Hospital-based mortality and morbidity related to induced abortion.

PIP: During 1989-1990, 1301 women were admitted to 3 types of government hospitals in Bangladesh with a diagnosis of abortion. 32.3% (420) cases had had a miscarriage. About 90% of cases presented with an incomplete abortion and bleeding. Around 20% had clinical signs of infection. Serious clinical infections (e.g., generalized peritonitis and septicemic shock) were present in about 6% of induced abortion cases. Induced abortion cases at admission were more likely than spontaneous abortion cases to have mechanical injury, clinical signs of infection, life threatening infections, and signs of renal/cardiac failure and of hypovolemic shock. 90.6% of induced abortion cases were multigravida. Most abortion cases did not know where one can obtain menstrual regulation/abortion services (79.5% for spontaneous and 67.3% for induced abortion cases). Most induced abortion cases (61.7%) chose to terminate the pregnancy because they did not want any more children. Almost 75% experienced a surgical procedure while in the hospital. The case fatality rate for induced abortion was 2.1%. The risk of death was highest for cases who had a serious clinical infection, underwent dilatation and curettage, and whose abortion was induced by insertion of solid sticks and native medicines. Urban dwellers and educated cases were most likely to seek an induced abortion from physicians, nurse midwives, family planning workers, and pharmacists while rural dwellers and less educated cases tended to seek an induced abortion from traditional healers, village doctors, quacks, and their husband/relative/neighbor. The mean number of days in the hospital was 3.3 days for spontaneous abortion cases and 4.6 days for induced abortion cases. Induced abortion cases comprised 8.9% of total OB/GYN admissions and 8.3% of bed occupancy. Induced abortion cases were more likely to need a blood transfusion and more blood than spontaneous abortion cases (0.8 vs. 0.5 units).^ieng

Saving lives with menstrual regulation.

PIP: Although Bangladesh law permits induced abortion only to save the life of the mother, menstrual regulation is legally available. In 1978, a large-scale menstrual regulation training program was organized for government physicians and family welfare visitors. By 1983, there were 11 menstrual regulation centers and the procedure had become incorporated into the National Family Planning Program. At present, 22% of abortions in Bangladesh are performed in menstrual regulation centers. At least a third of the 24,000 deaths in Bangladesh each year from pregnancy-related causes are associated with septic abortions performed by untrained abortionists in the rural areas. Menstrual regulation offers a means to prevent many of these deaths; however, rural women are largely unaware of the availability of menstrual regulation and must be reached by field-level health and family planning workers with information about the safety of this method. In addition, women must be made aware that menstrual regulation can be performed only up to the 10th week of pregnancy (up to 8 weeks, if performed by a family welfare visitor).^ieng

Menstrual regulation training and service programs in Bangladesh: results from a national survey.

Using nationally representative sample survey data collected in 1986, this study evaluates the training and service programs for menstrual regulation (MR), and estimates the number of MR procedures performed during 1986, in Bangladesh. The results show that most of the MR providers, who received either formal or informal training, were physicians and family welfare visitors (paramedics) employed by the government. They were trained in various aspects of MR performance, including contraindications and complications associated with MR, the techniques of MR performance and follow-up procedures, and maintenance and sterilization of MR equipment. Averages of 20.5 and 13.0 MR procedures were performed by formally and informally trained physicians, respectively, in the three-month period preceding the date of interview. The corresponding average numbers for formally and informally trained family welfare visitors were 11.6 and 9.1, respectively. A total of 241,442 MR cases were estimated to have been performed between August 1985 and July 1986.

PIP: Data from a 1986 nationally representative sample survey conducted in Bangladesh were used to evaluate the training and performance of various menstrual regulation providers. A total of 635 formally trained physicians, 827 formally trained family welfare visitors, 157 informally trained physicians, and 315 informally trained family welfare visitors were interviewed. In this analysis, the data on the providers were analyzed by their formal/informal training status. The absolute number of formally trained menstrual regulation (MR) providers who received their training through the government or the Bangladesh Association for Prevention of Septic Abortion (BAPSA) was much higher than the number who were informally trained by formally trained providers. The largest proportion of trained providers were family welfare visitors (52.9%), followed by physicians employed in government health agencies (33.3%), reflecting the training agencies' emphasis on training those who were associated with government family planning programs. For 74.1% of the physicians and 86.3% of the family welfare visitors, the duration of formal training was 3 weeks. 60.9% of family welfare visitors and 56.5% of physicians were trained both by demonstration and class lectures; a much lower percentage were trained by demonstration only (38.6% and 43.0%, respectively). Most of the physician providers and family welfare visitor providers were trained in various aspects of contraindications and complications associated with MR performance, in techniques of MR performance and follow-up procedures, and in maintaining and sterilizing MR equipment, but only 43.2% of the family welfare visitors and 65.9% of the physicians were trained in the application of anesthesia. The average numbers of MR procedures performed by formally and informally trained physicians in the 3 months preceding the interview were 20.5 and 13.0, respectively; the corresponding figures for formally and informally trained family welfare visitors were 11.6 and 9.1, respectively. 70.4% of formally and 78.5% of informally trained physicians provided treatment for incomplete abortion complications. The majority of providers used government clinics for MR performance, particularly the family welfare visitors.

