Front Cover
 The Bangladesh women's health...
 The service setting
 Staffing and supervision
 The importance of counseling
 Menstrual regulation services
 Record keeping for service, quality,...
 Portrait of a typical urban MR...
 Profile of Shamima, a typical rural...
 Management structure
 Costs of services
 BWHC as a training resource for...
 Looking to the future
 Lessons learned
 Resume en Francais
 Resumen en Espanol
 About the authors
 Back Cover

Group Title: Quality = Calidad
Title: The Bangladesh Women's Health Coalition
Full Citation
Permanent Link: http://ufdc.ufl.edu/UF00088792/00001
 Material Information
Title: The Bangladesh Women's Health Coalition
Series Title: Quality = Calidad
Physical Description: 24 p. : ill. ; 26 cm.
Language: English
Creator: Kay, Bonnie
Germain, Adrienne
Bangser, Maggie
Publisher: Population Council
Place of Publication: New York
Publication Date: c1991
Subject: Child health services -- Bangladesh   ( lcsh )
Birth control -- Bangladesh   ( lcsh )
Women's health services -- Bangladesh   ( lcsh )
Child Health Services -- organization & administration -- Bangladesh   ( mesh )
Family Planning Services -- Bangladesh   ( mesh )
Women's Health Services -- organization & administration -- Bangladesh   ( mesh )
Genre: non-fiction   ( marcgt )
Spatial Coverage: Bangladesh
Statement of Responsibility: by Bonnie J. Kay, Adrienne Germain, and Maggie Bangser.
General Note: Caption title.
General Note: Includes summaries in French and Spanish.
 Record Information
Bibliographic ID: UF00088792
Volume ID: VID00001
Source Institution: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 28293839
lccn - 94106308
isbn - 0878340572

Table of Contents
    Front Cover
        Front Cover 1
        Front Cover 2
        Page 1
        Page 2
        Page 3
    The Bangladesh women's health coalition
        Page 4
        Page 5
    The service setting
        Page 6
    Staffing and supervision
        Page 7
    The importance of counseling
        Page 8
        Page 9
    Menstrual regulation services
        Page 10
    Record keeping for service, quality, and evaluation
        Page 11
        Page 12
        Page 13
    Portrait of a typical urban MR client at the Khaka clinic
        Page 14
    Profile of Shamima, a typical rural client at the Bolora clinic
        Page 15
    Management structure
        Page 16
        Page 17
    Costs of services
        Page 18
    BWHC as a training resource for the government
        Page 19
    Looking to the future
        Page 20
    Lessons learned
        Page 21
        Page 22
    Resume en Francais
        Page 23
    Resumen en Espanol
        Page 24
    About the authors
        Page 25
    Back Cover
        Page 26
Full Text

The Bangladesh
omenis Health

-. -4.>
h *


/Calim/Q&ual IQ&

4'~ 3~;;

Quality/Calidad/Qualite, a publication of the Population Council, highlights
examples of family planning and reproductive health programs that are providing
unusually high quality care. This series is part of the Council's Robert H. Ebert
Program on Critical Issues in Reproductive Health and Population, which, through
scientific and practical efforts, seeks to improve and expand the scope and quality of
reproductive health care. The philosophical foundation of the program, and of this
series, is that women and their partners have a fundamental right to respectful
treatment, information, choice, and follow-up from reproductive health care pro-
viders. The pamphlets reflect one of the four main thrusts of the program: enhancing
the quality of family planning programs.
Projects are selected for documentation in the Quality/Calidad/Qualite series by
an Advisory Committee made up of individuals who have a broad range of experi-
ence within the field of reproductive health and are committed to improving the
quality of services. These projects are making important strides in one or more of the
following ways: broadening the choice of contraceptive methods and technologies
available; providing the information clients need to make informed choices and
better manage their own health care; strengthening the quality of client/provider
interaction and encouraging continued contact between providers and clients; mak-
ing innovative efforts to increase the management capacity and broaden the skills of
service providers at all levels; expanding the constellation of services and information
provided beyond those conventionally defined as "family planning;" and reaching
underserved and disadvantaged groups with reproductive health care services.
None of the projects documented in the series is being offered as a model for
replication. Rather, each is presented as an unusually creative example of values,
objectives and implementation. These are "learning experiences" that demonstrate
the self-critical attitude required to anticipate clients' needs and find affordable
means to meet them. This reflective posture is exemplified by a willingness to
respond to changes in clients' needs as well as to the broader social and economic
transformations affecting societies. Documenting the critical choices these programs
have made should help to reinforce, in practical terms, the belief that an individual's
satisfaction with reproductive health care services is strongly related to the achieve-
ment of broader health and population goals.

