A total of 25 trained MR providers were recruited from medical college hospitals and RHSTEP clinics, and all consented to participate in the semi-structured interviews. Twelve nurses and 13 doctors participated. There were 19 providers from medical college hospitals and 6 providers from RHSTEP clinics.
There were three predominant yet overlapping themes that providers used to discuss MR, PAC and abortion care in Bangladesh:
- Logistics of MR/PAC/abortion in Bangladesh: MR providers described the logistics of obtaining MR, PAC, and abortion in Bangladesh and defined each of the terms, gestational age cutoffs and who is providing them. They detailed their experiences treating patients that have sought out-of-clinic and self-managed abortion.
- Attitudes: MR providers detailed their own attitudes about MR in general, unsanctioned MR providers (including pharmacists), and self-management of abortion.
- Overcoming Barriers: MR providers outlined perceived barriers to clinic MR (and facilitators to out-of-clinic MR) and gave recommendations for interventions to overcome those barriers.
Interwoven among these themes were the impact of various factors on patient autonomy when deciding to have MR or abortion.
Logistics of MR, PAC, and abortion in Bangladesh
Definitions and gestational age cutoffs
Abortion is a complicated word with many meanings, and there was a lack of consistency among trained MR providers about the definition of MR, abortion, legality, and appropriate or legal gestational age cutoffs for receiving MR care. This lack of consistency was present among all sites, practice settings, and provider roles. Some providers defined the difference between MR and abortion based on the viability of the pregnancy—MR being provided only for viable pregnancies and abortion for non-viable pregnancies or in the setting of pregnancy loss with retained tissue. There were varying opinions as to whether abortion could be induced. One nurse stated, “MR is…when a patient decides to terminate their child…while abortion happens when it has already aborted but [is] not properly cleaned” (Nurse 10, medical college hospital). Another nurse agreed that “abortion is not a deliberate process, but MR is a deliberate process” (Nurse 4, medical college hospital). However, other providers acknowledged that though “abortion” refers to a non-viable pregnancy, it can be induced:
There is no bleeding in case of MR, she only wants to do termination. However, in case of abortion…she does not want to take this baby and take medicine, sometimes…the product is not released properly (Doctor 13, medical college hospital).
Others agreed that abortion is induced because it is done with knowledge of a pregnancy, whereas MR is done if the woman does not know she is pregnant:
MR is…if menstruation does not occur without being sure about pregnancy, then if the procedure is done that is called MR. But if it is done by knowing about the pregnancy then of course that is abortion (Doctor 4, medical college hospital).
With regards to legality and gestational age cutoffs, there was no standardization as to how far along MR or abortion could be performed or if abortion can actually be performed in Bangladesh:
Actually there is no abortion in Bangladesh…Some patients tell straightway, “I have come here for abortion.” Then we ask them how many months her period is stopped? Suppose she replies, 2 or 2½ months, then we make her correct that she has come for regularizing her menstruation (Nurse 2, RHSTEP).
In contrast, another doctor stated, “In Bangladesh we are doing abortion…those who are under 12 weeks, we do MR services to them” (Doctor 11, medical college hospital). Several providers acknowledged that MR can be performed up to 10-12 weeks depending on the type of provider, but there were many deviations from this standard. According to one nurse, “Abortion can be done within 35 weeks…MR can take place only within 14 weeks” (Nurse 8, medical college hospital). Another nurse stated, “Abortion can happen in 8 weeks or 12 weeks and even in 14 weeks but you have to do MR within 8 to 10 weeks. If it is 12 weeks, then it is risky” (Nurse 10, medical college hospital). One doctor said, “[MR can be done before] seven menstrual weeks” (Doctor 6, medical college hospital). One RHSTEP doctor stated, “MR is generally 10 weeks for doctors and 8 weeks for nurses” (Doctor 8, RHSTEP). If providers are unaware of the legal gestational age cutoffs for MR, it may contribute to patients begin turned away from facilities, even if they are within the legal gestational age limit.
Informal out-of-clinic providers
According to providers, patients sometimes are referred to informal out-of-clinic providers by brokers and via word-of-mouth from family and community members. Brokers intercept patients entering the hospitals/clinics for MR or PAC and receive a commission from informal clinics for bringing patients. Although some traditional healers and homeopathic providers perform out-of-clinic abortions, a lot of the informal providers have previously worked in the hospitals and sanctioned clinics as observing assistants but have not usually received formal training:
These service providers may have some experience, for example, this aunty has become an expert by watching MR regularly here. Like her, these service providers might have worked for a center and then they decide to open a private clinic by their own (Doctor 13, medical college hospital).
