How Bangladesh Made Abortion Safer
No one knows how many Rohingya became pregnant as a result of rape by the Myanmar military. No one knows how many babies were born to survivors of sexual violence living among the 750,000 Rohingya in camps in Bangladesh.
The systematic sexual violence against the Rohingya reminded many in Bangladesh of their own painful history: During Bangladesh’s war of independence in 1971, the Pakistani military and local collaborators killed about 300,000 civilians and raped and tortured as many as 400,000 women and girls.
After the fighting ended in late 1971, reports abounded of rape survivors who, shunned by their own communities, had killed themselves or their newborn babies, or died from attempts to self-induce an abortion. To combat the notion that rape is a stain on family honor, Sheikh Mujibur Rahman, Bangladesh’s first president, held the women up as “birangona,” or “heroines of the war,” and urged the nation to welcome them back.
Confronted with the aftermath of mass assault in a society still reeling from war, Bangladesh was compelled to intervene. In doing so, it planted the seeds for a safe abortion services program that continues today in the camps for Rohingya refugees and has lessons for the world.
In 1972, Mr. Rahman’s government temporarily waived its ban on abortion for victims of wartime rape and brought in teams of foreign doctors with the International Planned Parenthood Federation to terminate unwanted pregnancies.
Dr. Malcolm Potts of International Planned Parenthood, one of the world’s foremost experts on abortion, led the mission. For weeks, Dr. Potts and colleagues traversed the country treating patients in district hospitals. “We had a tiny numerical impact,” Dr. Potts recalled. “But it was highly visible, and I think it had a lasting impact.”
Though a bill to legalize abortion later failed to pass in Parliament, Bangladesh sanctioned what it calls “menstrual regulation,” or M.R: the removal of the contents of the uterus before a positive pregnancy test. Billed as a backup to contraceptive failure for a woman who has missed her period, M.R. was conceived as a means of reducing harm without engaging the law. And its rationale reflects the anxieties of the era in which it emerged.
Dr. Potts and other experts say that window of legality helped ease public opinion around the procedure by exposing health workers to the notion that abortion is a woman’s right. And while they themselves terminated late-stage pregnancies of rape survivors — operations requiring advanced skills, a surgical theater and supportive care — they also trained local doctors on a transformative new device: the manual vacuum aspiration syringe, also known as M.V.A.
Introduced by the U.S. Agency for International Development as part of a vast new family planning program aimed at curbing population growth in poor countries, the M.V.A. was ingeniously simple: a plastic hand-held syringe attached to a flexible polyethylene tube or cannula.
Suddenly, in places with little or no electricity, clinical infrastructure or skilled care, a midlevel health worker could quickly, safely and with minimal discomfort terminate an early pregnancy.
The M.V.A. revolutionized abortion care around the world, but in Bangladesh it did something more: It provided the rationale for a pragmatic policy and a path to limited legalization (in practice, if not in name).
A bill to legalize abortion failed to pass in the Bangladeshi Parliament in 1976, but M.R. was ruled exempt from the country’s restrictive ban, paving the way for its national rollout in 1979. Over the decade that followed, Bangladesh trained its legions of female paramedics, known as “family welfare visitors,” to perform the procedure, greatly expanding access to M.R. in a country with just one doctor for every 2,000 people.
Provided free of charge by the government and practiced at all levels of the health system, M.R. quickly came to be viewed as an essential piece of the national health care package. “It addressed a problem,” Rasheda Khan, a Bangladeshi anthropologist, told me, “without waking the sleeping lions — the religious fundamentalists.”
Bangladesh has since documented steep declines in maternal deaths, which fell by an estimated 70 percent between 1990 and 2015. Much of that owes to dramatic increases in the prevalence of contraceptive use, which has helped halve the country’s fertility rate, and better access to health facilities. But many believe M.R. played an important role, and even as Republican administrations have withheld aid to the N.G.O.s that support its implementation, successive Bangladeshi governments have kept the program afloat.
With the equipment and expertise in place, humanitarian agencies were able to discreetly deliver M.R. to Rohingya refugees soon after they started arriving. “We decided, for the Rohingya, we have to respond to their need,” said Dr. Sayed Rubayet, the Bangladesh country director of Ipas, the nonprofit tapped to oversee the delivery of M.R. to Rohingya refugees.
By early October, Ipas had trained health workers in eight facilities serving the camps. It has since expanded the training to 33, and other groups have joined the effort, making abortion care one of the standard health services available to Rohingya refugees.
“There was little awareness of it at first,” Dr. Rubayet said, noting that Myanmar’s abortion law is among the most restrictive in the world. “But once the message got out, we saw a big increase in demand.”
Founded in 1973, Ipas was created to manufacture and distribute the M.V.A. after passage of the Helms Amendment, which prohibited the use of American foreign aid to support abortion services overseas. By the early 1990s, Ipas had introduced the device in more than 100 countries, making it the most widely usedsafe and effective surgical abortion tool on the planet.
Nevertheless, safe abortion services are still severely limited or nonexistent in places like Yemen, Iraq, South Sudan and the Democratic Republic of Congo, where sexual violence has been well documented. Among humanitarian organizations, only Doctors Without Borders has provided safe abortion care as part of its medical response to crises, and only sporadically.
In 2016, researchers at Columbia University surveyed the field to find out why. They reported that humanitarian organizations often omit abortion care for reasons based on false premises — that abortion is too complicated, that donors don’t fund it and that women don’t need it.
“Now groups are publicly providing abortion care to the Rohingya,” said Sara Casey, director of the Reproductive Health Access, Information and Services in Emergencies Initiative at Columbia. “And look, the sky has not fallen. It is feasible and it can be done elsewhere.”
Patrick Adams is a freelance journalist.