Publication of this edition of Quality/ Statements made and views expressed in
Calidad/QualitM is made possible by sup- this publication are solely the responsibil-
port provided by the Ford Foundation, the ity of the authors and not of any organiza-
Rockefeller Foundation, and the United tion providing support for Quality/
Nations Population Fund (UNFPA). Calidad/Qualitg.

Copyright The Population Council 1991

Number Three 1991

ISSN 0-87834-057-2

The Bangladesh Women's

Health Coalition

by Bonnie J. Kay, Adrienne Germain, and Maggie Bangser

I'd heard about family planning before, but not this way. This is
the only clinic where I was asked to sit down and where I was treated as
an equal. If I knew about it this way, do you think I'd have six children?
Client, BWHC
Is a flexible, woman-centered reproductive health program responsive to women's needs an
unobtainable luxury? Are the standards of quality care that this implies simply too high for most
programs in developing countries to achieve? Does offering quality care mean that fewer clients
can be served, or that the cost per acceptor will be prohibitively high?
In recent years, the idea of promoting woman-centered reproductive health services that
emphasize quality of service delivery over quantity of contraceptive acceptors has been gaining
wide currency among researchers, practitioners, women's health advocates and donor agencies. Of
course, quality means different things to different people for the concept is a culturally and even
personally relative one. Yet despite a diversity of views, some common themes have begun to
emerge about what constitutes high quality reproductive health care for women. These include
building a relationship of trust between provider and client, encouraging continuity of care,
respecting the client's individual wishes and concerns, offering a range of fertility regulating
methods and the information necessary to make informed choices, providing a constellation of
additional services that respond to women's broader reproductive health needs and ensuring that
these programs meet accepted standards of technical competence. While these elements may
seem obvious, it is surprising how rarely they have been incorporated en bloc into most family
planning services. Indeed, to some administrators they represent a wish list of luxuries that cannot
possibly be attained in the resource-poor context of most developing countries.
The new emphasis on quality of care has come in large part from a dissatisfaction with the
performance of many traditionally structured family planning clinics. Dissatisfaction stems in part
from an inadequate choice of contraceptive methods, inconvenient service hours, long waits,
insufficient privacy for clients during interview and examinations and care-givers who at times
appear to be indifferent to clients' needs. For women unfamiliar with medical apparatus and
routines, visiting such clinics can be a difficult or unpleasant experience. In addition, some family
planning programs have been preoccupied with achieving a target number of acceptors in order to
meet the expectations of their own bureaucracies, national programs or donor agencies.

The Bangladesh Women's Health Coalition (BWHC) represents an important initiative in the
movement toward more responsive modes of family planning delivery. Although it is conventional
in its reliance on the model of the free-standing health clinic, BWHC is unconventional in its
philosophy, spirit and commitment to serving women in need. BWHC clinics are welcoming
places where clients feel comfortable, respected and understood. There is an emphasis on
informed choice among a wide array of birth control methods, including early termination of
unwanted pregnancy. BWHC clinics are also unusual in that family planning is not segregated from
women's other health needs and those of their children. Primary health services, such as treatment
of gynecological problems and early childhood diseases, are provided in the same setting; and all
this is accomplished while maintaining a high level of cost-effectiveness.
In the context of a society where there are strict limits on the social role and physical mobility
of most girls and women, BWHC has set itself the ambitious goal of enabling women-no matter
what their income or education-to learn how to manage their own reproductive health and the
health of their children in a way that enhances their sense of strength and competence.

The authors wish to acknowledge and thank Sandra Kabir, Executive Director of BWHC, for
her assistance and patience in providing information, answering questions and checking for accuracy.