Do you know that some of our Ayas [sisters/hospital workers], they introduce themselves as Nurse to the patients and take them? But they are not nurse, they do not have any training (Nurse 6, medical college hospital).
The settings in which these informal providers practice were described as unhygienic without proper sterilizing equipment, often located in the provider’s private home. One doctor explained, “We do autoclave regularly our instrument. We don’t use any instrument twice without autoclave. But those service providers don’t do that. They wash the instruments with water and use it again and again” (Doctor 3, RHSTEP).
The methods used to induce MR/abortion can vary by the type of provider. Traditional healers tend to use herbs and tree roots, though providers report this is becoming less common:
Previously we got many patients who have been maltreated by the traditional healers. They used herbs and indigenous methods…Nowadays these types of clients has reduced…Some patients arrived [at the] hospital with septic infections and herbal roots inserted into their uterus (Nurse 2, RHSTEP).
More commonly reported was use of MVA, as “MVA set is available to purchase…They perform with the instruments in this way” (Doctor 4, medical college hospital). Some informal providers perform abortion procedures “by hand-curette” (Nurse 3, medical college hospital).
Providers at RHSTEP and in the medical college hospitals come to know of these informal providers because they treat patients who have complications, which creates unfavorable opinions of the informal providers. They describe that some patients come after seeing unsanctioned providers with “…septicemia, septic abortion, incomplete abortion…Today, we had a patient [in which] part of the digestion system was cut off during MR” (Doctor 2, medical college hospital). Other providers acknowledge that some out-of-clinic MR could be performed safely, as “those who get performed without complications, they do not come to us. They go back from there. Those who face complications they come to us” (Doctor 4, medical college hospital).
Self-managed abortion
With regards to self-management of abortion, providers indicate that although traditional methods provided by herbalists and traditional healers are still being used, using Misoprostol (with or without Mifepristone) is being more commonly reported, which is often purchased over-the-counter in pharmacies. Patients obtain various methods “through others, friends and relatives and also from the brokers….The family members instruct them. Husband goes to the medicine shop and told the drug-seller that his wife missed her period” (Nurse 1, medical college hospital). Traditional methods include herbs and “medicine made from grass root. [One patient] put this medicine in cervix…she poked [back and forth] with it in the uterus. Many people think that if they put pressure in abdomen fetus can expel” (Doctor 5, RHSTEP). Often, providers described patients trying several different methods to self-manage abortion before finally presenting to a formal clinic, though one commonly reported method was medications purchased over the counter from pharamacies without a prescription. The providers also noticed a change in the number and type of services they provide due to these practices:
Some take medicine; some go to the sisters. In [many] cases those who come to us have tried all these methods. First they take homeopathic, then go to the kabiraj (herbalist) and go to the sisters. When it becomes incomplete, then they come to us (Doctor 7, medical college hospital).
MR services [are] decreased. You can get misoprostol pills at pharmacy and everyone is using it…They do not need anything to buy it from pharmacy. Pharmacy gives the medicine to everyone like to the patients or to the husbands (Doctor 5, RHSTEP).
Providers are aware of self-management practices because they treat patients with complications which creates unfavorable attitudes about self-management. Complications from self-management include “incomplete [abortion and] excessive bleeding…Another problem is that even though they do it, the pregnancy continues. They say that they had taken medicine but it continued [to] 16-18 weeks” (Doctor 9, medical college hospital). Another provider encountered a patient “with ectopic pregnancy! She came here after taking medicine advised by her neighbor. But, she needed an open surgery… Some of them who are taking medicine from the pharmacists are having incomplete abortion” (Nurse 2, RHSTEP). Many complications from pharmacies are thought to be due to inadequate screening and instruction:
The MR through medicine also needs doctor’s instructions. We have to tell them about the dose, its use, through which route it would pass, the complications that may arise, full warning signs. They will not get such instructions from the pharmacy (Doctor 10, RHSTEP).
Other providers acknowledge that, again, they are only seeing the complications from self-managed abortion, and other cases may be happening safely. One provider knows “about two to three persons who have done it by themselves without any problem. It was complete” (Doctor 10, RHSTEP).
