Delay in Care Seeking for Menstrual Regulation

Introduction

Safe motherhood is the legitimate demand and right of all women all over the globe. But it remains one of the most important and unsolved issues. Unwanted or unplanned pregnancy leads to unsafe abortion and it is a major cause of concern in safe motherhood program.

Each year women around the world experience 75 million unwanted pregnancies. According to the Bangladesh Demographic and health survey (DHS), 2% of a sample of 9640 currently married women said that they had terminated an unwanted pregnancy¹. Two-thirds of these terminations (65%) involved menstrual regulation which is considered as an” interim method of establishing non-pregnancy, for a woman at risk of being pregnant, whether or not she is pregnant infact”². The method is safe, effective and easy to maintain. The risks are less. In Bangladesh menstrual regulation services are available at all major government hospitals and health facilities and are legal for pregnancies of 6-10 weeks.

In spite of wide availability, women who do not use menstrual regulation services may resort to induce unsafe abortion herself, by non-medical person or by health workers in unhygienic condition. They do it by inserting a foreign object into the uterus or by indigenous oral medicine³, swallowing harmful substance or by improperly performed dilatation and curettage. Some of these are women who have been rejected from MR facilities due to longer duration of their pregnancy. Most women seeking abortion are married and having children. Adolescents are also resort to abortion. In comparison with adults, adolescents are more likely to delay the abortion, resort to unskilled persons to perform it, use dangerous methods and present late when complications arise⁴. Abortion performed after 12 weeks of gestation pose greater risks of medical complication than performed during the first trimester.

Induced abortion is a national problem in women’s health as it is for the whole world. Worldwide, nearly one in 10 pregnancies end in unsafe abortion⁵ and WHO estimate showed that 18 out of 20 unsafe abortions takes place in developing region of the world. Induced abortion leading to complication such as bleeding, infection, injuries and even maternal death. These deaths could be prevented if women had an access to safe abortion facilities.

a. Background:

 Menstrual regulation(MR), an early termination within 6-10 weeks without pregnancy confirmation, is widely provided through a network of the government health services since 1978.

Menstrual regulation(MR) using vacuum aspiration is widely available in Bangladesh through public, NGO and private sector facilities, even though abortion is illegal except to save a women’s life. For more than two decades the MR program was run as a vertical program. In 1998 the government of Bangladesh introduced the health and population sector program (HPSP) incorporating menstrual regulation into the essential services package. In spite of wide availability, barriers such as distance to health facilities and transportation costs, unofficial fees, lack of privacy, confidentiality and cleanliness in public health facilities, and   in some cases attitudes of service providers, are limiting access to MR services. Quality of care is compromised by inadequacies in infection control and in provider training and counseling. Health system weaknesses include gross under-reporting of cases by providers who do not wish to share unofficial fees, which affects monitoring and adequate provision of  supplies. The HPSP has caused uncertainty regarding supervision in public sector facilities  and adversely affected training by NGOs and government-NGO coordination⁶ .

b. Rationale of study:

Millions of women around the world risk their lives and health to end unwanted pregnancies. The situation is no different in Bangladesh. Overall, one third of births in Bangladesh can be considered as unplanned. 19% are mistimed and 14% unwanted. Low contraceptive continuation rates, method failure and high unmet need for contraceptives are some of the leading causes of unwanted pregnancies and abortions.

The issue under this study has important implications for the family planning program in Bangladesh. As noted, most of the women interviewed were not practicing contraception at the time they become pregnant.Primarily because of side effects, fear of side effects or the inconvenience of contraceptive use. These concerns could be addressed to some extent by providing better counseling on, and management of  side effects and by offering women more convenient access to a wide selection of methods. However, even with the implementation of such measures, some demand for pregnancy termination is likely to exist. . As lack of proper knowledge about MR, its timing some of them come delay in seeking for menstrual regulation. But when they are rejected for MR they get frustrated and attempts to get rid of it by induced abortion by themselves or  by untrained persons.  This unsafe procedure results in serious forms of morbidity and extreme cases death may occurs due to septic abortion.