Clinical acceptability, use-patterns and use-effectiveness of the vaginal contraceptive sponge and Neo Sampoon tablets--an international multi-center randomized clinical trial.

This paper describes the results from a randomized clinical trial comparing the Collatex vaginal contraceptive sponge (a predecessor of the Today sponge) and Neo Sampoon foaming vaginal contraceptive tablets; the trial was conducted from 1979 to 1983 in four centers located in three countries (two in Yugoslavia and one each in Taiwan and Bangladesh). The sponge was associated with more insertion and retention problems than the tablet, especially in the two Asian centers. More Neo Sampoon users complained of a burning or stinging sensation. This complaint, however, seemed to be well-tolerated and was not a frequent reason for irregular use and/or discontinuation of use of the tablets. Clinically significant medical complications were rarely reported for either method. Sponge users were more likely to report irregular use than tablet users, primarily due to inconvenience of use. Rates of discontinuation at six months of use were also consistently higher among sponge users than Neo Sampoon users in the four centers. Life-table pregnancy rates at 12 months of use ranged from 3.8 to 18.2 per 100 sponge users and 6.2 to 29.9 per 100 Neo Sampoon users, based on data from the two Yugoslavian centers and the Taiwan center (data from the Bangladesh center were excluded from analysis of pregnancy rates). Practical implications of these findings are discussed.

PIP: This paper describes the results from a randomized clinical trial comparing the Collatex vaginal contraceptive sponge (a predecessor of the Today sponge) and Neo Sampoon foaming vaginal contraceptive tablets; the trial was conducted from 1979 to 1983 in 4 centers located in 3 countries (2 in Yugoslavia and 1 each in Taiwan and Bangladesh). The sponge was associated with more insertion and retention problems than the tablet, especially in the 2 Asian centers. More Neo Sampoon users complained of a burning or stinging sensation. This complaint, however, seemed to be well-tolerated and was not a frequent reason for irregular use and/or discontinuation of use of the tablets. Clinically significant medical complications were rarely reported for either method. Sponge users were more likely to report irregular use than tablet users, primarily due to inconvenience of use. Rates of discontinuation at 6 months of use were also consistently higher among sponge users than Neo Sampoon users in the 4 centers. Life-table pregnancy rates at 12 months of use ranged from 3.8 to 18.2/100 sponge users and 6.2 to 29.9/100 Neo Sampoon users, based on data from the 2 Yugoslavian centers and the Taiwan center (data from the Bangladesh center were excluded from analysis of pregnancy rates). Practical implications of these findings are discussed.

Induced abortion in a rural area of Bangladesh.

Mortality rates from indigenous abortion practices have not been described previously. From September 1982 to August 1983, traditional birth attendants, under medical supervision, collected data on all identifiable pregnant women and pregnancy outcomes in a geographically defined population in rural Bangladesh. Of 9,906 pregnancies, 9,317 ended in live birth, 412 in induced abortion, and 177 in spontaneous abortion. All abortions were induced by indigenous health practitioners. The abortion-to-live-birth ratio was 44.2 per 1,000. Ten women died after induced abortion, yielding a death-to-case rate of 2.4 percent. The death-to-case rate was highest for women 35 and older and women of parity five and higher. The authors conclude that improved distribution of safe, acceptable means of fertility regulation may save many mothers' lives.

PIP: A survey in 1978 estimated that about 21,600 pregnancy related deaths occured in Bangladesh in that year of which 25.8% were due to complications of induced abortion. The study was conducted to determine the prevailing rate, causes, and correlates of maternal death in 2 rural areas: Melanda and 3 unions of Islampur. The study employed 109 traditional birth attendents (TBAs) to collect the data. The fact that they were able to report 28 cases of induced abortion in women not currently married strengthens the likelihood that underreporting of induced abortion was low. Mortality from induced abortion in this study was estimated at 1.1/1000 live births. Induced abortion practice is positively related to maternal age and parity. The death to case rate is also positively related to maternal age and parity. Women in Bangladesh seek abortion from clandestine sources, generally as a last resort to terminate an unwanted pregnancy. It seems plausible that many of these women would have used menstrual regulation services had they been readily available. It is probable that the provision of safe menstrual regulation services would result in fewer women seeking abortions and a subsequent reduction in maternal mortality.

Maternal mortality in rural Bangladesh: the Jamalpur District.

