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

"Pregnancy Termination in Matlab, Bangladesh: Trends And Correlates of Use of Safer and Less-Safe Methods," by Julie DaVanzo and Mizanur Rahman

"Repeat Use of Emergency Contraceptive Pills In Urban Kenya and Nigeria," by Dawn Chin-Quee, Kelly L’Engle, Conrad Otterness, Sarah Mercer and Mario Chen

"Fertility Decisions and Contraceptive Use at Different Stages of Relationships: Windows of Risk Among Men And Women in Accra," by Ivy Frances Osei, Susannah Harding Mayhew, Leticia Biekro, Martine Collumbien and the ECAF Team

"Contraceptive Method Skew and Shifts in Method Mix In Low- and Middle-Income Countries," by Jane T. Bertrand, Tara M. Sullivan, Ellen A. Knowles, Muhammad F. Zeeshan and James D. Shelton

Menstrual regulation, a procedure that uses manual vacuum aspiration to safely establish nonpregnancy after a missed period, has been part of Bangladesh’s national family planning program since 1979. It is legally allowed up to 10 weeks after a woman’s last period, and thus some women use it to terminate an unwanted pregnancy. Despite the availability of this service, hundreds of thousands of women in Bangladesh have abortion procedures that endanger their health. A new study, "Pregnancy Termination in Matlab, Bangladesh: Maternal Mortality Risks Associated with Menstrual Regulation and Abortion," by Mizanur Rahman, of the University of North Carolina, Chapel Hill, et al., found that in the period 2000–2008 a woman was more likely to die from complications of an unsafe abortion than from childbirth, whereas the risks of death from undergoing menstrual regulation and from giving birth were similar.

The study analyzed demographic surveillance data on pregnancy outcomes from the rural district of Matlab to assess mortality risks associated with menstrual regulation, abortion and delivery. Matlab is representative of most rural areas in Bangladesh, where the availability of traditional practitioners who provide unsafe abortions is greater than that of formally trained health care providers who provide safer but more expensive menstrual regulation procedures. In addition, the analysis compared data from one area within Matlab that receives standard government health and family planning services to another area that receives higher quality services through a special program called the Maternal and Child Health–Family Planning (MCH-FP) program.

The study found significant declines in women’s risk of dying from either unsafe abortion or menstrual regulation over time. Overall, for women in Matlab in 1989–1999, the odds of dying from complications of unsafe abortion were 12 times those of dying from childbirth and the odds of dying from complications of menstrual regulation were four times those of dying from childbirth. By 2000–2008, however, the odds of dying from complications of an unsafe abortion were five times those of dying from childbirth, and the odds of dying from complications of a menstrual regulation procedure were no greater than those of dying from childbirth. Notably, the decrease in maternal mortality risk between the two periods was greater in the MCH-FP area than in the area that received standard government services.

In all of Matlab, the proportion of pregnancy terminations by unsafe abortion decreased while the proportion by menstrual regulation increased over time: Menstrual regulation accounted for 55% of terminations done in 1989–1999 and 79% of those done in 2000–2008. The researchers suggest that this increase, the growing safety of both menstrual regulation and abortion procedures, and the earlier termination of unwanted pregnancies contributed to the overall reduction in maternal mortality observed during this period.

The researchers note, however, that despite these improvements, too many women still have to resort to abortion methods that put their life and health at risk. They recommend finding ways to reduce women’s use of unsafe abortion, such as addressing the reasons and conditions that lead women to turn to such methods.

"Pregnancy Termination in Matlab, Bangladesh: Maternal Mortality Risks Associated with Menstrual Regulation and Abortion," by Mizanur Rahman, of the University of North Carolina, Chapel Hill, et al., is currently available online from International Perspectives on Sexual and Reproductive Health.