In addressing future challenges the government plans to reduce maternal mortality by providing adequate support for antenatal care, post delivery services and emergency obstetric care. The government policy also emphasizes management of complication arising from unsafe abortions. This proposed study will try to find out the causes of delay in care seeking behavior, thus the government may need to publicize the risks involved in delaying MR care seeking behavior of these women, so that service seekers can make safer choices.

c. Research question:

What are the factors influencing delay in care seeking for menstruation regulation (MR) among the women attending in family planning unit, ICMH, Matuail, Dhaka.

d. Aims and objectives:

General objectives:

To find out the factors influencing delay in care seeking for menstrual regulation.

Specific Objectives :

i)              To find out the personal and social factors for delay in seeking MR care and socio-demographic characteristics of the delayed MR clients.

ii)            To assess the level of knowledge about advantages and disadvantages of MR.

iii)          To assess the level of knowledge regarding legalization, proper time and gestational period for receiving MR and its complications.

e. Literature review:

National studies:

Studies of pregnancy termination in Bangladesh usually involve women who have obtained menstrual regulation at a clinic or women hospitalized for abortion complications. Even given limited and somewhat biased samples, the studies indicate that menstrual regulation clients are comparatively well-educated and of higher than average socioeconomic status. In general, they are in their 20s and have 2-3 children. ⁷

A study of 212 menstrual regulation clients in Matlab found that the majority were motivated primarily by a desire to space births, with a minority wishing to limit overall family size. However the investigators also noted that clients often referred to economic problems and that contraceptive failure appeared to be a major problem. Two other studies found the desire to limit births to be the primary factor. Women who had undergone forms of pregnancy other than menstrual regulation were poorer and less educated. Several studies have described the risk of illegal abortion in Bangladesh. Studies of menstrual regulation have found it to be generally safe, but have raised some concerns over the technical training and skills of service providers.⁷

 Prior to the 1970s, pregnancy termination was illegal in Bangladesh except when a women’s life was considered to be endangered by the pregnancy. In 1974, however, the government of Bangladesh allowed a clinic in Dhaka to offer menstrual regulation (early termination without pregnancy testing), and in 1978 it began to train government doctors and paramedics to provide such services.⁸

 Menstrual regulation services are available at all major government hospitals and health facilities and are legal for pregnancies of 6-10 weeks. At upazila (sub district) health complexes, they are normally provided by physicians, and at union health and family welfare centers, they are performed by female paramedics called family welfare visitors. Nurses and family welfare visitors can provide menstrual regulation services if the length of gestation is no more than eight weeks; physicians can do so through 10 weeks of gestation.

In Bangladesh, women’s ability to control their fertility is limited. Though family planning methods are available everywhere in the country, a women may not use them because of financial constraints, lack of   access to family planning information and services, personal or religious beliefs, inadequate knowledge about the risks of pregnancy following unprotected sexual relations, women’s limited decision making ability with regard to sexual relations and contraceptive use, and incest or rape. On the other hand, contraceptive methods, even the most effective ones may fail for a variety of reasons related to the technologies themselves and or the way they are used.

Unsafe abortion may be induced by the woman herself, by non-medical persons or by health workers in unhygienic conditions. The majority of the women in the villages of Bangladesh depend on the services of the village doctor, herbal practitioner, homeopath, and religious healers. These village practitioners are conveniently located in the community, and the women are more familiar with them. However, about 15% of the women choose medically trained people in the community as their first health provider. Approximately half of the admissions to gynaecology units in major urban hospitals of the country are for complications of abortion. Every year 2-8% of all pregnant women undergo menstrual regulation and 1.5% undergoes induced abortion. These services are usually provided by untrained paramedics and ill trained doctors in a logistic constraint setting.¹

According to a recent study, the abortion rate in Bangladesh is about 26-30 per1000 live births. The annual number of induced abortion is about 1196, 00 in 2000.⁹ The overall rate of hospitalization for abortion is 2.4 per 1000 live births and about  75% of these complications are due to unsafe abortion and the remainder is due to menstrual regulation. The annual estimated number of complications requiring hospitalization that result from MR is about 193,000, which is approximately 4%   of the 468,000 MR performed annually.¹⁰ Induced abortion other than menstrual regulation is estimated to have a complication rate of about 40% and a hospitalization rate of about  20%.These complications not only are a burden to the women’s family but also drain scarce medical resources.

