The association between intimate partner violence and self-managed abortion: a cross-sectional study among women in urban Bangladesh.

In Bangladesh, abortion is illegal, except to save a woman's life. However, menstrual regulation (MR) to induce menstruation up to 12 weeks from the last menstrual period is permitted. Although safe and legal MR services are available, many women choose to self-manage their abortions. The prevalence of intimate partner violence (IPV) in Bangladesh is high. Whether IPV is associated with self-managed abortion is unknown. Between January and December 2019 we administered cross-sectional surveys to women presenting for MR or post-abortion care (PAC) services at facilities in six cities in Bangladesh assessing if women had ever experienced IPV and if they attempted to self-manage their abortion. We used multivariable logistic regression to assess the association between IPV and self-managed abortion and multinomial logistic regression to the association between IPV by type: (none, any physical, any sexual, or both) and self-managed abortion. Among 2679 women who presented for MR or PAC care and participated in the survey, 473 (17.7%) had previously attempted to self-manage abortion. Women who had ever experienced any IPV were more likely to attempt self-managed abortion prior to presenting for MR or PAC (adjusted odds ratio (aOR) = 1.52, 95% CI 1.24, 1.87). Women who ever experienced physical IPV were more likely to attempt self-managed abortion (adjusted relative risk ratio (aRRR) = 1.62, 95% CI 1.30, 2.03). Women who have ever experienced physical IPV may be more likely to attempt a self-managed abortion because they seek more covert ways of ending a pregnancy out of fear for their safety, or because of limited mobility or lack of resources. Interventions to support women to safely self-manage abortion should focus on populations with higher rates of IPV.

Out-of-clinic and self-managed abortion in Bangladesh: menstrual regulation provider perspectives.

BACKGROUND: In Bangladesh, abortion is illegal except to save a woman's life, though menstrual regulation (MR) is permitted. MR involves the use of manual uterine aspiration or Misoprostol (with or without Mifepristone) to induce menstruation up to 10-12 weeks from the last menstrual period. Despite the availability of safe and legal MR services, abortions still occur in informal setttings and are associated with high complication rates, causing women to then seek post abortion care (PAC). The objective of this study is to contextualize MR in Bangladesh and understand systemic barriers to seeking care in formal settings and faciltators to seeking care in informal settings via the perspective of MR providers in an effort to inform interventions to improve MR safety. METHODS: Qualitative individual semi-structured interviews were conducted with 25 trained MR providers (doctors and nurses) from urban tertiary care facilities in six different cities in Bangladesh from April to July, 2018. Interviews explored providers' knowledge of MR and abortion in Bangladesh, knowledge/experience with informal MR providers, knowledge/experience with patients attempting self-managed abortion, personal attitudes and moral perspectives of MR/abortion in general, and barriers to formal MR. Team based coding and a directed content analysis approach was performed by three researchers. RESULTS: There were three predominant yet overlapping themes: (i) logistics of obtaining MR/PAC/abortion, (ii) provider attitudes, and (iii) overcoming barriers to safe MR. With regards to logistics, lack of consensus among providers revealed challenges with defining MR/abortion gestational age cutoffs. Increasing PAC services may be due to patients purchasing Mifepristone/Misoprostol from pharmacists who do not provide adequate instruction about use, but are logistically easier to access. Patients may be directed to untrained providers by brokers, who intercept patients entering the hospitals/clinics and receive a commission from informal clinics for bringing patients. Provider attitudes and biases about MR can impact who receives care, creating barriers to formal MR for certain patients. Attitudes to MR in informal settings was overwhelmingly negative, which may contribute to delays in care-seeking and complications which endanger patients. Perceived barriers to accessing formal MR include distance, family influence, brokers, and lack of knowledge. CONCLUSIONS: Lack of standardization among providers of MR gestational age cutoffs may affect patient care and MR access, causing some patients to be inappropriately turned away. Providers in urban tertiary care facilities in Bangladesh see primarily the complicated MR/PAC cases, which may impact their negative attitude, and the safety of out-of-clinic/self-managed abortion is unknown. MR safety may be improved by eliminating brokers. A harm reduction approach to improve counseling about MR/abortion care in pharmacies may improve safety and access. Policy makers should consider increasing training of frontline health workers, such as Family Welfare Visitors to provide evidence-based information about Mifepristone/Misoprostol.