MRM without prescription: A violation risking women's lives

When 24-year-old Mithila Islam, mother of a nine-month-old, discovered she was pregnant again, she was already 10 weeks into conception.

Living in Dhaka, she was exhausted from managing the household and taking care of a child all alone. Her second pregnancy was unplanned and she was unsure about continuing with it.

The limited income of her husband, a private service holder, made it all the more challenging to support a second child.

After much deliberation, Mithila's husband bought her a menstrual regulation medication (MRM) kit, which he had heard about from a colleague.

Considering the difficulties surrounding termination at hospitals and the associated costs, the couple opted for the kit -- comprised of two tablets -- unaware of the potential risks.

Soon after taking the medicine, Mithila experienced severe bleeding, vomiting, and continuous diarrhoea.

After 15 days of bleeding, she was taken to a nearby clinic, where an ultrasound showed incomplete foetal removal.

She then had to undergo a procedure to remove tissue from inside the uterus.

However, she continued to suffer for two more months with unbearable pelvic pain while the bleeding continued.

Unfortunately, Mithila's case is not unique.

The comment sections of YouTube videos discussing medication abortion shows a concerning trend -- numerous couples are desperately opting for MRM kits to terminate pregnancies without consulting doctors and exposing themselves to physical danger.

What increases the risks is that the medications, which are not to be sold without prescription, are available over the counter in many pharmacies.

Many experience prolonged bleeding for up to five months, leading to hemorrhagic shock, severe anaemia, pelvic inflammatory disease, infertility and even death.

WHAT IS MRM

In Bangladesh, abortion is generally illegal under the 1860 penal code.

However, menstrual regulation -- a procedure of regulating the menstrual cycle when menstruation is absent for a short duration -- was introduced in 1979 in the family planning programme as a backup method to support contraceptive failure.

The government introduced MR medication in 2014, initially permitted within nine weeks of a missed period. In 2021, the DGFP's National Technical Committee approved extending MRM up to 10 weeks of a missed period.

Currently, the drug is widely recognised as an abortion medication and 12 pharmaceutical companies produce it under various names, and they are available over-the-counter in pharmacies.

This correspondent recently purchased a similar kit from a dispensary in Mirpur without being required to provide a prescription.

Dr Raunak Jahan, assistant professor of Shaheed Suhrawardy Medical College and Hospital's Gynae & Obstetrics department, said, "The kit includes two drugs -- Mifepristone and Misoprostol.

Mifepristone blocks the hormone needed for pregnancy to happen while the second pill -- Misoprostol --  causes the uterus to contract and then flush out the foetus.

Also a member of the Obstetrical and Gynaecological Society of Bangladesh, Dr Raunak stressed, "It is important to consult a doctor, as it entails some specific conditions and criteria.

"Neglecting professional advice may lead to complications, particularly in cases of ectopic pregnancy [when a fertilised egg grows outside of the uterus], where MRM kit is ineffective and can pose life-threatening risks if appropriate procedures are not promptly undertaken."

She added, "Moreover, MRM is not suitable for everyone -- especially for those who are dealing with chronic health conditions like cardiac, renal, or liver issues, or taking certain medications such as blood thinners or steroids, or have hypersensitivity."

The potential side effects of the medicines include nausea, vomiting and diarrhea, high temperature, pelvic pain, fainting, headache, dizziness, and asthenia (abnormal weakness).

According to Bangladesh National Comprehensive Menstrual Regulation and Post-Abortion Care Services Guidelines, MRM has the potential to greatly enhance safe abortion access.

However, without safety measures, doctor's consultation and risk assessment, taking the medication could result in dire consequences.

THE CONSEQUENCES

Data from Directorate General of Family Planning (DGFP) showed that from 2015 to 2019, nearly 50 percent of pregnancies were unintended in the country, leading to 60 percent of them being terminated through abortion.

DGFP documented around 800,000 yearly cases of menstrual regulation, but only approximately 150,000 were officially recorded.

Dr Raunak's department admits about 40 patients daily, with 5-6 facing incomplete abortions due to uncontrolled use of the MRM kit.

"These patients come in a state of shock with severe bleeding, requiring emergency procedures such as D&C or Manual Vacuum Aspiration to remove the foetus.

"Uterine perforation risks arise when such procedures are performed by untrained officials at hospitals or clinics."

She further said, "Even more alarming is that many don't seek help. They endure the bleeding, become anaemic, and consider everything is okay. They do not realise the internal impacts can be life-threatening."

Naripokkho's Project Director Samia Afrin, who conducted research on MRM services in 2018, noted that despite the medication needing to be taken within 10 weeks of pregnancy, many women lack the knowledge of how to count pregnancy weeks.

DANGERS FOR RURAL WOMEN

Under the DGFP's maternal and child health department, MRM kits are distributed among women while family welfare visitors are given training for counselling. However, some anomalies were noticed in recent years in several districts last year.

A 2023 study by Marie Stopes Bangladesh in Sylhet's Habiganj, Moulvibazar, and Sunamganj districts revealed that kits were not supplied to the union family welfare centers in these districts last year.

Monjun Nahar, head of advocacy at Marie Stopes Bangladesh, said, "We were surprised to discover no demand for MRM in these districts. We found out that due to the taboos surrounding abortion, women made discreet purchases from pharmacies through their husbands. These pharmacies lack strict monitoring, including counselling, selling with prescription, necessary follow-ups, or referrals to health facilities.

"These women end up at a health facility with permanent damage to their uterus."

Samia Afrin highlighted significant challenges in government health facilities -- insufficient training, social and religious barriers, inadequate MRM kit supply, negative behaviour by staffers, and a lack of monitoring.

Dr Raunak, based on her experience in Narsingdi and Manikganj, noted a significant number of cases with uterus perforation. "Due to the taboo, many seek procedures in other upazilas or inexpensive hospitals, leading to complications. When unable to control bleeding, they are referred to us, often leaving insufficient time for preparation."

She believes sexual and reproductive health and rights education is a necessity to stop child marriage and teenage pregnancy.

Dr Md Muniruzzaman Siddiqui, director (MCH Services), MCH Unit, DGFP, said they are aware of pharmacies selling MRM kits illegally.

"With the assistance from Association for Prevention of Septic Abortion, instructions for MRM kits for drug sellers are currently in the printing process."