title: Strengthening health systems capacity to monitor and evaluate programmes targeted at reducing abortion-related maternal mortality in Jessore district, Bangladesh.
abstract: BACKGROUND
  Abortion related deaths as a proportion of maternal mortality appears to have fallen dramatically in Bangladesh from 5 % in 2001 to 1 % in 2010. Yet complications from menstrual regulation (MR) and unsafe abortion continue to cause deleterious health, economic and social consequences for women in the country.
  
  
  METHODS
  This quasi experimental design study with a baseline (January to December 2008) and an endline survey (August to October 2009) was conducted in 69 public, private, and NGO sector health facilities in Jessore district of Bangladesh with the objective of adapting and implementing a set of process indicators, specifically to supplement the indicators for monitoring emergency obstetric care interventions. At the baseline, we collected retrospective data from all 69 health facilities that provided MR, legal abortion or post-abortion care (PAC), by reviewing their last one year's records. Three months after introducing the safe menstrual regulation and abortion care (SMRAC) model, endline data was collected. Signal function (critical services that facilities must perform in order to prevent and treat abortion complications) analysis was used to characterize facilities as providing basic care, comprehensive care, or neither. Facility mapping, and records on services provided and complications treated were used to further characterize service availability and to describe service use and quality.
  
  
  RESULTS
  No facilities fulfilled criteria for 'comprehensive' care at either the baseline or end line while only one met the 'basic' criteria during the endline of the project. Recommended uterine evacuation technology, manual vacuum aspiration (MVA) was used for 100.0 % of MR clients but only for 8.0 % or fewer PAC patients. MR clients were 37.5 times more likely than PAC patients to leave facilities with a contraceptive method (75.0 % vs. 2.0 %).
  
  
  CONCLUSIONS
  Persistent use of older uterine evacuation technologies was observed when recommended techniques were widely available in the facilities. Notable gaps were identified in providing post-abortion contraceptive services for women treated for PAC. By systematic implementation of the SMRAC model, health systems can track and measure progress and gaps in their implementation and identify strategies for further reduction of abortion-related morbidity and mortality in Bangladesh.
authors.affiliation: Centre for Reproductive Health, icddr,b, GPO Box 128, Dhaka, 1000, Bangladesh. fauzia@icddrb.org.
authors.forename: Fauzia Akhter
authors.initials: FA
authors.lastname: Huda
authors.affiliation: Centre for Reproductive Health, icddr,b, GPO Box 128, Dhaka, 1000, Bangladesh. anisuddin@icddrb.org.
authors.forename: Anisuddin
authors.initials: A
authors.lastname: Ahmed
authors.affiliation: Oregon Health & Science University School of Medicine, Portland, OR, USA. evelynrebeccaford@gmail.com.
authors.forename: Evelyn Rebecca
authors.initials: ER
authors.lastname: Ford
authors.affiliation: World Health Organization, Geneva, Switzerland. heidibartjohnston@gmail.com.
authors.forename: Heidi Bart
authors.initials: HB
authors.lastname: Johnston
mesh_terms: D000028:Abortion, Induced / Q000401:mortality*; D000328:Adult; D001459:Bangladesh / Q000453:epidemiology; D057191:Capacity Building; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D005260:Female; D019981:Health Care Sector; D006801:Humans; D008428:Maternal Mortality / Q000639:trends*; D008483:Medical Assistance; D011159:Population Surveillance; D011247:Pregnancy; D019984:Quality Indicators, Health Care / Q000706:statistics & numerical data; D012189:Retrospective Studies