International studies:

The number of induced abortion declined worldwide between 1995 and 2003 from nearly 46 million to approximately 42 million. About 1 in 5 pregnancy end in abortion¹¹.  Direct causes of pregnancy –related deaths worldwide are:

• Severe bleeding,25%
• Infection ,15%
• Unsafe abortion,13%
• Hypertensive disorders,12%
• Obstructed labour,8% and
• Other, 8%.

Abortion is a sensitive and contentious issue with religious, moral, cultural, and political dimensions. It is also a public health concern in many parts of the world.

More than one-quarter of the world’s people live in countries where the procedure is prohibited or permitted only to save the woman’s life. Yet, regardless of legal status, abortions still occur, and nearly half of them are performed by an unskilled practitioner or in less than sanitary conditions, or both.

WHO defines an unsafe abortion as ‘a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both’. When abortion is performed by qualified people using correct techniques in sanitary conditions, it is very safe. Worldwide, nearly one in 10 pregnancies ends in unsafe abortion is safe and legal with those where it is restricted and often unsafe. In low-income countries, women have an average of one unsafe abortion during their reproductive lives.¹²

Turkey is currently the most populous country in the Middle East and one of the 20 most populous countries in the world. Women constitute 36.1 million of the population, and half of this number is of reproductive age. Each year approximately 1.5 million births take place and 728-1000 mothers die due to pregnancy, delivery, and birth-related complications.

Turkey has made progress in improving reproductive health since the 1994. Despite the liberal nature of the abortion law, the number of legal abortions up to 10 weeks performed in the country has been sharply restricted by the requirement that the procedure be carried out only by or under the supervision of gynaecologists. This factor is especially critical in rural Turkey where medical specialists of any type are rare or nonexistent. Consequently rural Turkish women seeking an abortion within the first 10 weeks of pregnancy may not be able to obtain one. This paper aims to emphasize that the law for safe abortion services may itself represent a barrier to service provision for all women of reproductive age.¹³

Limited access to  and  low international of health services in the eastern and south eastern regions and rural areas throughout the country is often related to the low social status of families, especially of women.  The international health community and governments worldwide have repeatedly agreed that reducing deaths and injuries from unsafe abortion is a high priority.¹³

Although specific commitments have been made toward achieving this objective, progress to date has been wholly inadequate. Significant progress cannot occur until all women of reproductive age have much better access to safe abortion care in their communities. Abortion is safest when performed early in a pregnancy.¹⁴

Second-trimester abortion is known to be associated with increased morbidity and mortality rates. In this paper, possible reasons for delayed abortion are examined by: (1) reviewing the available literature to seek a synthesis of current findings, (2) discussing the findings within the theoretical context of decision-making under conflict which offers a conceptual framework for further understanding delay in seeking abortion, and (3) pointing to some methodological problems in studies of delay in seeking abortion.¹⁵

The differential characteristics of 697 women desiring induced abortion were studied according to when in pregnancy they presented, age, marriage, and level of formal education were inversely related.Those with greatest delay tending to be young, unmarried, and minimally educated. Religion was relevant, but generally was not .Null parity was only a weak correlate of delay. Contributory factors of denial, ambivalence, fear, and preceding menstrual irregularity accounted for two thirds of cases; they were uniformly distributed over the range of gestational age, but constituted the greatest proportion of reasons among those delaying decision longest. Physician delay and laboratory error accounted for all but one tenth of the remainder; they were concentrated particularly among gravidas presenting for care in the early part of the mid-trimester. Fear characterized the young, poorly informed noncontraceptors, and had the greatest relative impact in protracted delays; denial was more likely to be found among older and ostensibly better informed women.¹⁶

