Practices and Attitudes of Women Regarding Family Planning And Menstrual Regulation in The Sylhet Division of Bangladesh

Menstrual regulation (MR) is defi ned as “An interim method of establishing nonpregnancy for a woman who is at risk of being pregnant, whether or not she is pregnant in fact” [1-3]. On the other hand, Abortion is defi ned as the interruption or termination of pregnancy after the implantation of the blast cyst in the endometrium and before the resulting fetus has attained viability. Induced abortions are caused by deliberate interference, initiated voluntarily with the intention to terminate a pregnancy; all other abortions are called spontaneous abortion [4]. Abstract


Introduction
Menstrual regulation (MR) is defi ned as "An interim method of establishing non-pregnancy for a woman who is at risk of being pregnant, whether or not she is pregnant in fact" [1][2][3]. On the other hand, Abortion is defi ned as the interruption or termination of pregnancy after the implantation of the blast cyst in the endometrium and before the resulting fetus has attained viability. Induced abortions are caused by deliberate interference, initiated voluntarily with the intention to terminate a pregnancy; all other abortions are called spontaneous abortion [4]. woman. In all other circumstances, abortion-self-induced or otherwise-is a criminal offense punishable by imprisonment, fi nes or both. Menstrual regulation(MR)-offi cially recognized as an interim method for establishing non-pregnancy-has been available free of charge in the government's family planning program as a public health measure since 1979 [5].
One of the important goals of Health, Nutriton and Population Sector Programme (HNPSP) of the government of Bangladesh has been to improve the health and family welfare status of the most vulnerable groups-women, children and the poor. Bangladesh has achieved signifi cant progress in health and population indicators over the last few years (due to increased access to health and FP services) through a combination of facility level, community and household level service provision strategies. The fertility transition is already underway in the country and the success of the immunization program is most impressive, including reductions in infant and child mortality. The contraceptive prevalence rate has already reached more than 50% level. On an average, women in Bangladesh now give birth to only 2.3 children as compared to 6.3 children in the mid 1970s. More than 50 per cent of married couples of reproductive age have been protected by modern contraception now as compared to only 8 per cent in the early seventies. The expectation of life at birth for both sexes has increased from about 45 years in the mid 1970s to 66.7 years in 2008. These are some of the notable changes that have occurred in the demographic profi le of Bangladesh. It is remarkable that despite adverse socio-economic environment, commendable success in reproductive and child health has been achieved over the period of three decades. The infant mortality rate showed a steady decline from 150 deaths per 1000 live births in 1973 to 94 in 1991, 47 by 2007 [6] and 43 in 2011 [7], while the under fi ve-mortality rate declined from around 260 deaths per 1000 live births to only 53 over the same period [7]. Immunization coverage at the age of 12 months increased from as low as 54% in 1990 to 82.5% in 2011 and the country is expecting to attain polio-free status very soon [8].

Objectives
The main purpose of the present impact study is to assess whether and to what extent the interventions of the implementing agencies (i.e. MSCS/FPAB) have had an impact in terms of increasing awareness regarding MR among women and in increasing knowledge on safe timeline and appropriate place for performing MR and to what extent has the intervention been effective in increasing the social awareness regarding MR and abortion issues and removing misconceptions related to MR. Signifi cance of the study is to identify some problems/ issues of women regarding MR which will help for further policy implementation. The rest of the paper is organized as follows. Section 3 provides literature review, section 4 provides methodology, section 5 describes knowledge and attitudes of women regarding FP and MR and section 6 will discuss results and fi ndings.

