Abortion in Bangladesh

Abortion in Bangladesh

By Rathi R.

Abortion is illegal and governed by the penal code, Act XLV, in Bangladesh. The law, implemented on October 6, 1860, is a colonial relic of the English Common Law, which the British brought to the Indian subcontinent. Even though England changed its laws in 1967, abortions in Bangladesh remain unrecognized to date and constitute an offense unless sought to save the life of the pregnant woman. 

Despite the restrictive laws, nearly 1,194,000 abortions were performed in 2014 alone—many of them by untrained providers and/or in unsafe conditions. According to the Guttmacher Institute, the annual abortion rate in Bangladesh for the same year was 29 per 1,000 women between the ages of 15 and 49.

Historical Context of Abortion in Bangladesh

Historically, abortion has been a significant matter in Bangladesh, particularly in the years after the Liberation War. Between 200,000 and 400,000 women were raped during the war. Ostracized by their family and society, many of these women died, either by suicide or during unsafe abortion procedures, or left the country. The Mujibur Rahman government took immediate action, temporarily waiving off the ban on abortion for survivors of wartime rape and declaring them, birangana, or war heroines. Seba sadans were set up across the country to offer clinical support and rehabilitation. Doctors associated with the International Planned Parenthood Federation (IPPF), International Abortion Research and Training Centre, and other humanitarian agencies were brought in to provide safe abortions and end unwanted pregnancies.

In a survey conducted by Bangladesh Development Studies (BDS) in 1979, premarital conception and rape emerged as real circumstances where “approval of abortion is virtually universal” [1]. During the 1971 War of Liberation and in the following years, rape was a national issue, and its overwhelming incidence united different opinions, including on abortion. For instance, the survey revealed that while urban women supported abortion more liberally under all circumstances, in the eventuality of rape or premarital conception, rural women showed more approval, if only slightly.  

The matter of abortion also remained crucial during the nation-building years. During the First Five-Year Plan (1973-1978), the government acknowledged the potential role of legalized abortion in controlling the population growth in Bangladesh [2]. In 1976, an attempt was made by the Bangladesh National Population Policy to legalize first-trimester abortion on social and medical grounds, an attempt that subsequently failed. 

Abortion Law in Bangladesh

The Act XLV, 1860, of the Penal Code addresses the matter of abortion under the term miscarriage and is the only code that does so. It states that abortion is only permitted if the pregnant woman’s life is in danger; in such a case, the abortion must be performed by a physician in a hospital setting. This means that a woman cannot avail abortion on request, even under dire circumstances, such as rape and sexual assault, fetal malformation or congenital disorders, and socio-economic stresses, etc. unless the pregnancy threatens her life.    

Sections 312 to 316 detail the punishments for inducing miscarriage for the offending people (including the pregnant woman) with imprisonment of between three to ten years, transportation for life, and/or liability for fines. For instance, section 316 states, “Whoever without lawful excuse does any act knowing that he is likely to cause death to a pregnant woman, and does by such act cause the death of a quick unborn child, shall be punished with imprisonment of either description for a term which may extend to ten years, and shall also be liable to fine.”

However, Bangladesh introduced Menstrual Regulation (MR) – a method that regulates the menstrual cycle when menstruation is absent for a short period – in its national family planning program in 1979. By 1975, the population in Bangladesh had already crossed the 76 million mark with a fertility rate of 6.3 and a significant number of child brides. MR was an attempt by the Directorate General of Family Planning to control the population growth and reduce the total fertility rate (TFR).   

Methods of Abortion in Bangladesh

1. In-Clinic or Out-Patient Abortion

Nearly 1.2 million abortions and menstrual regulations happen in Bangladesh every year. The abortion law in Bangladesh allows abortion only in cases where the woman’s life is in danger. 

Under these circumstances, safe abortions can be performed surgically or with medication in public and private sector facilities. In 2012, the Drug Administration for Bangladesh legalized the combination of Mifepristone and Misoprostol for medical abortion. The combination is currently used across the world and is highly effective, safe, and well accepted by women. The success rate for early medical abortion is 95 to 98% with a combination of 200mcg of Mifepristone followed by 400 or 800mcg of Misoprostol. Mifepristone acts as an antiprogestin agent and causes the breakdown and detachment of the embryo. When followed with Misoprostol, the cervix softens stimulating the contraction of the uterus. Together the medication causes the sloughing of the uterine lining and the subsequent expulsion of any uterine tissue. The medical termination of pregnancy is preferred because it is cheap, noninvasive, and safe. 

