women often lack access to the necessary information about sexual and reproductive health services like menstrual regulation (MR) and menstrual regulation with medication (MRM) because it is a sensitive issue. Though MR must be done in a limited time period, women frequently exceed the safe period of MR because they lack proper information about the time window and the quality services that are available. They resort to low-quality but cheap services from informal providers as they are easily accessible in urban communities. In most instances, these informal providers do not have enough qualifications or basic training to provide these services safely. Every year a huge number of unintended pregnancies occur in Bangladesh.
Here is one woman’s story:
Rashida, a 16 year old girl, wanted to do Menstrual Regulation (MR) because her husband did not acknowledge her baby and was not willing to live with her. She lived with her father, who is a poor day labourer, and faced difficulties in providing her food and medical expenses. Despite having a kidney problem she desperately wanted to do MR because her husband would not bear her expenses and she did not want to become a burden for her family. As she was pregnant, nobody wanted to give her employment…But she did not have the necessary information on how to obtain MR so she had tried to collect information from different informal providers like drug sellers and dai (traditional birth attendants). She got conflicting information from many different people. Some of them told her that doing MR is easy and some told her she cannot do MR because of her young age and health problem and that she might die. She could not get the right information or proper counselling about MR or quality services for Antenatal Care (ANC). While she was searching for information, one of her relatives took her to a clinic where an MR service is provided. However, it was revealed after having an ultrasound that she had already passed the safe time period for having MR because of the delay. She was told to take ANC care but she was willing to terminate her pregnancy at any cost. So, she went to a drug seller and bought medicines which can induce abortion. After taking the medicine she had severe bleeding and had to be taken to hospital for a blood transfusion and post abortion care which cost a lot of money and put her in debt.
Community health workers (CHWs) work as a bridge between the community and health care facility. A range of CHWs, both formal and informal, are available in Bangladesh. Formal providers are the health workers are affiliated to NGOs and government and informal providers are those who do not have any institutional affiliation. Usually formal CHWs are trained and play an important role in child, maternal, and sexual and reproductive health (SRH). They are the first point of contact at community level, and do promotional and preventive health services in urban communities. CHWs disseminate health related information like clinic addresses of nearby health facilities to make the community aware of available health services and related cost. This information helps clients to take decisions about health care services especially sensitive issues such as MR. Poor women can avoid unnecessary hassles, save time and money, and protect themselves from clandestine operators and brokers by getting the right information from trained CHWs.
As part of REACHOUT, efforts are being made to build the capacity of these CHWs. In Bangladesh, the project focuses on the improvement of CHW’s effectiveness on MR. This project provided training to the CHWs on facilitative referral so that they can understand the referral system and how to provide information dissemination, networking, counselling, and efficient and timely referral. The aim is to provide accurate information to the client, provide a referral card, and lower the rate of unsafe MR. Training of CHWs can enhance their motivation and commitment levels.
Facilitative referral training has strengthened capacity of CHWs in the intervention area. CHWs showed improved counselling techniques, greater confidence regarding field work, rapport building skills, and prioritized the clients’ perspective which has resulted in better quality services by CHWs and increased service uptake by clients. As the next case study shows, by utilizing their new skills CHWs can support poor women to get quality health services especially on sensitive issues like MR where they may face problems in telling others or seeking help.
When Amina, a 24 year old women, became pregnant again, she already had three children and could not afford to feed, clothe, and educate another child. She wanted to do MR but she did not know where to go. A CHW from Marie Stopes Bangladesh, partner organization of REACHOUT, visited her house for their service promotion. The CHW had received facilitative referral training. Amina shared her problem with the CHW who explained the process for obtaining a quality service within the safe time period. The CHW also mentioned that if a client took the MR service from the health care centre they will provide her family planning counselling and suitable methods for family planning. The CHW gave her all the information she needed about the clinic and the cost of MR and MRM services, maintaining confidentiality, and quality of service. After that the CHW gave Amina a referral card where the address and time of the service was clearly written. The client got all the information she wanted, she took consent from her husband, and went to the clinic with the CHW. She was very satisfied with the service and now she can share this information with her neighbours who need it.
In 2014, an estimated 1,194,000 MR and abortions were performed and many of these were done in unsafe conditions or by untrained providers. Currently, 53% of government facilities are permitted to provide MR services. Some NGOs and private sector also provide MR Services though they are not sufficient for the whole population. So there is a huge unmet need for safe MR services. The results from the REACHOUT project training intervention come from two intervention areas in Dhaka city. Scaling up the intervention in other areas will allow more CHWs to strengthen their capacity and help poor and vulnerable adolescents and women to get quality and safe MR services. Access to accurate information and quality services will make a big contribution to better reproductive health outcomes in Bangladesh.
 Menstrual regulation (MR) is a part of Bangladesh national family planning program. Bangladesh government allow MR procedures up to ten weeks of pregnancy by paramedics and 12 weeks by a doctor, after last menstruation period.
 Menstrual Regulation with Medication (MRM) can be given to women having amenorrhea for eight weeks or less.
This blog was written by REACHOUT Bangladesh team members – Tamanna Majid (Research Associate, BRAC JPGSPH), Sushama Kanan (Research Associate, BRAC JPGSPH), Farzana Islam (Assistant Scientist, BRAC JPGSPH), Malabika Sarker (Professor and Director of Research, BRAC JPGSPH), and Sabina Faiz Rashid (Dean, BRAC JPGSPH).