Study Team: Dr. M. A. Mannan (Team Leader), Dr. Rumana Huque, Dr. S. M. Zahedul Islam Chowdhury and Humayra Ahmed

Sponsor: Policy and Operations Evaluation Department (IOB), Ministry of Foreign affairs, the Netherlands

Introduction

Menstrual regulation (MR) is defined as an interim method of establishing non-pregnancy for a woman who is at risk of being pregnant, whether or not she is pregnant in fact. In Bangladesh, unsafe abortion is one of the leading causes of maternal death. While termination of pregnancy is legal only to save the life of the pregnant woman, there is an increasing demand for pregnancy termination despite a steady increase in contraceptive use rate. With financial support from the Embassy of the Kingdom of the Netherlands, a project was launched in 2008 titled “Strengthening of National Menstrual Regulation Programme for Reduction of Maternal Mortality and Morbidity in Bangladesh”. The overall aim of the initiative was: 

•    To improve knowledge of and equitable access to quality MR service for the prevention of unsafe abortion and unsafe MR;

•    To create an increased awareness among the target communities on women’s rights in relation to violence against women, the risk of early marriage and teen pregnancy.

Evaluation Objectives

The main purpose of the impact study is to assess whether and to what extent the implementing agencies i.e. Marie Stopes Clinic Society (MSCS) and Family Planning Association of Bangladesh (FPAB) have achieved their desired objectives and goals as reflected in their proposal. The specific objectives of the evaluation are:

(1)    To assess the appropriateness, effectiveness and efficiency of the activities implemented under the MR project. 

(2)    To identify the barriers for women to access and utilize reproductive health services including Family planning and MR;

(3)    To identify constraints and other factors hampering the effectiveness of MSCS’ and FPAB’s approach related to introduction and implementation of MR.

Methodology

The present evaluation has been carried out to assess the impact of the EKN supported interventions on MR performance in terms of quality and utilization of services. The study was carried out in two intervention (Sylhet and Maulvibazar) and one control (Habiganj) areas. The study sample included 1200 respondents- 600 women respondents aged 15-49 years, 300 male household heads and another 300 MR clients. The sample was equally divided among the three areas-i.e. 400 from each area (consisting of 200 women, 100 male-heads, and 100 MR clients). Impacts of the interventions are assessed in terms of their knowledge on family planning (FP) methods, current use of FP methods, time-line for safe MR and service providers for MR. Both quantitative and qualitative data were utilized for the study. Quantitative data was collected through Household survey and Exit survey of MR clients. The major contents of the questionnaire included information on the timeline of MR, service providers who performed the MR procedure, side effects or complications resulting from MR procedure, etc. Qualitative data was collected through Focus Group Discussion (FGD) and Key Informant Interview (KII)

Key Findings

The initiative was intended to increase awareness on prevention of unwanted pregnancy and MR services and to improve quality of safe MR services. The MR clients were asked about the places where they did the MR. The data suggests that in the intervention areas, 88.5% of the MR was performed at public health facilities, while in control area the proportion was only 60%. The proportion of MR cases assisted by unqualified provider was also considerably high in control area (30%). 

Little variation was found among women and MR clients about their knowledge on different methods of family planning in the intervention and control areas. However, the women and the MR clients in intervention areas were more aware of emergency pill, azol/withdrawal and safe period as compared to their counterparts in control area. 

Knowledge about timeline of MR is crucial for safe MR. The present study also assessed the knowledge of women and MR clients based on their awareness on the timeline of MR. It was found that 51% of women and 74% of the MR clients had correct knowledge about the timeline of safe MR in control area, while the proportion was considerably higher in intervention areas (79% and 88% respectively). 

The intervention has been successful in improving both the male and female respondents’ knowledge about the timeliness of MR, ceteris paribus. However, it appears that the intervention had a significantly stronger positive effect on the male respondents than on the female respondents. Education and age also seem to influence the knowledge of the female, while the male knowledge is associated with health seeking behavior.

Overall Impact of the intervention

Overall, the MR initiative has been successful in achieving the targets, as reflected through:

•    Increased demand for post abortion care and post MR family planning (FP) advices;

•    Improved quality and capacity for delivering safe MR, FP, post abortion care and post MR FP services; however, there is room for improvement of the quality of pre-counseling. 

•    Community leaders, local level elected representatives, school/college teachers and health-FP-field workers are found to utilize their awareness for advocacy in SRH related issues, even beyond the project period;

•    Quality of MR services (measured by the occurrence of complications after MR procedure), delivered by project and public health centers improved significantly in the intervention area;

•    Capacity of service providers to provide quality MR services has improved significantly.

The present evaluation shows that the initiative has produced excellent results in:

•    Increasing post abortion care services among the women (including adolescents);

•    Increasing capacity of service providers of the two implementing agencies for delivering safe MR, FP, Post abortion care and post-MR family planning services;

•    Creating an enabling environment and obtaining support of local communities (community leaders, elected bodies etc.) and other stakeholders for promotion of safe MR and prevention of VAW, early marriage and early pregnancy.

Findings from the study show that overall knowledge regarding key aspects of reproductive health (knowledge regarding modern methods of FP, emergency pill) and MR related issues (safe timeline for MR, skilled provider for MR) has increased substantially because of the intervention. To be effective, however, MR providers require good training, management, and community support— essential prerequisites that the EKN supported intervention programme has been able to provide. However, one distressing aspect is that women who came to FPAB or MSCS for MR after 8 weeks of LMP were referred to public facilities (DH/UHC). 

Concluding Remarks:

The present study has been undertaken to examine the impact of the MR intervention. Three independent indicators are used to see the impact of the program –how far the program has been successful in: (a) increasing awareness regarding timeline for safe MR, (b) enhancing access to services to get rid of unwanted pregnancy, and (c) reducing the incidence of unsafe abortions, early marriage and violence against women. About 4 million pregnancies occur in Bangladesh annually out of which around one million is unwanted. Due to this high-unwanted pregnancy rate, several hundred thousand women terminate their pregnancy either by MR or through abortion. Government policy in Bangladesh does not recognize abortion; but there exists a policy on menstruation regulation (MR), which permits termination of unwanted pregnancy up to 10 weeks from the last menstrual period. Access to safe MR is limited, and unskilled and untrained providers mostly conduct termination of pregnancy. MR facilities are not available at village level, service providers are not adequately trained and post abortion care facilities are insufficient. Huge BCC gap also exists, and procuring funds for promotion of safe abortion service is difficult. However, with funding from the Kingdom of the Netherlands, the FPAB and MSCS have played a crucial role in promoting safe MR in their respective working areas.