Status of Maternal Mortality
There are two indicators for monitoring the reduction of maternal mortality -maternal mortality ratio and proportion of births attended by skilled health personnel. In 2006 the estimated MMR of Bangladesh was 290 (UNFPA), but according to BBS, the MMR is 315 for 2007 estimated from the Sample Vital Registration System . According to government statistics, maternal deaths fell by at least 60% from 1990 to 2010-2011 [9]. Further evidence in this regard comes from the two offi cial government studies of maternal mortality (Bangladesh Maternal Mortality Surveys, or BMMS), which were conducted in 2001 and 2010. Their fi ndings offer further evidence of this steep decline: a drop in maternal mortality of two-fi fths in less than one decade. In 2011, MMR was 194. Maternal mortality has declined considerably in Bangladesh over the past few decades. Some of that decline-though precisely how much cannot be quantifi ed-is likely attributable to the country's menstrual regulation (MR) program, which allows women to establish non-pregnancy safely after a missed period and thus avoid recourse to unsafe abortion [10]. According to Hossain, et al. [10]. Bangladesh has succeeded in reducing deaths during pregnancy and childbirth by improving access to maternal health care and lowering fertility, especially births that pose above-average health risks (e.g., births occurring to highparity women). What makes the country unique, however, is the potential contribution of an authorized procedure-known as menstrual regulation, or MR-to "establish non-pregnancy" after a missed period [2]. A national level survey conducted during 1978-79 found that complications from unsafe abortion played a major role in 26% of maternal deaths [11]. Similarly, a study of rural areas conducted during the 1980s found that the proportion of maternal deaths attributable to abortion was 15% [12]. However, there has been substantial improvement in this regard over the last two decades as will be clear from the following. Findings from fi rst national maternal mortality survey of 2001 [13], found a substantially lower proportion of maternal deaths attributable to abortion-only 5% of maternal deaths were related to induced abortion [14]. The 2011 BMMS found an even smaller percentage, merely 1% of maternal deaths were attributable to abortion during 2008-2010. If this last estimate is accurate, it points to a steep decline in the proportion of maternal deaths due to unsafe abortion [7].
However, it needs to be emphasized that the various surveys used different methodologies, some methodologies were less rigorous than others. Again, surveys related to maternal mortality in general, and of abortion related mortality in particular, are likely to suffer from recall lapse and high levels of under-reporting [9].
It is to note that Bangladesh is a moderate Muslim country with some cultural values of conservative nature. Living together with partner, extramarital sex and getting children without being married is against the norm of the society.
Such women are socially excluded and their children cannot be reared as other children in the society. Women therefore try to hide their relationship with their partner, and in case of pregnancy outside wedlock, they try to abort the child in secrecy. In this backdrop, MR is considered as a tool to hide the 'sin' of secret sexual relations, and therefore is socially unacceptable in Bangladesh. MR is also considered as a sin from religious point of view. 'Children' are considered to be 'gift of God' and any harm to them is not religiously acceptable.
Moreover, there remains some misconception about the health hazards associated with MR, which makes it unpopular among general people. Social, cultural and religious norms along with some misconception make MR a sensitive issue in Bangladesh.  [17]. In 1979 MR was legalized and incorporated into the National Family Planning Program. The government stated unequivocally that MR services were to be available in all government hospitals and health and family planning complexes at the district and upazila levels. In order to promote this program the government issued a circular including MR in the national family planning program and encouraging service providers to offer service in all government hospitals and health and family planning complexes (the present day UHCs) [18].

The marie stopes clinic society (MSCS)
The program was designed to train government doctors, a few private doctors, and female family planning workers (Family Welfare Visitors, or FWVs, employed at upazila/union level health posts) in MR techniques. Menstrual regulation (MR) is widely available in Bangladesh through public, NGO and private sector facilities, even though abortion is illegal except to save a woman's life. For more than two decades, the MR programme was run as a vertical programme. However, in1998the Government of Bangladesh introduced the Health and Population Sector Programme (HPSP) incorporating menstrual regulation into the essential services package (ESP).
MR is allowed up to 10 weeks after the last menstrual period (LMP) if performed by a physician [19]. Family welfare visitors (FWVs) and paramedics such as sub-assistant community medical offi cers (SACMOs) are permitted to provide MR services up to eight weeks after the LMP. The predominantly female FWVs have a minimum of 10 years of schooling and receive at least 18 months' training in reproductive and child health services, including training in how to perform MRs [20]. If MRs were universally accessible in Bangladesh, they could greatly reduce the potential need for women to have an unsafe clandestine abortion. Currently, a lot of women who would like to get an MR face barriers to obtaining one; many of them resort to unsafe abortion as a result. Because induced abortions are legally restricted in Bangladesh, they are often practiced clandestinely in unhygienic settings, performed by untrained providers, or both. By averting unsafe abortions and their associated health complications, MR could have a positive impact on women's health and survival [10].