2. Menstrual Regulation

MR is officially recognized and available free of charge in Bangladesh. The procedure can be performed by a physician up to 10 weeks from the last menstrual period (LMP) and up to eight weeks when provided by community-level providers, such as a family welfare visitor (FMV) [3]. FMVs are usually stationed in rural health centers to make MR more accessible to rural women and girls.     

Until 2010, the Manual Vacuum Aspiration (MVA) or Dilation and Curettage (D&C) methods were allowed to remove tissue from the uterus. The D&C has been used less frequently. The MVA is a simple and safe procedure requiring a vacuum aspirator to remove uterine contents through the cervix; in many cases, it is performed without the use of anesthesia. 

In 2014, the Ministry of Family Health and Welfare also approved the use of Mifepristone and Misoprostol (a dual-drug regimen) for menstrual regulation after successful pilots in 2009. The procedure, known as Menstrual Regulation with Medication (MRM) is permitted up to nine weeks after the LMP and is a noninvasive, nonsurgical procedure. It uses a combination of Mifepristone and Misoprostol.   

Defined as “an interim method for establishing nonpregnancy,” MR does not conflict with the existing abortion laws in Bangladesh [4]. It is often used as an alternative to abortion because pregnancy cannot be established at an early stage and, therefore, it makes criminal prosecution impossible. The method, however, is considered a contraception and is provided in district and medical college hospitals, maternal and child welfare centers, upazila health complexes, and union health and family welfare centers. The centers house trained paramedics who can perform MR up to eight weeks from the last menstrual period.   

Between 2010 and 2014, an estimated 430,000 MR procedures were performed in Bangladesh [5]. While the method is available for free, lack of access to information about MR, securing funds, and locating a provider can act as barriers. Many centers refuse to offer MR services if the pregnancy is beyond 10 weeks, leaving women distraught and forced to seek alternate options. Socioeconomic factors, stigma, logistical concerns relating to financial cost (such as transportation to a nearby town or city, the opportunity cost of missing work, and costs occurring at private clinics), employment, childcare, and changing relationship dynamics with a partner also prevent women from accessing the procedure. Additionally, delays in visiting a clinic owing to caring for family members, inability to take time off from work, conflicting feelings about the pregnancy, fear of mistreatment, and stigma are also influential factors [6].  

3. Use of Over-the-Counter Medication

In recent years, the use of over-the-counter Misoprostol and other abortifacients is becoming a trend in Bangladesh. An unpublished study has documented the use of Misoprostol for inducing abortion [7]. A common drug used for postpartum hemorrhage, Misoprostol is effective, cheap, and relatively safe. According to the World Health Organization (WHO), the use of Misoprostol alone has a success rate of 75-90% in inducing abortion for pregnancies of up to 12 weeks of gestation. 

While effective and safe, a recent study found that only 7% of pharmacy workers offered information concerning dosage, method of using the medication, etc. Far fewer provided counseling on complications that may arise or when to seek additional care.   

4. Out-of-Clinic Abortions

The restrictive abortion laws in Bangladesh also force women to seek out-of-clinic abortions when they are denied or cannot access MR services. The number of “illegal” abortions in Bangladesh is known to be very high, but there are no statistics available. Out-of-clinic abortions are usually provided by trained doctors, paramedics, and nurses. Others include untrained providers such as village doctors, homeopaths, relatives, herbalists, religious healers, and traditional birth attendants (TBAs), etc. [8]. In these cases, the abortifacient is usually a foreign body, such as a root or herb inserted vaginally; oral medications; or oxytocic injections. Some women also eat certain herbs and vegetables while others use jute bindings around their lower abdomens. 

