Health Seeking Behavior and Health Service Facilities of Menstrual Regulation (MR) Clients in The Northeast Region of Bangladesh

Many women in Bangladesh terminate their pregnancy either by menstrual regulation (MR) or through abortion. Government policy doesn’t recognize abortion; but there exists a policy for MR, permitting termination of unwanted pregnancy up to 10 weeks from the last menstrual period. But access to safe MR is limited—unqualified and untrained providers mostly perform termination of pregnancy, creating unsafe abortion one among the leading causes of maternal deaths in Bangladesh. So, to cut back maternal mortality and morbidity within the country, some initiative was launched. The aim was to enhance knowledge of and access to quality MR services for the prevention of unsafe abortion and unsafe MR. the current study will examine health seeking behavior and attitudes towards MR of MR clients/patients in intervention and control areas. Findings suggest that overall respondents within the intervention area are far better off in terms of awareness regarding timeline of safe MR (88% of the MR clients) compared to their control group counterparts (74%), Different service providers have played a vital role in promoting safe MR within their respective working areas in the aspects of awareness creation, standard guideline on MR, enabling environment, and rights-based approach. However, there still remains scope to enhance quality of care.


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" [1][2][3]. On the other hand, Abortion is defined as the interruption or termination of pregnancy after the implantation of the blast cyst in the endometrium and before the resulting fetus has attained viability.  [6] and 43 in 2011 [7], while the under five-mortality rate declined from around 260 deaths per 1000 live births to only 53 over the same period (NIPORT 2011). Immunization coverage at the age of 12 months increased from as low as 54% in 1990 to 82.5% in 2011 and the country is expecting to attain polio-free status very soon [8].

Objectives
The main purpose of the present study is to assess whether and to what extent the interventions of the some service providers that perform MR services have an impact in terms of increasing awareness regarding MR and increasing knowledge on safe timeline and appropriate place for performing MR and to what extent has the intervention been effective in increasing the social awareness regarding MR and abortion issues and removing misconceptions related to MR. It will also examine quality and utilization of MR services of service providers including pre-and post-counseling and barriers in accessing services. The rest of the paper is organized as follows. Section 3 provides literature review, section 4 provides methodology, section 5 describes knowledge, attitudes, health seeking behavior and health service facilities of MR client regarding FP and MR and section 6 will discuss results and findings.

Status of Maternal Mortality
There are two indicators for monitoring the reduction of maternal mortality -maternal mortality ratio (MMR) and  [9]. Further evidence in this regard comes from the two official government studies of maternal mortality (Bangladesh Maternal Mortality Surveys, or BMMS), which were conducted in 2001 and 2010 [10]. Their results offer further evidence of this steep decline: a drop in maternal mortality of two-fifths in less than one decade. In 2011, MMR was 194. Maternal mortality has dropped considerably in Bangladesh over the past few decades. Some of that declinethough exactly how much cannot be quantified-is likely attributable to the country's menstrual regulation (MR) program, which allows women to establish non-pregnancy safely after a missed period and thus avoid recourse to unsafe abortion [11].
According to [11] Bangladesh has succeeded in reducing deaths during pregnancy and childbirth by improving access to maternal health care and lowering fertility, especially births that pose above-average health risks (e.g., births occurring to highparity women). What makes the country unique, however, is the potential contribution of an authorized procedure-known as menstrual regulation, or MR-to "establish non-pregnancy" after a missed period [2]. A national level survey conducted during 1978-79 found that complications from unsafe abortion played a major role in 26% of maternal deaths [12]. Similarly, a study of rural areas conducted during the 1980s found that the proportion of maternal deaths attributable to abortion was 15% [13]. However, there has been substantial improvement in this regard over the last two decades as will be clear from the following. Findings from first national maternal mortality survey of 2001 (NIPORT 2001) found a substantially lower proportion of maternal deaths attributable to abortion-only 5% of maternal deaths were related to induced abortion [14].
The 2011 BMMS found an even smaller percentage, merely 1% of maternal deaths were attributable to abortion during 2008-2010. If this last estimate is accurate, it points to a steep decline in the proportion of maternal deaths due to unsafe abortion [10]. However, it needs to be emphasized that the various surveys used different methodologies, some methodologies were less rigorous than others. Again, surveys associated to maternal mortality in general, and of abortion related mortality in particular, are likely to suffer from recall lapse and high levels of under-reporting [9]. It is to note that Bangladesh is a moderate Muslim country with some cultural values of conservative nature. Living together with partner, extramarital sex and getting children without being married is against the norm of the society. Such women are socially excluded and their children cannot be reared as other children in the society.
Women therefore try to hide their relationship with their partner, and in case of pregnancy outside wedlock, they try to abort the child in secrecy. In this backdrop, MR is considered as a tool to hide the 'sin' of secret sexual relations, and therefore is socially MR is also considered as a sin from religious point of view.
'Children' are considered to be 'gift of God' and any harm to them is not religiously acceptable. Moreover, there remains some misconception about the health hazards associated with MR, which makes it unpopular among general people. Social, cultural and religious norms along with some misconception make MR a sensitive issue in Bangladesh.