Menstrual regulation (MR) Services
The original impetus for introducing MR services came from scientists, government and international leadership. Support for provision of this reproductive health service is broad based and includes these as well as other stake-holders such as service providers and women's rights organizations [15]. Nevertheless, studies have suggested that there is room and need for improvement in access to quality MR services. In addition, a recent review of the MR program has argued that it has been marginalized within overall health policy in Bangladesh over the last decade [20]. A government authorization rule regulates MR [2], which is generally performed with manual vacuum aspiration (MVA). The rule gives specifi c guidance for the provision of MR services, covering the types of providers who can offer the service, namely, doctors, family welfare visitors (FWVs) and paramedics (include providers such as SACMO, and medical assistants); the context of service provision, either outpatient or inpatient; and the maximum number of weeks permitted since the last menstrual period (LMP). Although MR is allowed up to eight weeks after LMP when performed by FWVs and paramedics, and up to10 weeks after LMP when performed by a physician, providers sometimes perform the procedure later as well [21][22][23][24][25][26][27].

Study design
The present study was limited to project areas of Family In addition, as male of household heads are assumed to have an important role in the decision making, information was also obtained from male-heads to have an idea about the role of men and their infl uence on pregnancy termination through MR. In most of Bangladesh, the family is mainly patriarchal, patrilocal and patrilineal and the South Asia region is well known for the kinds of in-egalitarian gender relations that are related with gender discrimination. In view of the above, the present study has covered 300 male-heads of household from three districts-Sylhet, Maulvibazar and Habigonj-taking 100 from each district. From each sample village/mohalla, 25 male-heads were selected randomly. Thus, there were a total of 300 male household heads from the three districts-200 from intervention area and 100 from control area. A pretested structured questionnaire was applied to obtain relevant information for both women and male household head.

Qualitative data collection methods
The study also examined the role of service providers to assess their knowledge on job responsibility, opinions on the quality of MR services, extent of follow-up services and so on.

Health seeking behaviour of the women respondents
The respondents were asked about the places where they usually visit for treatment during sickness. In case of a mild illness, a person may use family based practices only, or buy some drugs from the pharmacy or consult unqualifi ed practitioners. In case of service or long lasting illness, s/he may consider using either professional or lay care remedies, or both of them. In Sylhet, 84.5% of the respondents mentioned that they generally go to the district hospital for the treatment of household members during sickness, while 60% and 65% go to the UHC and FWC respectively for treatment purposes. for treatment purposes (ranging between 28.5 to 42.5%) ( Table   1).

Marriage and reproductive health of the women respondents
Age at marriage: Respondents were asked about their age at fi rst marriage. According to data as presented in Table 2, about a fi fth of the women in Sylhet (19%) and Maulvibazar (18.5%) were married by age 14, the corresponding fi gure for Habigonj was 14%. Similarly, 31% of women in Sylhet, 34% in Maulvibazar and 27.5% in Habigonj were married by age 15.
The fi ndings show that an overwhelming proportion of women in the sample areas (58% in Sylhet, 66% in Maulvibazar and 54% in Habigonj) were married before they were 18 years of age (i.e. before the legal minimum age at marriage for girls).
This implies that more than half of the marriages in the study areas were, in fact, child marriages, which is forbidden by law.
The average age at fi rst marriage is found to be 16.95, 16.76 and 17.13 years in Sylhet, Maulvibazar and Habigonj respectively.

Consequences of early marriage
Historically, Bangladeshi women are married early. women who marry early become mother at an early age and are more likely to experience higher morbidity and mortality compared to those who marry after their teens.

Number of children born alive and living children
Respondents were also asked about the number of children born alive and currently living. It is evident from  (Tables 2,3).
Regarding the last pregnancy, respondents were asked about the way how the decision of being pregnant was taken-whether husband-wife decided mutually, or it was due to contraception failure. An overwhelming proportion of women (ranging between 70 to 87%) mentioned that decision was made by mutual understanding of the couple (Table 4). However, about a quarter of the women in intervention area (23.85) maintained that pregnancy occurred due to failure of FP method (7.75%), or it was unplanned pregnancy (14.6%). The corresponding fi gure was 10.7% in Control (Habigonj) area. An insignifi cant proportion of women said that pregnancy occurred due to husband's own decision in both areas.

Family planning
Knowledge and awareness about family planning methods: Information on knowledge of family planning was obtained by asking women whether they have ever heard of family planning method. It is evident that knowledge about family planning is universal-100 percent respondents in both the intervention and control areas possess this knowledge. Knowledge was also assessed for different methods of family planning (Pill, condom, injection, IUD, Implant/Norplant, ligation, vasectomy, Azol/ withdrawal, safe period etc.) ( Table 5).
It may be mentioned that Bangladesh has achieved a remarkable progress in raising the contraceptive prevalence rate from less than 8 per cent in 1975 to about 56 per cent in 2007-a seven-fold increase over a period of three decades. The steady increase in the use of contraception has been the major determinant of fertility decline in Bangladesh.