For most of the 45 million girls and
women who live in rural Bangladesh, life has
been the same for generations-a struggle to
survive in the face of unrelenting poverty. A
work day of 14 to 16 hours is not uncommon for,
in addition to caring for her children, husband
and in-laws, a woman often takes on other work,
such as processing rice in a neighbor's house, to
earn much needed money. Young girls are usu-
ally occupied in caring for younger siblings and
managing the house, and have no time to go to
When a girl reaches puberty, custom
demands that her family protect her from all
encounters with men who are not members of
her own family. Early marriage is the norm, but
potential in-laws often demand a large dowry-
clothing, a watch and a transistor radio-which
can cost as much as a family earns in three
months. Social pressures force most women in
Bangladesh to have many children quickly,
especially sons; yet girls and women rarely have
access to modern health care because services
are unavailable or too expensive. This situation
is aggravated by the fact that most doctors are
men and it is usually unacceptable for women
to be examined by a male doctor except in a
dire emergency, and by then it is often too late.
About three million Bangladeshi women
of reproductive age live in urban areas. Increas-
ingly, poor rural families send their daughters to
work in the homes of relatives or wealthier peo-
ple in towns and cities. Rural women who have
been widowed or divorced-approximately ten
percent of women aged 25 to 49-also move to
urban areas to try to earn a living. For most of
them, life is hard. They live in slums and work
at whatever they can find. Some prepare food
for lunch boxes which their sons deliver to fac-
tory and office workers. Many work as servants,
earning only food and a place to sleep. If they
become pregnant, they will be fired. Other
young and mostly unmarried women work in
modern industries such as garment factories,
bakeries or pharmaceutical plants. They too will
be fired if they become pregnant. Away from
the protection of their families, some inevitably
do, and they and their children become out-
casts. Hardly any services exist to help them.
Among better off, urban families, many
young brides and mothers remain in traditional

seclusion, only leaving their homes covered
from head to foot in a burkah, or veil, and
accompanied by a husband, mother-in-law or
other responsible family member. Opportuni-
ties are, however, increasing for the daughters of
some middle class urban families. With a high
school or a university education, they can
become government health and family planning
workers, and teachers. However, as with poorer
women, their future depends on being able to
control their childbearing safely and effectively.
Although the lives and opportunities of
Bangladeshi girls and women differ tremen-
dously, they all have a common need for repro-
ductive health services. At any one time,
approximately five million women in Bangla-
desh are pregnant, 13 million are at risk of
becoming pregnant and, of these, no more than
25 to 30 percent use modern contraception.
Since 1971, the Government of Bangla-
desh, in collaboration with local, national and
international non-governmental organizations
(NGOs), has sought to provide contraceptive
services, especially in rural areas. Reversible
contraceptive methods, including the IUD, hor-
monal methods (pills and injectables), condoms
and foam, as well as male and female steriliza-
tion, are offered through NGO and government
clinics and field programs. In addition, a large
social marketing program sells condoms, foam
and pills at subsidized prices through a nation-
wide network of small shops.
Little care is available for most pregnant
women, although government and non-govern-
ment programs do attempt to provide tetanus
vaccinations, nutrition information and health
education. The majority of women give birth
at home, attended only by relatives or an
untrained midwife. Approximately 24,000
women die in childbirth every year and, within
one year, 95 percent of the children born to
them are also dead.
Every year, an estimated 750,000 Bangla-
deshi women may resort to abortion, mostly in
dangerous, clandestine circumstances. At least
7,500 of them (one in a hundred) die and sev-
eral thousand others are left sterile or seriously
ill. (Induced abortion is legally restricted in
Bangladesh, and only the major teaching hospi-
tals are equipped to provide abortions after ten
weeks' gestation.) The Government of Bangla-
desh also provides menstrual regulation (MR)

services for women who fear they may have an
unwanted pregnancy. In all, the practice of MR
(both reported and unreported) saves at least
100,000 to 160,000 women in Bangladesh from
the dangers of unsafe abortion every year.
While accomplishments in the area of
reproductive health have been substantial-
approximately one third of reproductive age
couples say they use some form of modern con-
traception-much remains to be done to reach
the remaining two thirds. Women who know
about and want contraception or MR often have
to travel long distances to clinics and wait hours
for services. Sometimes, no staff or supplies are
available when they arrive and the trip has to be
repeated. Women who want to use contracep-
tives or MR often face strong opposition from
their husbands, in-laws or community leaders.
As a result, millions of women do not yet have
access to family planning and health services,
and those who do need to be better served.