Compared to the other Western industrialized countries for which complete abortion data are available, the U.S has a high concentration of abortions among younger women and unmarried women and efforts should be directed toward them to increase the prevalence and effectiveness of contraceptive practice. Nearly half of pregnancy among  American women are unintended. Four in ten of these are terminated by abortion.¹⁷. The majority of abortions in the United States were obtained by younger (50%) than 25.Women aged 20 to 24 obtain 33%.Of all abortions teenagers obtain 17%, 40% of pregnancy among white women,69% among blacks and 54%among  Hispanics are unintended.¹⁸.A major task of the social scientist is to determine why some women tend to delay in seeking abortion. The ultimate objective should be to prevent such delay as much as possible. Sociological research in this field has been focused upon 2 questions: which groups of patients show an increased risk in receiving treatment during a later stage of pregnancy and what are the reasons for this delay. An attempt is made to answer these questions primarily with respect to the situation in Holland. Because of legal barriers or a general lack of adequate facilities in their countries of residence, every year many women from abroad come to the Netherlands to have an abortion in 1 of the Dutch clinics. According to data collected from practically all Dutch clinics in 1979, 32000 German women, 7500 Belgian women, and 1900women from other countries were treated in Netherlands. 13,200 Dutch residents also underwent an abortion in a clinic.  An additional number of approximately 3500 women were treated in a general or an academic hospital. The median duration of pregnancy was lowest among  Dutch residents: 7.8 weeks; it was 8.3 weeks among German women, 8.4 weeks among Belgian women, and 9.1 weeks among women from other countries. Dutch residents generally have an abortion at an earlier stage of pregnancy than foreign women. The number of midtrimester abortion/100 abortions among dutch residents was rather low. Only in Sweden, Japan, and some Eastern European countries have lower figures been reported. As the incidence of abortion is generally  extremely low in the Dutch population( 5.6/1000 womin aged 15-44 in  1979), the incidence of 2^nd trimester pregnancy termination is also very low, between0.4-0.5/1000 women aged 15-44. Data on Dutch patients who show an increased risk in delay are remarkably similar to those found in other areas. Women most likely to delay abortion show the following characteristics; very young or over age 40, unmarried or previously married, not living with a partner and especially those living with their parents; having no children or many children; and of low educational level and socioeconomic class. These characteristics represent circumstances that are known to contribute to the unacceptability of pregnancy and parenthood .The reasons for delay can best be understood and systematically dealt with by focusing on the process of decision making. Within this process, at least 3 phases can be distinguished: recognition of pregnancy; decision in favor of or against abortion; and finding a facility where the abortion can be performed. During the recognition of pregnancy phase, denial of pregnancy and irregular menstruation are the most common reasons for delay. Other reasons are unfamiliarity with pregnancy and incorrect diagnosis. In the 2^nd phase ambivalence is the most frequently stated reason. Lack of information, delay in referral, and lack of funds are major reasons in the 3^rd phase.¹⁹

The South African Choice on Termination of Pregnancy (CTOP) Act, no92 of 1996, replaced the previously restrictive abortion and sterilization Act, no 2 of 1975. The act promotes a woman’s reproductive right and choice to have an early, safe and legal abortion. As a direct result of the new abortion legislation, abortion related morbidity and mortality have decreased significantly. However, despite the legislation there are still major barriers to women accessing abortion services. These include provider opposition, stigma associated with abortion, poor knowledge of abortion legislation, a lack of providers trained to perform abortions and facilities designated to provide abortion services particularly in the rural areas.^2o

In South Africa, little is known about the reasons why  women delay seeking an abortion until the second trimester^21..Exploring the reasons why women attend later in pregnancy for an abortion is important for informing interventions to reduce the proportion of second trimester abortions in south Africa. This paper results from a qualitative study that explored the factors that contributed towards women accessing abortion services in their second trimester of pregnancy.²²

Materials and Method:

  h.  Operation definitions:

Menstrual regulation:  Aspiration of uterine contents by Karman’s 50 cc syringe and flexible plastic canula to regulate menstruation within 6-10 weeks is called MR.

Time of MR operation: MR is done within 8 weeks of pregnancy or 60 days from 1^st day of LMP or 28 days from the missed period.

Delay in care seeking: Seeking for Menstrual regulation after 10 weeks of  amenorrhoea.