Advantages and disadvantages of family planning methods
The respondents were asked about their perceptions regarding advantages/demerits of FP methods. About 90.5 percent of respondents in intervention area stated about 'solvency of the family', followed by'easier to provide education for children' (maintained by 70.5%), 'mother's health and nutrition is ensured' (reported by 69.5%), and 'better health and nutrition of children' (mentioned by 60.25%) . Regarding disadvantages of FP methods, the various responses included "side effects" (ranging between 72 to 94%), "risk of infertility" (ranging between 35 to 70%), "husband does not like" (ranging between 26 to 49%), etc (Tables 6,7).

Consequences of frequent pregnancies
Respondents were also asked about their opinion regarding consequences of large family and frequent pregnancies. Regarding adverse consequences of repeated pregnancies, 96.25 % espondents of intervention area mentioned about poor health of mother and children, followed by fi nancial burden (89.75%), and inadequate birth spacing (62.75%). Similar observations were also made about adverse consequences. However, more than a half of the respondents in control area (58%) mentioned about positive aspects of frequent pregnancies -i.e. the benefi ts of a large family, compared to     one-fourth of the respondents in the intervention area who mentioned about benefi ts of large family (Table 8).

Knowledge on different family planning methods
The respondents were asked to mention some of the specifi c family planning methods they know about. It is evident that pill, condom, injection and female sterilization is almost universally known (more than 90% in the study area), while knowledge of other methods like IUD, implant/ norplant, vasectomy varies between 70 percent to 90 percent. A further statistical analysis of the data points to the fact that the intervention did not infl uence the decision of neither male, nor female respondents to use family planning.
However, the intervention did increase both male and female respondents' knowledge on several family planning methods.
It appears that the female respondents benefi tted from the intervention regarding their knowledge of the emergency pill, in safe period and azol/withdrawal. Furthermore, the intervention helped male respondents increasing their knowledge about implants, ligation and, again, safe periods. The male knowledge on vasectomy and IUD, however, decreased (Table 12).

Ever use of FP methods
Regarding past use of contraception, the respondents were asked whether they have ever used any contraceptive method     used any FP methods. The method-mix of ever users has more or less similar pattern like the current users. The pill was the most frequently used method (ranging between 70 to 78%), followed by injection (ranging between 11% to 17%), and condom. However, 3.5 percent women in control area were found to have ever used traditional method.The corresponding fi gure was nil for the intervention area (Tables 13,14).

Consequences of not using family planning methods
Respondents were asked about their perception regarding consequences of not using family planning method. The data shows that a vast majority of respondents in both the program and control areas are aware of the adverse effect of not using family planning method. Among the different responses, "economic burden" was mentioned by highest proportion (reported by 81 to 94%), followed by "frequent pregnancies" (mentioned by 77 to 82%) and "burden of large family" (reported by 55 to 77%). There is no major difference in the perception of respondents in the two areas about the consequence of not using family planning (Table 15).

Attitude towards abortion
Women were asked about their perception regarding abortion. It was found that the proportion of women who considered abortion can be performed: 'if the health of a woman is at risk due to pregnancy', 'abortion as a sin' and 'abortion as a FP method' was considerably higher in control area than in intervention area ( Figure 2).       termination. The impact of the intervention is clearly visible in the sense that an overwhelming majority of respondents in the program area mentioned about MR to terminate an unwanted pregnancy. By contrast, about a quarter (24%) of women in control area compared to only 5.5 % in intervention area mentioned abortion to get rid of unwanted pregnancy, which has enormous health risk for women. Surprisingly, one-fourth (25%) of the women in control area compared to 3.5% in intervention area (3% in Sylhet and 4% in Maulvibazar) said that they would seek advice from Hekim/Kabiraj/Herbalist for the purpose. About a tenth of the (10.75%) women in intervention area and a quarter of the (23.5%) women in control area said that they would opt for homeopathy medicine to get rid of unwanted pregnancy. This implies that a sizeable proportion of respondents in the control area still prefer to go to herbalist or homeopathy medicine to terminate unwanted pregnancy (Tables 16-18).