The Marie Stopes Clinic Society (MSCS)
The Marie Stopes Clinic Society has been providing a wide

The Menstrual Regulation (MR) Program in Bangladesh
The exceptional contribution of MR to women's health care in Bangladesh dates from the early 1970s. During the early 1970s, the government of Bangladesh introduced MR services in a few urban family planning clinics and district hospitals under the guidance of an expert team from Bangladesh, India, the United Kingdom, and the United States [15,16]

Menstrual Regulation (MR) Services
The original impetus for introducing MR services came from scientists, government and international leadership. Support for provision of this reproductive health service is broad based and includes these as well as other stake-holders such as service providers and women's rights organizations [21]. Nevertheless, studies have suggested that there is room and need for improvement in access to quality MR services. In addition, a recent review of the MR program has argued that it has been marginalized within overall health policy in Bangladesh over the last decade [19]. A government authorization rule controls MR [2], which is generally done with manual vacuum aspiration (MVA). The rule provides specific guidance for the provision of MR services, covering the kinds of providers who can deal the service, namely, doctors, family welfare visitors (FWVs) and paramedics (include providers such as Sub-Assistant Community Medical Officer-SACMO, and medical assistants); the situation of service provision, either outpatient or inpatient; and the maximum number of weeks allowed since the last menstrual period (LMP).
Although MR is allowed up to eight weeks after LMP when performed by FWVs and paramedics, and up to 10 weeks after LMP when implemented by a physician, providers occasionally perform the procedure later as well [20][21][22][23][24][25][26][27][28]. Currently MR is widely practiced throughout the country and is available at all tiers, from district and

Study Design
As FPAB and MSCS are crucial service providers for performing MR services, the present study is limited to project areas of Family

Selection of Respondents for Survey
The survey covered 200 MR clients in project/intervention area and 100 MR clients in control area. In each district, the sample

Qualitative Data Collection Methods
The study also observed the role of service providers to measure      Table 4, we also found some significant results. The intervention did, however, raise the knowledge of the MR clients of the emergency pill, azol/withdrawal, the safe period, ligation and the implant, from largest to smallest effect respectively.    knowledge about the timeline of safe MR in control area, while the proportion was considerably higher in intervention areas (88%).

Some Important Issues regarding MR
( Figure 1). The intervention has been successful in improving the MR clients' knowledge about the timeliness of MR, ceteris paribus.
However, it appears that the intervention had a significantly stronger positive effect on the MR clients.

d) Duration of Pregnancy when MR was Performed:
Safe MR requires maintaining safe timeline. Among the MR clients in intervention areas, 59% reported that MR was done within 8 weeks from the LMP which was 9.9% in the baseline survey. This is a good indication that the interventions of the project have been highly successful. However, 5.5% respondents in intervention areas told that their MR was performed more than 10 weeks after LMP.
In control area, 29% of MR clients had the procedure performed after 10 weeks of LMP, which is a risky procedure involving life threatening consequences, and needs attention of the policy makers (Table 8 and Figure 3). Good quality of care reduces the risk of complications. Quality of care includes that clients will be informed on the procedure, that the provider is technically competent and operates in clean premises that the provider is friendly towards the client and that follow-up mechanisms are in place. Good quality of    The findings suggest that in intervention areas, 40% MR clients faced complications after MR (35% in Sylhet and 45% in Maulvibazar), and the remaining 60% did not face any post MR complication. However, the proportion of respondents who faced complications after MR was markedly higher in control area (64%) than intervention areas (Figure 4). The MR clients who mentioned that they experienced complications were asked about the type of complications they faced after MR. It was evident that excessive bleeding and abdominal pain were the major problems the MR clients faced in both intervention and control areas. However, a considerable proportion of MR clients (36%) in control area also faced uterus infection after MR. This is not unexpected because more than one-third of the MR cases in the control area were performed by unskilled providers. It was found that 100% of the respondents in Sylhet started using FP methods after MR, while in Habigonj, 91% respondents started using FP methods after MR. The proportion was 86% in Maulvibazar. It was also evident that some of the respondents did MR more than once. The average number of MR done was lower in intervention area than control area (Tables   9 & 10).   information from the client before performing MR. However, the scenario is not the same across the areas. In intervention areas, majority of the respondents informed that the providers asked about last date of menstrual cycle, whether it was first pregnancy, age of the last child, and whether any C-section was done. The proportion of MR client who were asked such questions were lower in control area. Relatively small number of respondents, in both intervention and control areas, stated that providers asked about their knowledge on MR or whether they used any family planning method before (Table 11). When clients come to the provider for MR, the provider is supposed to inform the MR clients about the various steps involved in the MR procedure. The study finds that a considerably higher proportion of MR clients in intervention areas were told about the steps of MR by the provider as compared to control areas (85% vs 61%). The percentage of respondents who received advice on FP from the MR provider was also noticeably higher in intervention areas than in control area (95% vs 64%) ( Table 12). The study also explored the type of advice the MR clients received from the provider after the MR procedure was complete. The findings are presented in (Table 6-   The proportion was considerably lower (about half) in intervention areas (Table 14). MR clients were asked to mention the problems they faced after coming to the facility/provider for doing MR. Long waiting time, no place to rest, no counseling and spending of money were identified as the major problems they faced in the facility (Table 15).    From OLS estimation, for all types of providers together, the costs in the intervention area are significantly lower (99% confidence interval) than in the control area (Table 17). This may be partly explained by the fact that due to capacity building and    Table 19.  (Tables 20-22). MR related complications are an important indicator of quality of MR. The proportion of respondents who faced complications after MR was markedly higher in control area than intervention areas. In the intervention area, a significantly larger proportion of clients had the procedure performed by a skilled doctor than in the control area. Income also significantly contributed to going to a skilled doctor, both in the intervention and in the control area. However, the procedure itself was not sufficiently clearly explained to the clients, neither in the intervention nor in the control area. Complications occurred more frequently in the control area and the difference is statistically significant. Clients in the intervention area also received more frequently suggestions after the MR procedure than clients in the control area, including the advice to take rest and to start using family planning methods.
However, the procedure itself was not sufficiently clearly explained to the clients, neither in the intervention nor in the control area.

Conclusion
The study is carried out in two intervention (Sylhet and