Age of marriage: The age at which a female marries and enters the reproductive period of life.

Parity:  Condition with delivery of live children.

MR clients:  Women attending the clinic for MR services irrespective of age  and marital status.

Family planning: Planning about number of children and their spacing by certain birth control methods.

Education status:

Illiterate- persons having no formal education   .

SSC- person who have passed secondary school certificate examination.

HSC-  person who have passed higher secondary school certificate

i. Outcome  variables:

1. socio-demographic characteristics

• Age
• Marital status
• Education level of the respondents
• Occupation of the respondents
• Monthly family income

2. Reproductive variables

• Married life of respondents
• Number of live births
• Number of living children
• Age of the last child

3. Contraceptives use by respondents

4. Knowledge of the respondents about MR

5. Source of knowledge

6. Knowledge of correct time of doing MR

7. Knowledge about advantages of MR

8. Knowledge about adverse effects of MR

9. Knowledge about the legal aspect of MR

10. Causes of delay for seeking MR

j. Procedure : Data was  collected by investigator in a pretested  questionnaires which is given in appendix. The cases were  included after      determination of last menstrual period by taking menstrual history and USG whenever possible. Name, age, socio economic condition of the clients were recorded. Contraceptive history, obstetric history and knowledge about MR, timing of doing MR, side effects were found  by questionnaires and lastly tried to find out the causes for delay in care seeking for menstrual regulation.

k. Ethical measure: the study was applied for approval  by ethical review committee of ICMH. Informed consent was taken from the respondents.

l. Data processing and statistical analysis:

All the data were checked and edited after collection. The data entered into computer, with the help of SPSS for windows’ XP  program version 12.0. an analysis plan was developed keeping in view with the objectives of the study. Frequency  distribution  and normal distribution of all continuous variables was calculated. Cross tabulation  was  prepared and a comparison was made between respondents from both the areas, male and females, different age groups etc. Background variables were controlled during analysis. Appropriate statistical tests (Chi- square)  were  done according to the need of the study objectives  where and whenever required.

Results

Fig I: The bar diagram showing that 37% of the respondents were below 20 years.  30% were from 21-25 years.  19% were from 26-30 years. 10% were from 31-35 years and the least number 4 % of the respondents were from above 35 years age group. Mean age 22.14 years.

Table I  Distribution of the respondents by level of education

 Table II  Distribution of the respondents by their husband’s educational status

Respondent’s husbands education level showed that 37% were from class1-5. About 33% respondents were illiterate, 19%  were class6-10 and only 11% respondents were from SSC level and above .

Table II Distribution of respondents  by age at marriage

 Table III : distribution of respondents by age at marriage shows that mean age of their marriage was 19.5 and  forty two percent  got married by 17-20 years.

Table IV   Distribution of respondents by earning member in the family

 Table IV: Showed that 67% husbands were the only earning member of the family and both.were in case o 25%.

Table V  Distribution of respondents by family’s monthly income

 Table V: Showed that 56%  family’s monthly income were within 3001-5000 taka, about 29%  family’s income was more than 5000 taka,  11%  family’s income were 1000-3000taka and only 4% family’s income was within 1000 taka.

Table VI  Distribution of respondents by number children

 Table VI: Showed that 73%  delivered 1,2, and 3 children, whereas rest 16% delivered 4-5 children.

Table VIII   Distribution of respondents by age of last child.

 Table VIII Showed that mean age of last child was 3.04.

Table VIII   Distribution of respondents by source of knowing about MR.

 Table VIII: Showed that 65% learnt about MR from relative/neighbor  and 25% from Health workers.

Table IX   Distribution of respondents by their knowledge about legal aspects of MR

  Distribution of respondents by their knowledge about legal aspects of MR showed that  63% didn’t  know about its legalization.

Table X   Distribution of respondents by knowledge about side  effects of MR

 Table  X: showed that 85% knew about  the side effects of MR and 15%  respondents didn’t know.

Table XI   Distribution of respondents by knowledge about patterns of adverse effects of MR

 Table XI showed that  37% said about adverse effects of MR was excessive bleeding and 33% for pain , 8% for sterility , 6% for perforation and rest of infection .