The Bangladesh Women's Health
The Bangladesh Women's Health Coali-
tion (BWHC), which offers a high standard of
reproductive health care at reasonable cost, is
an example of what can be done. BWHC was

founded in 1980 by Sandra Kabir, with encour-
agement from the International Women's
Health Coalition (IWHC). At the time, Ms.
Kabir was working as a program officer in the
Southwest Asia regional office of Family Plan-
ning International Assistance (FPIA), an agency
disbursing U.S. Agency for International Devel-
opment (USAID) funds to NGOs providing fam-
ily planning services. One group supported by
FPIA was Concerned Women for Family Plan-
ning (CWFP), an NGO delivering birth control
information and services to women in the slum
areas of Dhaka, the capital of Bangladesh.
When USAID placed increasingly stringent
requirements on CWFP to segregate menstrual
regulation from its other services, the agency's
director, Mrs. Mufaweza Khan, and Ms. Kabir
agreed that Ms. Kabir should establish a sepa-
rate clinic for women who needed MR.
From one urban clinic focusing on MR,
BWHC has grown to include seven multi-
service clinics in urban and rural areas. In FY
1989-90, BWHC clinics served approximately
97,000 women and children and provided over
145,000 reproductive health services including
counseling, contraception, menstrual regula-
tion, basic children's and women's health care,
prenatal care, immunization and referral to hos-
pitals and clinics for other gynecological and
obstetric care and for sterilization.

Table 1

Service Mix for All Coalition Clinics
and for an Urban and a Rural Clinic

July 1989 to June 1990

Service All 7 clinics Urban Rural
(Mirpur) (Bolora)
(Percent distribution of services)
Contraception 17.3 25.9 12.9
Menstrual Regulation* 8.1 15.7 3.6
Gynecology & Obstetrics 9.7 8.9 5.0
General adult 27.8 22.0 28.7
General child 20.9 23.8 35.5
Child immunization 16.2 3.7 14.3
Total 100.0% 100.0% 100.0%
Number of services 145,953 19,282 12,113

"Including follow-up, deferrals and rejections

From its beginning, BWHC has been
managed and staffed primarily by women com-
mitted to providing other women with effective
and caring contraceptive, health and pregnancy
termination services. BWHC's guiding premise
is that informed choice is as essential to a repro-
ductive health program as are medical safety
and access to contraceptives. Therefore, from
the outset, BWHC established the following
basic principles for quality care:
Each woman should be treated with
Each woman's particular needs should be
carefully discussed with her; and
Each woman should be provided with suf-
ficient information and counseling to make
her own choices about her reproductive
Designing services to meet these basic princi-
ples has required an openness to clients' needs,
much experimentation with the means of deliv-
ering services and the mix of services offered,
and cooperation with government and other
NGO programs.
While BWHC was originally founded to
provide MR, its openness to the needs of its
clientele quickly led to the delivery of more
comprehensive services for women and their
children. For instance, women coming for MR

services told BWHC staff that they also wanted
contraceptives and were concerned about the
well-being of their children. Mothers often give
priority to their children's health over their
own, and in Bangladesh, children's health is
generally inseparable from that of their moth-
ers. In 1989-90, for example, 25 percent of
BWHC's services were for family planning,
including MR; 38 percent were for women's
gynecological, obstetrical and health problems;
and 37 percent were for children's health and
On average, 1,700 services per month are
provided at each of BWHC's clinics, although
the number varies according to the clinic and
the time of year. For example, women are less
likely to visit rural clinics at harvest time or
during religious holidays. At one suburban
clinic (Narayanganj, southeast of Dhaka), as
many as 3,000 clients have received services in
one month. The mix of services also varies:
MR procedures are in greater demand at urban
and suburban facilities than in Bolora, a rural
clinic, where the largest share of services pro-
vided is for general health and immunization
(see Table 1).
No matter what the reason for the initial
visit, once at the clinic, all clients learn about
and have access to all other services. For exam-
ple, a nurse's aide, giving an injection to a boy,

notices his skin is scaly and advises his mother
what vegetables to feed him; a client seeing a
doctor about her daughter's cough is reminded
that she also needs a tetanus shot and they are
sent to the paramedic; another client, whose
gynecological problem has been successfully
treated, requests contraceptive services; and a
woman who comes for a contraceptive injection
is reminded to bring her children for immuniza-
tion. Return visits are very high. As one young
woman put it, "Everyone knows they give good
medicine. It works."

