A mixed-methods study exploring women’s perceptions of terminology surrounding fertility and menstrual regulation in Côte d’Ivoire and Nigeria

Background Women use various terms when discussing the management of their fertility and menstrual irregularities and may interpret the experience of ending a possible pregnancy in nuanced ways, especially when their pregnancy status is ambiguous. Our study aims to understand the terminology used to refer to abortion-like experiences (specifically menstrual regulation and pregnancy removal), and the specific scenarios that these practices encompass among women who reported doing something to bring back a late period or ending a pregnancy in Nigeria and Côte d’Ivoire. Methods Our analysis draws upon surveys with women in Nigeria (n = 1114) and Cote d’Ivoire (n = 352). We also draw upon qualitative in-depth interviews with a subset of survey respondents in Anambra and Kaduna States in Nigeria, and Abidjan, Cote d’Ivoire (n = 30 in both countries). We examine survey and interview questions that explored women’s knowledge of terminology pertaining to ending a pregnancy or bringing back a late period. Survey data were analyzed descriptively and weighted, and interview data were analyzed using inductive thematic analysis. Results We find that the majority (71% in Nigeria and 70% in Côte d’Ivoire) of women perceive menstrual regulation to be a distinct concept from pregnancy removal, yet there is considerable variability in whether specific scenarios are interpreted as referring to menstrual regulation or pregnancy removal. Menstrual regulation is generally considered to be more ambiguous and not dependent on pregnancy confirmation in comparison to pregnancy removal, which is consistently interpreted as voluntary termination of pregnancy. Conclusions Overall, menstrual regulation and pregnancy removal are seen as distinct experiences in both settings. These findings have relevance for researchers aiming to document abortion incidence and experiences, and practitioners seeking to address women’s reproductive health needs.

Menstrual Regulation as a Means of Reproductive Control: The Law's Response to Disabled Bodies and Menstruation

Every day, millions of people make decisions about menstruation. They make decisions about what sanitary products to use, about pain relief, about with whom they will discuss their experience of menstruation. They make decisions about contraception to induce amenorrhea. These decisions may be influenced by family, poverty, society, and culture, but they remain, for the most part, up to the individual. However, this right to autonomy is not extended to all people equally. Some disabled people, for example, have these decisions made by substituted decision makers, including the courts. This is in violation of their rights; nevertheless, this practice continues in various jurisdictions, including through guardianship and conservatorship laws.

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.

AN AYURVEDIC AND CONTEMPORARY OVERVIEW OF MENSTRUAL CYCLE

Ayurveda stands on the framework of tridoshas, sapta dhatus and trimalas. Apart from sapta dhatu, updhatu also plays an essential role. Artava, the updhatu of rasa dhatu is responsible for conception in females. Henceforth, the healthy status of Artava is of prime importance when we talk about reproductive health. Any anomaly in Artava and its functions has an impact on menstrual regulation as well as reproduction. The menstrual cycle is the cyclical events that appear in the endometrium of uterus to form visible flow of menstrual blood every month. Menstrual cycle in Ayurveda is termed as artavachakra. The word chakra signifies regular onset at regular intervals, just like a wheel or cycle. It manifests a periodicity of one chandramasa (28 days). Ayurvedic acharyas has not interpreted artavachakra into stages, but depending upon available references in Samhitas, it is divided into following phases – rajahsravakala, ritukala, rituvyatitkala. Abnormal menstruation is the most common and important cause of many gynecological disorders and infertility. The present paper emphasizes on the study of day, duration and events of menstrual cycle in Ayurveda and with that of contemporary science.

Complication of Menstrual Regulation (MR)-A Study On It's Clinical Presentation And Outcome

Background: Menstrual regulation is the aspiration of endometrial content within 14 days from the missed period or within 42 days from the last menstrual period having previous normal cycles. So embryonic implantation either can not occur or can not be maintained.This technique is also known as menstrual aspiration, menstrual extraction, interception and uterine aspiration.This technique was first developed in 1927. In spite of its safety and effectiveness, to some extent it is contributory to some minor and major complications. Objective: The aim of this study was to determine the clinical presentation and outcome of the complication of menstrual regulation (MR). Materials and Methods:This cross sectional prospective study was done in Obs.&Gynae department of Dhaka Medical College Hospital, from November 2008 to February 2009. This study was on MR complications, it's clinical presentation and outcome. The cases diagnosed by history, examination and investigation. Results: Total number of Gynaecology admission was 1680 out of which 5.71% was due to MR complications . 89.58 % were multipara . In 77.07% cases gestational age was between 7 to 9 wks, in 52.08% cases MR was performed in private chamber. 12.5% patients suffered from p/v bleeding,2.08% suffered from shock and acute abdomen due to visceral injury. In 9.37% cases required abdominal surgery . Death was recorded in 2.08% cases. Conclusion: To reduce the incidence of complications, contraceptive practice should be popular and available to the community and MR service should be used as back up service when needed. KYAMC Journal Vol. 11, No.-4, January 2021, Page 208-211