Spectrum of provider attitudes
MR in general
There were a variety of attitudes among trained MR providers with regards to the ethics and practice of MR, and ethics was often tied to religion. Providers working for RHSTEP tended to have a more positive view of MR, explaining the value of MR services and the benefit to patients. They also tended to respect patient autonomy and did not change practice based on the patient’s situation. One RHSTEP provider explained, “[MR] is useful for [many] girls. Otherwise many girls had to commit suicide or suffer a lot” (Nurse 2, RHSTEP). Some providers in medical college hospitals also had positive views and respected patient autonomy in decision making:
From religious point of view I had some obligations. But when I got the training of PAC and MR from IPAS, my view had changed. That training was positive for me. Now I always provide this service to the patients (Doctor 1, medical college hospital).
[I tell patients when deciding on MR] Even husband’s confirmation is not needed; your right is the main. You have to do which is right for you. You have to think about your health, your in laws will not think about it (Nurse 11, medical college hospital).
However, when providers have negative attitudes about MR or impose their own moral judgement on the patient’s decision, patient autonomy can be affected, creating barriers to MR. Some providers had religious hesitations to providing MR, and others would only perform MR in certain situations:
Usually we do not try to give MR and PAC services to the patients. First of all, we see how many children they have, how much her demand is… If we see her child age is one year or 8/9 months old then we think about MR and PAC services for her because these are good for her as her child is very much young for taking another child (Nurse 7, medical college hospital).
I think that one should not go for a MR. This would be advantageous for all. We are Muslims. It is not the question of a Muslim only, in fact, every religion forbids killing a life (Nurse 8, medical college hospital).
Other providers will only perform MR “if there is husband, mother-in-law, or mother with them” (Doctor 7, medical college hospital). If providers refuse to perform MR, this creates barriers, causing women to seek care from other informal sources. According to one nurse:
She has to do an abortion anyhow. It can be by doctor or nurse. But sometimes doctors or nurses do not give her any counseling and blame her to be pregnant because she is unmarried and ignore her. That time she goes to inexpert midwife or quack (Nurse 10, medical college hospital).
Patients seeking MR
Providers sometimes judged patients for their decisions, especially if they sought an out-of-clinic abortion. One provider described punitive behavior toward patients presenting with complications from out-of-clinic abortion:
We then tell them, “Why have you delayed? Why have you done this?”…They need blood but will not come to hospital. “Now you have come when you are about to die.” We rebuke them like this when they come with problem (Nurse 6, medical college hospital).
Other providers judged patients who seek MR in general as having lower education, affecting how providers view their decision making capacity. This was common throughout all provider roles and practice settings. One doctor explained, “Educated people are not much to come for MR, they are conscious. MR services take place around mostly lower class” (Doctor 3, RHSTEP). Another provider thought lower class women had different motivations than other women, stating, “Women do not want to destroy [their] baby – those who want it – it is done by the slum dwelling women…They want to do it. But directly no woman wants to destroy her baby” (Nurse 1, medical college hospital).
Overcoming barriers to safe MR
Identifying barriers
Providers identified several barriers to obtaining in-clinic MR care, including logistical, cultural, provider/health facility related barriers, and brokers. Logistical barriers include cost, lack of knowledge and family obligations. When seeking MR, “the hospitals seem distant for [the clients], and they think about the expense that will occur because of the distance [so] they get a sister beside them who does the MR” (Doctor 1, medical college hospital). Furthermore, clients “may not be aware of service. As you know sister, in many villages these messages have not reached yet” (Nurse 6, medical college hospital). With regards to family, husbands and mothers-in-law often dictate the care that a woman receives, and family obligations require the woman to stay close to the home. Opinions of the family can affect patient autonomy. One nurse spoke of the consequences of disobeying the mother-in-law:
Some in-laws say like “Do not go there. It will work out if you take herbs, if you drink holy water…” Then they will go to the religious leader [and] traditional healers. When they come they say that their mothers-in-law were creating obstructions for them…[but] if they do not obey their mothers-in-law…maybe they will be divorced, they will be thrown out of their house, their in-laws will arrange another marriage (Nurse 6, medical college hospital).
Another doctor discussed that women’s family obligations make it difficult to be away for longer periods of time:
Many feel that coming to the hospital means staying here for 2/3 days…If someone gets service in her locality from a quack doctor or a herbal doctor, she can then avail it…In addition, if she gets anything done in the locality, she can also look after her family (Doctor 10, RHSTEP).