The Service Setting
All BWHC clinics are open five days a
week from 8:00 a.m. until 3:30 p.m. Clients do
not make appointments because telephone
communication is limited and making an
appointment would require an additional clinic
visit. On a busy day, a woman could be at the
clinic for several hours, but a visit of an hour
and a half is more typical. Minimal registration
fees are charged at all clinics. The two oldest
clinics, both in urban areas, charge fees for ser-
vices on a sliding scale basis. Since February
1990, nominal service fees also have been
charged in the other clinics because paying for
services increases clients' self-respect, and
because BWHC wants to demonstrate it can be

partially self-supporting. A woman's ability to
pay is determined by the receptionist or coun-
selor, primarily on the basis of what the woman
says and how she appears. However, no one is
ever turned away because she cannot pay.
Clinic services are provided in modest
buildings in low-income neighborhoods of
Dhaka, and in semi-urban or rural areas. Fur-
nishings and equipment are simple, inexpensive
and usually locally made. While physical facili-
ties vary, all of the clinics are spotlessly clean
and airy, their walls decorated with posters and
their windows hung with freshly laundered cur-
tains. Chairs or benches are always provided, as
are toilet facilities for clients and their children.
BWHC offers a choice of family planning
methods including the pill, injectable, IUD
and barrier methods. Counselors discuss all
these methods, plus sterilization, with clients.
As BWHC does not perform sterilization pro-
cedures, a woman choosing this option is re-
ferred to the nearest medical facility offering
this service.

Staffing and Supervision
Family planning services are provided by
women paramedics because in Bangladesh
women prefer to be treated by women. When-
ever possible, paramedics are recruited from the
community and are chosen for their interest in
serving other women as well as for their profes-
sional skills. They must have a minimum of ten
years of formal education, and 18 months of
government training as Family Welfare Visitors
(FWVs). Most of them have also had at least
seven to eight years of professional experience.
All paramedics are specially trained by BWHC
in counseling and medical techniques, and then
attend periodic two-week refresher training
Each BWHC clinic is staffed by two or
three paramedics (FWVs), a project coordina-
tor or administrator (who usually has a master's
degree), a counselor (who is a university gradu-
ate), a nurse's aide who dispenses medicine, two
attendants ayahss) and two guards. All staff,
except the guards, are trained to provide health
and family planning information to clients.
Medical staff are supervised by full-time physi-
cians who also provide all maternal and child
health services except immunizations. Two clin-
ics have full-time counselors while the project
coordinators serve as the counselors at the

other five clinics. In the near future, it is antici-
pated that all clinics will have full-time coun-
selors so that project coordinators will have
more time for community development work.
BWHC's policy is that all staff should not
only master the technical aspects of their jobs,
but should also demonstrate interpersonal
skills. Salary increases and promotion depend
on providing not only quantity but quality care.
Staff at the newer clinics, who are less experi-
enced, generally receive lower salaries than
their counterparts at more established clinics.
Performance, however, is always the criterion:
One administrator at a newer clinic, who was
particularly sensitive to clients and worked long
hours, received the highest salary increase
ever given to an administrator at the end of her
first year.
Following initial screening by a reception-
ist, clients are directed to the appropriate staff.
In the three clinics where there are resident
female doctors (Dhaka, Narayanganj, and Mir-
pur), women with gynecological problems are
treated by physicians. At the other four clinics
(Palash, Bolora, Tangail, and Lohagara), women
are examined by paramedics who work under
the supervision of a male doctor.
The basic health care services for women
and children offered at all BWHC clinics

include treatment for primary illnesses such as
dysentery, scabies, upper respiratory tract dis-
eases, eye infections and anemia. If diagnosis or
treatment of a health problem is beyond the
resources of the clinic, clients are referred to
other medical facilities. BWHC has established
working relationships with a variety of health
providers, including government hospitals and
private physicians, and a BWHC registration
card, with a doctor's comments, is honored by
these providers.

The Importance of Counseling
At BWHC, counseling is an important
component in the delivery of all services. The
aim is to put the client at ease and encourage
her to ask questions as well as to share informa-
tion with her. Counseling is an aspect of service
delivery not widely practiced or understood in
Bangladesh. BWHC clinics are unique because
not only is there a staff person specifically
trained in and responsible for counseling, but
most of the clinical staff, including the doctor,
the nurse's aide and attendants, are also
involved in counseling to some degree. A con-
scious effort is made to overcome the class bar-
rier that exists between the counselors and
most of their clients and to avoid patronizing or