A qualitative study on health care providers’ experiences of providing comprehensive abortion care in Cox’s Bazar, Bangladesh

Background Humanitarian settings are characterised by limited access to comprehensive abortion care. At the same time, humanitarian settings can increase the vulnerability of women and girls to unintended pregnancies and unsafe abortions. Humanitarian actors and health care providers can play important roles in ensuring the availability and accessibility of abortion-related care. This study explores health care providers’ perceptions and experiences of providing comprehensive abortion care in a humanitarian setting in Cox’s Bazar, Bangladesh and identifies barriers and facilitators in service provision. Method In-depth interviews (n = 24) were conducted with health care providers (n = 19) providing comprehensive abortion care to Rohingya refugee women and with key informants (n = 5), who were employed by an organisation involved in the humanitarian response. Data were analysed using an inductive content analysis approach. Results The national menstrual regulation policy provided a favourable legal environment and facilitated the provision of comprehensive abortion care, while the Mexico City policy created organisational barriers since it made organisations unable or unwilling to provide the full comprehensive abortion care package. Supplies were available, but a lack of space created a barrier to service provision. Although training from organisations had made the health care providers confident and competent and had facilitated the provision of services, their knowledge of the national abortion law and menstrual regulation policy was limited and created a barrier to comprehensive abortion services. Even though the health care providers were willing to provide comprehensive abortion care and had acquired skills and applied strategies to communicate with and provide care to Rohingya women, their personal beliefs and their perceptions of Rohingya women influenced their provision of care. Conclusion The availability and accessibility of comprehensive abortion care was limited by unfavourable abortion policies, a lack of privacy, a lack of knowledge of abortion laws and policies, health care providers’ personal beliefs and a lack of cultural safety. To ensure the accessibility and availability of quality services, a comprehensive approach to sexual and reproductive health and rights is needed. Organisations must ensure that health care providers have knowledge of abortion policies and the ability to provide quality care that is woman-centred and non-judgmental.

Experiences of a ‘screen and treat’ cervical cancer prevention programme among brothel-based female sex workers in Bangladesh: A qualitative interview study

Objectives: Little is known about sex workers’ experiences of cervical cryotherapy. We sought to understand sex workers’ perspectives of ‘screen and treat’ programmes and their management of the World Health Organization post-treatment guidance to abstain from sex or use condoms consistently for 4 weeks. We explored contraceptive preferences and use of menstrual regulation services. Methods: We conducted semi-structured interviews with 16 sex workers and six brothel leaders in an urban brothel complex in Bangladesh between October and November 2018. All had undergone cryotherapy. We conducted a thematic analysis using deductive coding, informed by a priori themes, and inductive data-driven coding. Results: Most sex workers could not abstain from sex during the healing period. Consistent condom use was challenging due to economic incentives attached to condomless sex and coercive behaviours of clients. The implications of non-adherence among high-risk groups such as sex workers are not known. Use of short-acting methods of contraception was common, and discontinuation was high due to side effects and other perceived health concerns. The majority of sex workers and brothel leaders had utilized menstrual regulation services. Barriers to accessing timely menstrual regulation and other sexual and reproductive health services included limited mobility, economic costs, and discriminatory attitudes of health care workers. Conclusion: Service innovations are required to enable sex workers to abstain or use condoms consistently in the post-cryotherapy healing phase and to address sex workers’ broader sexual and reproductive health needs. Further research is required to assess the risk of HIV and other sexually transmitted infection transmission following cryotherapy among high-risk groups.

Out-of-clinic and Self-managed Abortion in Bangladesh: A Qualitative Study of Menstrual Regulation Providers

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 occur outside of the legal system and are associated with high complication rates. Methods: Qualitative semi-structured interviews (SSIs) were conducted with 25 trained MR providers from urban tertiary care facilities in six different cities in Bangladesh. SSIs explored providers’ attitudes about the practice of unsanctioned MR/abortion providers and self-managed MR/abortion, their experiences treating patients who sought abortion services out-of-clinic, barriers/facilitators to safe MR/abortion, and MR/abortion definitions.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. Lack of consensus among trained providers revealed challenges for defining MR/abortion and gestational age cutoffs. Increasing post-abortion care (PAC) services may be due to patients purchasing Mifepristone/Misoprostol from pharmacists who do not provide adequate instruction, or patients may be directed to untrained providers by brokers, who intercept patients entering the hospitals/clinics and receive a commission from unsanctioned clinics for bringing patients. Perceived barriers to accessing in-clinic MR include distance, family influence, brokers, lack of knowledge, and provider attitudes toward MR.Conclusions: Providers in urban tertiary care facilities in Bangladesh see primarily the complicated MR/PAC cases, and the safety of out-of-clinic/self-managed abortion is unknown. Lack of standardization among providers of MR definition/gestational age cutoffs may affect patient care and MR access. MR safety may be improved by eliminating brokers. A harm reduction approach to improve MR/abortion care provided by pharmacies may improve safety and access. Policy makers should consider increasing training of frontline health workers, such as Family Welfare Visitors (FWVs) to provide evidence-based information about Mifepristone/Misoprostol.