Also in this issue of International Perspectives on Sexual and Reproductive Health :

Community-Level Gender Equity and Extramarital Sexual Risk-Taking Among Married Men in Eight African Countries,” by Rob Stephenson of Emory University;

The Integration of Family Planning with Other Health Services: A Literature Review,” by Anne Sebert Kuhlmann of MANILA Consulting Group, Inc. et al.;

Comment, “Making the List: The Role of Essential Medicines Lists in Reproductive Health,” by Jane Hutchings of PATH et al.

Two studies released in the December 2010 issue of International Perspectives on Sexual and Reproductive Health provide strong evidence that expanded access to family planning, maternal health and menstrual regulation services significantly reduces maternal mortality and morbidity in Bangladesh. Together, the studies demonstrate how a country with limited resources and a restrictive abortion law can make strong progress in improving women’s health by making basic services more widely accessible.

In the first article, authors Mizanur Rahman of Pathfinder International, et al., compare several measures of maternal mortality between two areas in Matlab, Bangladesh, over a 24-year period: One area is covered by the Maternal-Child Health–Family Planning (MCH-FP) Project, which offers intensive family planning interventions and maternal and child health services, while the other receives only standard government services. According to their analysis, women in the MCH-FP area had a 37% lower lifetime chance of dying from maternal causes than those in the comparison area (one in 82 vs. one in 51, respectively). The authors note that because women in the MCH-FP area had a lower pregnancy rate than women in the comparison area (12% vs. 15%), their chance of exposure to pregnancy-related risks was not as high. In addition, women in the MCH-FP area who had induced abortions, miscarriages or stillbirths were less likely to die than such women in the comparison area.

Women in the MCH-FP area also experienced fewer unintended pregnancies than those in the comparison area and were more likely to seek antenatal care and maternity services both at home and in hospitals. Rahman and colleagues believe that these differences likely resulted from the MCH-FP Project’s success in increasing women’s knowledge of and access to contraceptives and safe-motherhood care. These outcomes were achieved through such strategies as assigning female community health workers to provide family planning counseling and supplies to women in their communities on a regular basis and posting midwives in community-based health centers where they were on call 24 hours a day to attend home deliveries and to provide basic obstetric care. These services were supported by well-organized referral services linked with higher-level facilities.

The authors conclude that the Matlab MCH-FP Project and other programs that seek to increase contraceptive use; reduce unsafe abortion, miscarriage and stillbirth (all of which carry greater health risks than live births); and strengthen antenatal care could substantially reduce maternal mortality and morbidity in Bangladesh and similar countries.

The second article finds that the provision of menstrual regulation services averts unsafe abortions, one of the leading causes of maternal death in Bangladesh. In addition, these services save scarce health system resources. In Bangladesh, the abortion law is highly restrictive; however, menstrual regulation—using manual or electric vacuum aspiration to induce menstruation—is provided by the government within 10 weeks of a woman’s last period as a backup to contraception.

The authors, Heidi Bart Johnston, an independent consultant formerly with the International Centre for Diarrhoeal Disease Research, Bangladesh (commonly known as ICDDR,B), and colleagues present evidence that suggests that by offering menstrual regulation as a basic service, the Bangladeshi government is not only providing women with much-needed care, but also preventing unnecessary and expensive complications that result from unsafe abortions. According to the study data, the incremental cost per case of providing menstrual regulation in 2008 was just 8–13% of the cost of treating severe abortion complications, depending on the level of care. The authors conclude that the menstrual regulation program has played an important role in reducing abortion-related morbidity and mortality that consume limited health system resources. According to Johnston and her colleagues, policymakers in countries with high rates of abortion-related morbidity and mortality could use Bangladesh’s experience with menstrual regulation as a model.

Together, these two studies demonstrate the clear benefits of smart investments in the full range of effective family planning and maternity care services, even in countries with restrictive abortion laws. Bangladesh’s approach can serve as a model for other countries in implementing programs and policies that address high levels of maternal mortality and morbidity and help achieve the Millennium Development Goal of a 75% reduction in maternal mortality between 1990 and 2015.

The articles, “The Role of Pregnancy Outcomes in the Maternal Mortality Rates of Two Areas in Matlab, Bangladesh” and “Health System Costs of Menstrual Regulation and Care for Abortion Complications in Bangladesh” both appear in the December 2010 issue of International Perspectives on Sexual and Reproductive Health.