Table XII   Distribution of respondents by causes for delay in care seeking for MR

 Table XII   Distribution of respondents by causes for delay in care seeking for MR shows that 56% had personal causes, 19% had social causes, 15% had service related causes and rest 10% had familial causes.

Table XIII   Distribution of respondents by personal causes

Distribution of respondents by personal causes of delay in MR shows that 51.72%  took oral tablets for abortion, 41.37% failed to understand about the pregnancy and rest 6.9% don’t know where get MR service.

Table XIV   Distribution of respondents by family causes

 Table XIV: Distribution of respondents by family causes shows that 60%  pointed out in security of the house as the causes for delay.

Table XV   Distribution of respondents by service centre related causes.

Distribution of respondents by service centre related causes showed that 62% delay due to treatment cost and rest were due to distances  of centre and substandard services.

Table XVI   Distribution of respondents by age group and delay in MR due to personal cause

Table XVIII showed that 21%  of the respondents delayed due to personal causes were <20 years age group and 17% were 21-25 years.Chi –square test (X²=.23, df=4, p=.993) was done. No significant association was found among age group and delay in MR.

Table XVII   Distribution of respondents by monthly income and delay in MR

 Table XIX showed that 40% of  respondents whose monthly income <5000 were delayed due to personal causes.Chi –square test (X²=.51, df=3, p=.9164) was done in which no significant association was found among monthly income and causes for delay.

Table XVIII   Distribution of respondents by level of education and knowledge about timing of  MR.

 Table XVIII showed that 48% of  illiterate respondents gave wrong answer about proper time of doing MR.

Chi –square test (X²=1.09, df=3, p=.778) was done.  No significant association was found among level of education and knowledge about  timing of MR.

Table XIX   Distribution of respondents by relation with occupation and knowledge about legal aspect of MR.

 Table XIX showed that 52% of house wives didn’t know about legal aspect of  MR.

Chi –square test (X²=2.48,  df=3, p=.478) was done.  No significant association was found among occupation and knowledge about legal aspect of MR.

Discussion

The termination of pregnancy by willful means has always created dilemmas for civil societies. Many citizens abhor the practice, other support the right of women to make their decisions; no one seems to be neutral on the subject. Menstrual regulation (MR) an early termination within 6-10 weeks without pregnancy confirmation is widely available in Bangladesh through public, NGO, and private sector facilities, even though abortion is illegal except to save a women’s life This cross-sectional study was carried out to know the factors causing delay in care seeking behavior of menstrual regulation among fifty women in selected MR clinic in  institute of child and mother health.

The study was done with the objective to find out the personal and social factors for delay in seeking MR care and to find out the level of knowledge about MR like advantages, disadvantages, indication, proper time of receiving MR and its complication. The mean age of respondents was 22.14 years. One study showed that the mean age of the MR clients was 26 years.²  and few other study results stated the mean age of MR clients was 24 year.^23,24 this findings showed that the MR clients were almost in the middle of their reproductive life. Most of them were married and 4% were divorced as their husbands left them after they conceived. The mean age of marriage was 19.5 years. Seventy five percent were housewives and 79% were illiterate. In 67% cases husbands were the only earning member. The decision making process for MR by these uneducated, housewives women could not made by themselves, their elder family member played an important role. Women were undecided in their decision to terminate pregnancy which leads to delay in seeking MR. The study showed  that thirty seven percent  of the respondent’s husband’s educational level was calss1 –class5 and 49% of them were day laborer, 22% were service holder and rest do small business. The monthly family income of the respondents was within 3000-5000 taka, in 56% cases. This indicates that the clients were poor. This findings was similar to the of  Bhuiyan and Begum.²⁴  Most of them having 1-3 living child, on the other hand 11% respondents had no living child still came for doing MR.