Knowledge about early marriage
Respondents were asked whether they know about minimum age of marriage for girls and boys. In the intervention area, 76.5 and 36 percent of respondents know about minimum age of marriage for girls and boys respectively. However, a much lower proportion of women in control area (69.0 %) know about minimum age of marriage for girls and boys (31.5%) respectively.
Respondents were asked about their perception regarding impact of early marriage on the girl. The various consequences mentioned by both program and control group women are shown in Table-

Knowledge and Attitude towards Menstrual Regulation (MR)
The women aged 15-49 were asked to respond on questions related to family planning methods and MR to explore their level of knowledge, attitude, beliefs, and perceptions about MR.

Knowledge on MR
Currently, MR is the most reliable (and govt. approved)

Assistance and service providers for MR
Respondents were asked about their perception regarding the place where MR service is available, in the intervention area, or their knowledge on availability of service providers for MR in their locality. The data in Table 23 shows that in Sylhet, 77 per cent of respondents mentioned about FPAB followed by district hospital (64.8%), FWC (62%), UHC (60%), MSCS (44%), private clinic (33%), MCWC (24.4%) and other NGO clinics (24.4%). In Maulvibazar, the pattern was more or less similar where the highest proportion mentioned about FWC (75.9%) followed by Marie Stopes Clinic (68.4%), DH (58.8%) and UHC (58.8%). In the control area, Habigonj, a lesser proportion of respondents mentioned about public facility/ skilled personnel (23 to 48%), while a much higher proportion mentioned about traditional practitioners like kabiraj/hekim (34.6%) or homeopathy medicine (13.5%). However, because of the advocacy and awareness raising programme of FPAB and MSCS, a higher proportion of respondents in the intervention area possess the knowledge regarding skilled personnel who perform MR in their respective areas.

Attitude towards MR
Respondents were asked about their opinion on when one      Respondents were also asked about their opinion regarding abortion as a method of termination of pregnancy. Only 10% of the respondents in the intervention area with too many children were in support of abortion as a way of pregnancy termination for fi nancial well-being. Only in case of pregnancy outside wedlock, a large majority of respondents in the intervention area were in support of abortion. The data shows that a vast majority of the respondents in the intervention area were against abortion irrespective of poverty of households or age at pregnancy, or on health grounds. The picture was quite different in the control area where most of the respondents mentioned that "poor parents with too many children" should go for abortion (57%), "unwanted pregnancy" should be terminated through abortion (61.5%). Respondents in control area also mentioned that pregnancy at a very late stage of life should be terminated through abortion (35.6%), or if the health of the woman is at risk because of pregnancy then abortion can be performed (36.3%). The fi ndings imply that a vast majority of the women in the control area are not aware about the difference between "MR" and "abortion". Pregnancy termination through abortion is a risky procedure involving life threatening risks for women -including the risk of "dying" because of abortion. Unfortunately, a signifi cant proportion of women in the control area are not aware of the health risk associated with abortion. More than a tenth of the control group women (12.6%) still maintain that abortion can be used as a method of family planning. This needs immediate attention by planners and policy makers. It is also observed from the Table 26 that about a third (32.8%) of the women in the intervention area and one-half (50.4%) of the women in the control area are of the opinion that such an act is a great sin and would debar them from heaven.

Experience of MR
The respondents were also asked whether they know any

Complications faced after MR
Respondents were asked whether they know of any proportion ranged from 58% in Sylhet to 48% in Maulvibazar (intervention area), and to 36% in control area. Since a higher proportion of MR in the control area was performed  Moreover, their awareness regarding consequences of not using family planning and adverse impact of frequent pregnancies has increased tremendously.

Conclusion
The study was carried out in two intervention (Sylhet and The intervention has been successful in improving both the MR clients' and female respondents' knowledge about the timeliness of MR, ceteris paribus. However, it appears that the intervention had a signifi cantly stronger positive effect on the MR clients than on the female respondents. Education and age also seem to infl uence the knowledge of the female, while the male knowledge is associated with health seeking behavior.
The fi ndings indicate that both male and female respondents were more aware on MR in intervention areas as compared to control area. Women reported that early marriage and violence had reduced in the intervention area, though this could not be sustained by data from the surveys. Finally, women in the intervention area perceived that they received more respect and were more consulted regarding resolving crucial family situations. Women in the intervention area reported increase in self-worth, confi dence and competence that they often translate into redefi ning social customs and rituals for themselves and their children. Women from poor households and marginalized communities now can have easy access to RH services including access to safe MR. Women also have gained positively in their ability to seek help from skilled provider in case of unwanted pregnancy.