condescending attitudes toward clients. This
means both the service provider and the client
must learn new behaviors in order to partici-
pate equally. While an initial counseling session
lasts only about 15 minutes, it represents an
opportunity offered almost nowhere else in the
Although the clinic is usually crowded
with clients, their friends and children, women
are counseled in as much privacy as possible-
either in a separate room or a curtained alcove.
As a family planning client responds to ques-
tions about her reproductive history, the coun-
selor seeks to establish rapport and to alleviate
any nervousness the client may feel. When all
the particulars have been noted, the counselor
and client then discuss the woman's knowledge
of family planning, her thoughts about what she
wants, and the appropriateness of that method
for her particular situation. For instance, will
her husband use a condom regularly? Can she
keep track of taking a pill every day? Does she
need to build up her hemoglobin level before
having a tubal ligation? Can she travel every two
or three months to the clinic for an injection?
Does she have health problems that contraindi-
cate the injectable contraceptive or the pill?
This process generally brings to light a
great deal of misinformation. For example: "We

f4 uraq'I"

use the condom as much as possible" or "I took
the pill on the day I had intercourse" or "I
heard that if you had the injection two or three
times, you would never get pregnant"' The
counselor corrects wrong information and,
if the client is dissatisfied with her current
method of contraception, she helps her con-
sider alternatives. In one case, an MR client
who had six children said that the pill made her
sick and she did not want to use another contra-
ceptive method after the MR procedure. Dis-
cussion revealed that she thought the only other
method available to her was sterilization. She
was very pleased to learn about the IUD and
decided to have one inserted.
Once a decision has been reached, the
counselor explains the procedure in detail to
the client so she will know exactly what to
expect. When appropriate, the counselor will
also suggest other services available at the
clinic, such as immunization and nutrition edu-
cation. If husbands accompany their wives, they
are encouraged to participate in counseling ses-
sions. The counselor tries to help the client and
her husband understand that although no con-
traceptive method is perfect, a reasonable
option can probably be found to meet their
needs. For example:
A woman who experiences nausea and
dizziness from the pill, but whose hus-

band does not want her to use the IUD,
may be advised to try the condom or the
A woman who has had eight pregnancies
and six children, who is anemic and afraid
of sterilization and whose husband refuses
even to think of a vasectomy, will be helped
to weigh the risks of injectable contracep-
tives against those of an IUD.
A woman who cannot use the IUD
because her cervix is eroded, whose hus-
band does not want her to have a tubal
ligation and who has to walk eight or nine
miles to reach the clinic, may be advised to
try the pill rather than the injectable. This
is because pills can be procured locally
whereas the injectable involves a clinic
visit every two or three months.
A woman who does not want another
child, and has had an IUD removed
because it gave her severe cramps, may be
advised to consider sterilization.
A woman's decision about which contra-
ceptive method to use is influenced not only by
health considerations but by her partner's pref-
erence. The learning process a client goes
through with the counselor often brings to light
not only intimate human relations, but the
power relations that affect a woman's contra-

Table 2

Contraceptive Method Mix for all Coalition Clinics
July 1989 to June 1990

Method* Dhaka Narayanganj Tangail Mirpur Palash Bolora Lohagora
(Percent distribution of methods)
Pill 44.0 49.5 38.8 46.0 57.8 36.0 49.2
IUD 5.6 6.8 16.3 9.9 14.7 21.0 5.7
Injectable 38.7 33.7 37.5 36.2 24.5 39.4 25.9
Condom 11.7 10.0 7.4 7.9 3.0 3.6 19.2
Total 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Number of
Services 4,067 5,665 3,134 3,719 1,760 1,222 652

*Excluding method switches, and referrals for tubal ligation. Percentages refer to services pro-
vided, e.g., three-month pill supplies, two or three-month injections, IUD insertion, one-month
condom supply.

ceptive choices: Husbands often object to spe-
cific methods because of inconvenience to
them rather than out of consideration for their
wives' health. At BWHC, no particular contra-
ceptive method is promoted; rather each client
is urged to make her own choice once she
understands the benefits and possible disadvan-
tages of each method. It is made clear to the
client that she may return and make a new
choice if problems develop or if she changes
her mind about the method she has chosen.
(See Table 2)

Menstrual Regulation Services
Menstrual regulation (MR) is vacuum
aspiration of the uterus by means of a hand held
suction syringe, or an electric pump, connected
to a flexible plastic tube called a cannula. MR
can be used for diagnostic purposes or to elimi-
nate the possibility of an unwanted pregnancy.
No pregnancy test is required, but a careful, bi-
manual pelvic examination is a prerequisite to
determine the exact position and size of the
uterus. MR is a simple, low-cost, safe procedure
that can be done by a trained paramedic as well
as a doctor. It usually takes from three to five
minutes, depending on the condition of the
uterus and the skill and experience of the pro-
vider. In Bangladesh, MR is performed primar-
ily by trained paramedical workers (FWVs).