During the 12-month period from September 1982 to August 1983, 9,317 live births and 58 maternal deaths were recorded in Melanda and Islampur upazilas in the Jamalpur district of rural Bangladesh, giving a maternal mortality rate of 62.3 per 10,000 live births. Maternal mortality was positively related to maternal age and parity, with the mortality risk rising very sharply beyond age 35 years, and beyond parity four among women aged 25-34 years in particular. The most common causes of maternal death were eclampsia (20.7 percent), septic abortion (20.7 percent), postpartum sepsis (10.3 percent), obstructed labor (10.3 percent), and antepartum and postpartum hemorrhage (10.3 percent). These findings indicate that family planning, by decreasing the likelihood of pregnancy after age 35 and parity four, can help reduce the proportion of women at risk of maternal mortality.

PIP: This study was conducted to determine: the present rate, demographic correlates, and major causes of maternal mortality in rural Bangladesh; the pattern of health practices in relation to maternal mortality; the rate and pattern of neonatal mortality in rural areas; and the reliability of traditional birth attendants as reporters of maternal mortality-related data. During the 12-month period from September 1982 to August 1983, 9,317 live births and 58 maternal deaths were recorded in Melanda and Islampur upazilas in the Jamalpur district of rural Bangladesh, giving a maternal mortality rate of 62.3/10,000 live births. The age-specific maternal mortality rate is lowest in the 20-24 year old age group. Mortality risk increases with age after 29 years, particularly in the 35-39 and the 40-and-over groups. For all ages combined, mortality rates show a positive relation to parity. Although a positive relationship between parity and mortality is visible in the 25-34 group, the relationship is negative in the 35-and-over group. The single most common cause of death was septic abortion. Other causes include eclampsia (20.7%), delivery complications including obstructed labor, retained placenta (17.2%), postpartum sepsis (10.3%), and hemorrhage (10.3%). The classic triad of causes of infection--eclampsia--hemorrhage, accounted for 68.9% of all maternal deaths in the study area; direct obstetric causes accounted for 86.2% of all maternal deaths. The positive correlation between maternal age and maternal mortality risk found in the study indicates that childbearing in women aged above 35 years is significantly more hazardous than in younger women. A high mortality risk was also found among high parity (4) women. Family planning can reduce the risk of maternal mortality.

Risks and costs of illegally induced abortion in Bangladesh.

PIP: This article reports on women admitted to Dhaka Medical College Hospital for incomplete, illegally induced abortion. Women with low complication rates more often had abortions induced by medical practitioners. These women were younger, of lower parity and better educated than women having abortions initiated by other practitioners. Poorly educated women from slum areas almost always had an abortion induced by a nonmedical practitioner through the insertion of a solid object. These women experienced high complication rates and often required hysterectomies. This group also had high mortality rates. The drain on hospital resources needed to treat these abortion patients was great.^ieng

Pelvic infections following gynecologic procedures in Bangladesh.

Data were collected to establish the rate of pelvic infection following various gynecologic procedures, including postpartum intrauterine device (IUD) insertions, IUD insertion following menstrual regulation procedures, IUD insertion in women who were not recently pregnant, and induced and spontaneous abortions. The pelvic infection rate was only 1% in 97 women who underwent postpartum IUD insertions. The infection rate was related to the timing of IUD insertion and the type of IUD used. Finally, the pelvic infection rate was unacceptably high (10.3%) in women undergoing induced abortions vs. women having spontaneous abortions (1.1%).

A clinical trial of Neo Sampoon vaginal contraceptive tablets.

Results are reported of a clinical trial of Neo Sampoon vaginal contraceptive tablets, conducted by the International Fertility Research Program (IFRP) in collaboration with the Dacca Medical College Hospital, Bangladesh. Of the 150 women enrolled, 115 remained in the study at the end of 12 months. The 12-month cumulative gross life-table rates per 100 women were 6.5 for pregnancy and 24.8 for discontinuation due to other reasons. Discomfort associated with the heart generated by the tablets' effervescence was the primary side effect of Neo Sampoon use, and was one of the major causes of discontinuation. Regularity of use and acceptability of this foaming tablet appeared to be high compared to other barrier methods. Further research is needed on Neo Sampoon and other vaginal contraceptives to develop and promote methods that can help meet the worldwide demand for fertility control.

PIP: In mid-1978, the International Fertility Research Program initiated a clinical trial of Neo Sampoon Loop vaginal tablet contraceptives. Data were recorded on standardized forms in several countries. The Bangladesh study was conducted at the Dacca Medical College Hospital. Results from the Bangladesh study are discussed and tabulated. The study showed good acceptability of this method. Of the 150 women enrolled in the study, 115 were still in it after 12 months. After 12 months, there was a 6.5/100 women pregnancy rate and a 24.8/100 women discontinuation rate. These rates are encouraging since most of the women had no previous experience with barrier contraception. Discomfort and a burning sensation were the main reasons for discontinuance. This method can be easily distributed outside the medical system, a system which will be necessary if all at-risk people in the world are to be covered. The fact that regularity of use fell off by 12 months indicates that sustaining motivation may be the main problem with this method of contraception.