Similar to other study the study finding suggests that problems in suspecting a pregnancy were an important cause of delay^12,21 with irregular periods and poor recall and recording of menses. Resulted in difficulties recognizing pregnancy symptoms, which if identified earlier may have prompted women to confirm a pregnancy sooner.  In the study about 41% were failed to understand about pregnancy as their cycle was irregular and took irregular oral contraceptive pill. About 83% respondents used family planning methods and of them majority 72% were pill users. But most of then took irregular OCP and inject able contraceptive though, 91% stopped contraceptive method before the present pregnancy. Despite limited use of contraceptive method, women did not make link between amaenorrhoea and pregnancy. On the other hand women experienced difficulties in detecting a pregnancy with at least two months elapsing prior to pregnancy confirmation. This study result similar with findings of Harries et al. study.²²

The study findings suggest that 87% knew about advantage  of MR as it is safe for health, less chance of infection. Of them  70%pointed out excessive bleeding and pain as disadvantages of MR. the respondents said that they learnt about MR from relatives or NGO workers.

But the study showed  that though they had knowledge about MR, 65% don’t know about its legal aspect. They did not consider it as their “right”. And most were not aware of the time restrictions involved.¹² 

Most women described multiple barriers to obtaining MR early and did not  identify one reason as being more important than another. Women tended to relate more too personal (58%), social (18%) issues than service related barriers (14%)^12,22 . When the respondents confirm about their pregnancy at first majority (51%) tried home abortion by taking gynaecosid, cytomis, emergency pill or other abortificient drugs and when they failed they were already delay. The study shows that majority in this group belong to age group of less than 20 years.

This study revealed several important shortcomings in the health care system and with regards to MR care provision. Initial delays in suspecting  a pregnancy was underscored by further delays once women decided to have  MR. Delays due to inappropriate referral evidenced by women attending numerous facilities before obtaining MR, waiting periods of over two weeks and difficulties locating a facility providing second trimester abortions is concerning. Unofficial fees and substandard service of some MR centre was also a factor for delaying.

Women intimated that reproductive choice was often difficult, particularly in a climate of judgmental and negative attitudes displayed by healthcare providers. Opportunities for values clarification training designed to promote more tolerant attitudes by service providers should continue and extend to health care providers working within all areas of reproductive health. Such interventions would play an important role in improving the quality of care and long term health outcomes of women seeking MR.

Limitation of the study

1. This study was carried out a tertiary level hospital, which was selected purposely. A wider study could not be possible due to financials constrains. There are many MR clinics in our country and date was collected from a single centre.
2. Purposive sampling was done due to time constrain. If enough time was available more respondents could be covered. So, this result may not be representative to our country.
3. The research had to depend upon the stated answers by the respondent for many of the information link monthly income, previous frequency of MR, contraceptive practices. As there was a question of validity.
4. The research could not obtain all the correct information due to lack of opportunity to maintain proper privacy during information collection.
5.  The study design was taken as a cross section one, though a comparative study would be more suitable for this topic.

Conclusion

The main aim of MR is to  provide an assurance and return of normal menstrual function by a simple technique.It is safest when performed early in a pregnancy.

In my study, a wide range of factors for delayed was explained by the respondents. Many of these reasons were personal rather than service related due to lack of knowledge about signs and symptoms of pregnancy. The main social causes of delaying MR shows that most of them was due to spiritual bindings and fear of public disgrace and from the service related causes unofficial fees was the main factors. About familial causes insecurity of the house was the main cause. The study showed that though that they had satisfactory knowledge about MR, they were unaware about its legalization and proper timing for doing it.

Now safe MR service and management of MR related complication is consider to be one of the priority of reproductive health strategy. Information on the availability of MR services particularly the time restrictions should be included in reproductive health care counseling, so that women with unintended pregnancies are able to make informed choices. To contribute the achievement of the MDG 5 target to reduce the maternal mortality ratio by 75% from 1990-2015, MR services should be made easily available to the rural people, where the mortality and morbidity due to abortion is high.

Recommendation

Depending on the study findings following study recommendation were made

1. More mass made advertisement should be present.
2. Legal aspect of MR should be well knows to its target population.
3. Raising greater awareness about the sigh of symptoms of pg.
4. To improve the acceptability of MR education on the behind of MR has to the made available to the whole population.
5. Service related hassles should be minimized.
6. The quality of MR services should be improved.

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