A Choice Without Information Is Not a Choice
We have read with interest the article "The Incidence of Menstrual Regulation Procedures and Abortion in Bangladesh, 2014" [2017, 43(1):1–11, https://doi.org/10.1363/43e2417], by Susheela Singh et al. The article uses the Bangladeshi government's definition of menstrual regulation (MR): "the procedure of regulating the menstrual cycle when menstruation is absent for a short duration."1 MR is provided using manual vacuum aspiration up to 12 weeks from the last menstrual period if provided by a physician or a dual regimen of mifepristone and misoprostol up to nine weeks after a woman's last menstrual period. MR, so defined, does not refer to the regulation of menstruation in case of menstrual disorders, but rather to a technique of terminating a pregnancy.
According to the labels of mifepristone and misoprostol used in Bangladesh, these products are indicated as a "medical alternative to surgical termination of intrauterine pregnancy."2 When a search is made for "termination of pregnancy" in the thesaurus vocabulary for PubMed, the retrieved term is "abortion, induced." Also, when citing mifepristone, Planned Parenthood and the Guttmacher Institute use the term "medication abortion" in their websites. In scientific settings, there is no doubt that MR, as defined in Bangladesh, is a procedure that can terminate a pregnancy.
Women with missed periods might not realize that they could be pregnant. If MR is offered to them without explaining that it could end an ongoing pregnancy, it could be understood as a medication for menstrual disorders or irregular cycles. Pregnancy causes missed periods (amenorrhea) but it is not a menstrual disorder. Therefore, the term MR could be misleading, especially for less-literate women.
It is remarkable that studies published in PubMed using the term MR were all conducted in Bangladesh. We are concerned that using this term instead of medical abortion or other official terms hinders the understanding of the well-known abortive effect of mife-pristone to Bangladesh women. Providing confusing information about medical abortion jeopardizes women's right to informed choice in family planning,3,4 even though MR is a legal procedure in Bangladesh.
Some could argue that Bangladesh has made a specific choice to frame these interventions (mifepristone or manual vacuum aspiration) as MR or that this is merely a matter of accurate language use regarding abortion. However, when women's right to make informed choices in sexual and reproductive health is at stake, clear information is crucial because it has been shown to improve women's health and decrease maternal mortality.5
Cristina Lopez-del Burgo
Jokin de Irala
University of Navarre
Pamplona, Spain
REFERENCES
1. Singh S et al., The incidence of menstrual regulation procedures and abortion in Bangladesh, 2014, International Perspectives on Sexual and Reproductive Health, 2017, 43(1):1–11.
2. Incepta, Products, http://www.inceptapharma.com/view-product.php?pid=544; https://renata-ltd.com/wp-content/uploads/2015/04/MIF.pdf.
3. Upadhyay U, Informed choice in family planning: helping people decide, Population Reports, 2001, Series J, No. 50.
4. Lopez-del Burgo C et al., Knowledge and beliefs about mechanism of action of birth control methods among European women, Contraception, 2012, 85(1):69–77.
5. Koch E et al., Women's education level, contraceptive use and maternal mortality estimates, Public Health, 2014, 128(4):384–387.
Authors' Response
We thank Cristina Lopez-del Burgo and Jokin de Irala for their comments, as well as their interest in our article. We appreciate that outside of Bangladesh, the term menstrual regulation (MR) may be unfamiliar. We chose to use this term in our article, however, because it is the term most widely used within Bangladesh by women, providers and government to refer to manual vacuum aspiration and, more recently, to medication MR (or MRM), the dual regimen of mifepristone and misoprostol, when provided within approved limits and by authorized providers. It is also the term that has been used since the MR procedure was first permitted by the Bangladesh government in 1979.1,2 It is thus not particularly surprising that studies indexed in PubMed using the term MR were all or almost all conducted in Bangladesh, because this term is widely understood and used in the country. Abortion is illegal in Bangladesh except to save the woman's life, and abortion services would be against the law except when provided for this reason.
We agree that informed consent is a key component of all medical services, including sexual and reproductive health care. Previous research has found, however, that women in Bangladesh (including those living in rural or poorer areas) often do not distinguish MR, the safe procedure that is authorized by government, and illegal abortion services.3,4 This can actually be a barrier to receiving safe MR services from trained providers. In a report accompanying our article, we recommended that the government do more to educate women about the MR program as well as about sources for obtaining MR services from trained providers and the gestational limits under which it can be provided.5
REFERENCES
1. Government of the People's Republic of Bangladesh, Memo No. 5–14/MCH-FP/Trg. 79, Dhaka, Bangladesh: Population Control and Family Planning Division, 1979.
2. Directorate General of Family Planning, Bangladesh National Menstrual Regulation Service Guidelines, 2014, Dhaka, Bangladesh: Directorate General of Family Planning, Kingdom of the Netherlands, World Health Organization Country Office for Bangladesh, 2014.
3. Khan R et al., Menstrual Regulation: A Decision Tainted with Stigma, Pain and Suffering—An Anthropological Study, Dhaka, Bangladesh: Embassy of the Kingdom of the Netherlands (EKN), Marie Stopes Bangladesh, and icddr,b, 2016.
4. Hashemi A, Rashid S and Rashid M, Where do women go and why? Understanding the barriers to safe MR services in Bangladesh, unpublished report, Dhaka, Bangladesh: James P. Grant School of Public Health, BRAC University, 2012.
5. Hossain A et al., Access to and Quality of Menstrual Regulation and Postabortion Care in Bangladesh: Evidence from a Survey of Health Facilities, 2014, New York: Guttmacher Institute, 2017.