Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, 9300 Campus Point Drive, La Jolla, San Diego, CA, 92037, USA.
Ipas, P.O. Box 9990, Chapel Hill, NC, 27515-7052, USA.
Reprod Health. 2021 Mar 25;18(1):69. doi: 10.1186/s12978-021-01123-w.
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.
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.
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.
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.
在孟加拉国，堕胎除了挽救妇女生命外是非法的，尽管允许进行月经调节（MR）。MR 涉及使用手动子宫吸引或米索前列醇（有或没有米非司酮）来诱导月经，从上次月经开始最多 10-12 周。尽管有安全合法的 MR 服务，但堕胎仍在非正式场所发生，并伴有高并发症发生率，导致妇女随后寻求堕胎后护理（PAC）。本研究的目的是从孟加拉国的角度了解 MR，并了解在正规医疗机构寻求护理的系统障碍和在非正式医疗机构寻求护理的促进因素，通过 MR 提供者的视角，为提高 MR 安全性的干预措施提供信息。
2018 年 4 月至 7 月，在孟加拉国六个不同城市的城市三级保健设施中，对 25 名经过培训的 MR 提供者（医生和护士）进行了定性的个人半结构化访谈。访谈探讨了提供者对孟加拉国 MR 和堕胎的了解、对非正式 MR 提供者的了解/经验、对试图自行管理堕胎的患者的了解/经验、对一般 MR/堕胎的个人态度和道德观点，以及对正式 MR 的障碍。由三名研究人员进行了基于团队的编码和有针对性的内容分析方法。
有三个主要但重叠的主题：（i）获得 MR/PAC/堕胎的后勤问题，（ii）提供者的态度，（iii）克服安全 MR 的障碍。关于后勤问题，提供者之间缺乏共识表明，在确定 MR/堕胎的妊娠年龄截止点方面存在挑战。PAC 服务的增加可能是由于患者从药剂师那里购买米非司酮/米索前列醇，而药剂师没有提供足够的使用说明，但药剂师在后勤方面更容易获得。患者可能会被经纪人转介给未经培训的提供者，经纪人会拦截进入医院/诊所的患者，并从非正式诊所获得带患者的佣金。提供者对 MR 的态度和偏见会影响谁接受护理，为某些患者提供正式的 MR 带来障碍。对非正式环境中的 MR 的态度基本上是负面的，这可能导致护理延迟和危及患者的并发症。获得正规 MR 的障碍包括距离、家庭影响、经纪人以及缺乏知识。
MR 妊娠年龄截止点提供者之间缺乏标准化可能会影响患者护理和 MR 的获取，导致一些患者被不恰当地拒绝。孟加拉国城市三级保健设施的提供者主要看到的是复杂的 MR/PAC 病例，这可能会影响他们的负面态度，以及非诊所/自行管理堕胎的安全性是未知的。消除经纪人可能会提高 MR 的安全性。减少伤害的方法来改善关于 MR/堕胎护理的咨询在药店中可能会提高安全性和可及性。政策制定者应考虑增加基层卫生工作者的培训，例如家庭福利访客，以提供关于米非司酮/米索前列醇的循证信息。