While some of these methods have been practiced for a long time, and some successfully induce abortion, others can cause serious complications and may require institutional care. Additionally, a whopping 7-16% of maternal deaths in Bangladesh are a result of unsafe induced abortions taking the number to as much as 8,000 each year [9]

Recent Developments 

The high incidence of maternal mortality in Bangladesh, particularly from complications arising from abortion, calls attention to the restrictive nature of the abortion laws. A recent High Court ruling sought to challenge the law, asking if the penal code itself should not be declared illegal and void. The law contradicts the fundamental rights of women as guaranteed in the Constitution, imposes parenthood, and violates the right to privacy, life, and liberty in a country where the literacy rate and use of contraceptives is low, and the incidence of gender-based violence is high. The ruling has inspired hope and built momentum in the fight for legal and safe abortions in Bangladesh. 

[1] Ahmad, Raana. “Attitude Towards Induced Abortion in Bangladesh.” The Bangladesh Development Studies, vol. 7, no. 4, 1979, pp. 97–108. JSTOR, www.jstor.org/stable/40794284. Accessed 18 Feb. 2021.

[2] Ahmed, M. Kapil., et al. “Induced Abortions in Matlab, Bangladesh: Trends and Determinants.” International Family Planning Perspectives, vol. 24, no. 3, 1998, pp. 128–132. JSTOR, www.jstor.org/stable/3038209. Accessed 20 Feb. 2021.

[3] Ahmed, Shameem., et al. “Induced Abortion: What’s Happening in Rural Bangladesh.” Reproductive Health Matters, vol. 7, no. 14, 1999, pp. 19–29. JSTOR, www.jstor.org/stable/3775058. Accessed 20 Feb. 2021.

[4] “Bangladesh: Abortion Law.” Women On Waves, 2021, www.womenonwaves.org/en/page/4866/bangladesh–abortion-law. Accessed 20 Feb. 2021.

[5] “Safe Abortion Hotline launched for Menstrual Regulation in Bangladesh.” International Campaign for Women’s Right to Safe Abortion, 2013, https://www.safeabortionwomensright.org/safe-abortion-hotline-launched-for-menstrual-regulation-in-bangladesh/.  Accessed February 2021.

[6] “Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: A systematic review.” Bulletin of the World Health Organization, 2011, doi: 10.2471/BLT.10.084046,  www.who.int/bulletin/volumes/89/5/10-084046/en/. Accessed February 2021.

[7] “High Court asks why five ‘anti-abortion clauses’ in penal code should not be revoked.” The Business Standard, 2020, tbsnews.net/bangladesh/court/high-court-asks-why-five-anti-abortion-clauses-penal-code-should-not-be-revoked. Accessed February 2021.

[8] Hossain, A., Moseson, H., Raifman, S., et al. “‘How shall we survive’: a qualitative study of women’s experiences following denial of menstrual regulation (MR) services in Bangladesh.” Reproductive Health 13,  no. 86, 2016, doi.org/10.1186/s12978-016-0199-8. Accessed February 2021.

[9] Huda, FA., et al. “Understanding Unintended Pregnancy in Bangladesh: Country Profile Report.” STEP UP Research Report, 2013,.

[10] “Menstrual Regulation and Unsafe Abortion in Bangladesh.” Guttmacher Institute, 2017, www.guttmacher.org/fact-sheet/menstrual-regulation-unsafe-abortion-bangladesh#. Accessed February 2021.

[11] Nashid, Tanzina and Pia Olsson. “Perceptions of women about menstrual regulation services: qualitative interviews from selected urban areas of Dhaka.” Journal of Health, Population, and Nutrition, vol. 25, no. 4, 2007, pp. 392-8. 

[12] Nawaz, Rafat. and Saha, Kakali. “Early Pregnancy Termination with Oral Mifepristone and Vaginal Misoprostol.” Bangladesh Journal of Obstetrics & Gynaecology, vol. 2, no. 2, 2012, pp. 44-49, www.banglajol.info/index.php/BJOG/article/view/29917. Accessed February 2021.

[13] Singh, Susheela., et al. “The Incidence of Menstrual Regulation Procedures and Abortion in Bangladesh, 2014.” International Perspectives on Sexual and Reproductive Health, vol. 43, no. 1, 2017, pp. 1–11. JSTOR, www.jstor.org/stable/10.1363/43e2417. Accessed 20 Feb. 2021.