Additionally, religion can create a cultural barrier to accessing in-clinic MR, though there were varying opinions on the ethics of MR in the context of the Muslim religion. In certain situations, some providers unequivocally stated that “There are religious obstacles…especially the Muslims face religious obstacle” (Nurse 11, medical college hospital). However, one doctor in Dhaka disagreed:
If there are religious reasons they will not be coming to centre for MR. Even the wife of a Huzur [Muslim religious leader] is also coming to us for MR as well as the wives of a Moulana or Imam…It is not the religious influence (Doctor 1, medical college hospital).
Other providers indicated that religious opinions of MR may not be homogeneous, varying with different levels of knowledge and conservativism:
There are some types of people but they are not real huzur. Who are real huzur, they understand these issues, and they are conscious persons…However, who are fanatical they think my wife would not go there [for MR] (Nurse 7, medical college hospital).
Regardless, it seems like religion can be a barrier for women in certain circumstances.
Furthermore, providers discussed that there are aspects of the health centers and the providers themselves that create barriers to in-clinic MR. Time constraints and provider attitudes cause patients to seek care elsewhere, especially in government health facilities:
One physicians supposed to see 200 – 300 patients within 6 hours. The same physician…in a private clinic, he has to see 5 – 6. He gives 20 minutes to 30 minutes to each patients in a private clinic…In [other] centers many patients come for service but the providers don’t provide services at all (Nurse 2, RHSTEP).
Providers also recognize that their own behavior can deter patients from coming to health centers. One provider explained, “We doctors don’t want to do counselling. Because of this the patients don’t understand what has happened to them… we also cannot explain properly due to lack of time. There is a gap here” (Doctor 8, RHSTEP).
Overwhelmingly, providers of all roles from all different practice settings and sites indicated that brokers create immense barriers for patients in seeking in-clinic MR. Brokers intercept patients seeking MR from RHSTEP or the government health facility and take them to other clinics, which are often unsanctioned, where they receive a commission:
They maintain a strong syndicate from the main gate of the hospital…They convince patient to go the private clinic to receive better quality medical service compare to government hospital. The service receivers go to the private clinic and take treatment facilities from [a] quack (Doctor 12, RHSTEP).
Brokers not only stand outside the hospital gate, but can be members of the hospital staff as well, charging patients for referrals. One nurse said that “the maids, ward boys, they are brokers…they are taking one thousand taka from [patients]” (Nurse 12, medical college hospital). Since they may be members of hospital staff and health centers can be large and difficult to navigate, patients often trust the brokers to take them to the correct location, though they end up in informal clinics. Even if patients become suspicious of brokers, once they are in another informal clinic, they sometimes have to pay just to leave:
[One woman] was searching for RHSTEP clinic. A broker took her to another clinic. Seeing the environment…the patient assumed that something is wrong. She told that broker, “…I don’t want to stay here, I want to go back.” The broker then said, “…You have to pay before you leave otherwise we won’t let you leave” (Nurse 2, RHSTEP).
In this case, the broker created a barrier to in-clinic MR and affected the woman’s autonomy since she was not taken to her choice of provier.
How to improve MR care
When discussing how MR care can be improved in Bangladesh, providers suggested further education/outreach, training, increasing services in more peripheral settings, and punitive action against brokers. Some providers recommended education of villagers about MR services via meetings and leaflets. Although some advocated for punishing untrained providers, others advocated for further training, stating “It would be better if those [untrained providers] could actually be identified. And it would be best if they could be provided with training…As you know, sisters can be trained” (Doctor 4, medical college hospital). One nurse also suggested training providers in appropriate behavior:
When you do adequate counselling then the patient will go and tell that [this provider] is so good, she spoke to me nicely. Behaviour is also very good…and she would speak well of us. She would go back and propagate (Nurse 5, medical college hospital).
Although there are some providers doing MR in more rural settings, many providers thought that care outside of the tertiary care centers could be improved and expanded to include community based trained frontline health workers called family welfare visitors (FWV):
There are also some trained nurses who can do this kind of service. They are also working in periphery. We can trained them more and send them to the sub centres. Even we can train the FWV. At least they have some knowledge and they will act accordingly (Doctor 1, medical college hospital).
Finally, many providers wanted punitive action against the brokers:
If any journalist would help [with the brokers], investigate this issue placing self as a patient, then these criminals would have been exposed…These people are harassing these MR patients, this should be stopped (Nurse 2, RHSTEP).