Approximately 95,000 MR procedures a
year are reported in Bangladesh, with most per-
formed in government hospitals and health and
family planning clinics. Many more, however,
are performed by trained personnel but go
unreported. Many NGOs used to provide MR as
a basic component of family planning services
but discontinued the service in the early 1980s
due to USAID restrictions. Today, BWHC is
one of two NGOs in Bangladesh providing MR.
In 1989-90, 6,523 MR procedures were per-
formed in BWHC clinics.
Although MR clients occasionally want
the procedure for social reasons, such as sexual
relations outside marriage or before a bride has
gone to live in her husband's house, most MR
clients are married women of various income
levels, ages and parity. The reason they are in
need of MR varies: They may not have had
access to contraceptives; not having had regular
periods since their last delivery, they may not
have known they were at risk of pregnancy; they
may have experienced a contraceptive failure;
or they have used a method incorrectly. For
example, a new client seeking MR recently
came to a BWHC clinic. She had one child, her
husband was using a condom "sometimes', and
she was taking the pill only on the days she was
having sex.
An MR procedure is performed only if no
more than ten weeks have passed since a wom-

an's last menstrual period, no medical contrain-
dications exist, and she gives her full and
informed consent. (Her husband's consent is
not required.) Women are not eligible for MR if
they have a significant gynecological infection
or a serious medical complication.
As awareness of the availability of MR ser-
vices has increased, more women are coming to
the clinic within two to four weeks after a
missed period, but even so one out of every four
women who request MR has to be turned away
because more than ten weeks has elapsed since
her last menstrual period. Another 14 percent
may be deferred until a medical problem can be
corrected. BWHC is attempting, through social
workers and word-of-mouth, to encourage
women with delayed periods to come to the
clinic early.
Whether or not she is eligible for MR,
each woman has access to all of the clinic's
counseling, medical and family planning ser-
vices. If she is too late for MR, she will be given
counseling and prenatal care and urged not to
resort to dangerous, clandestine abortion proce-
dures. If she is eligible for MR, she will be
encouraged to use effective contraception after
the procedure. While BWHC discourages
repeated use of MR, a client is never refused
the procedure for this reason. Records show

that 88 percent of MR clients in BWHC clinics
use a contraceptive method following an MR
procedure. A study of contraceptive use after
MR, conducted in 1987-88 at the BWHC clinic
in Narayanganj, found that 72 percent of post-
MR clients were still contracepting one year

Record Keeping for Service, Quality,
and Evaluation
The maintenance of accurate and accessi-
ble records is a vital component in the provision
of high quality care. It requires a system that
can provide data on each client's medical his-
tory, health problems, recent symptoms and use
of clinic services. Data collection, however,
must be selective in order to avoid needless
repetition that only burdens a system and
reduces its effectiveness.
Prior to September 1986, the record sys-
tem in use at BWHC was extremely compli-
cated, with over 25 different registration books
used to record information on each type of ser-
vice provided. Even with all this data, it was still
impossible to know, for example, whether a cli-
ent who brought her child for immunization
had also received family planning services.
Therefore, BWHC decided to streamline its

record keeping and design a system that could
track a client and not just record services pro-
vided. The new system was also designed to
help staff better serve the needs of a client's
One sign-in registration book is now
maintained for all clients visiting a clinic so that
if a client has lost or forgotten to bring her regis-
tration card, the book serves as a backup. Each
family (mother and children) is given a num-
bered registration card to keep. The card
records the name and address of the mother
and the names of all her children. There is
space on the reverse side to note the dates of
follow-up visits for individual family members.
In this way, continuity of care can be provided
and assessed. The core of the new system, how-
ever, is the family file. This file contains service
summary sheets and health, family planning
and prenatal forms. It is opened at the first visit
and is kept at the clinic.
The new system, designed with the input
of the service-giving staff, was introduced in all
BWHC clinics in September 1986. Now, when-
ever a staff member provides a service to a cli-
ent during the course of a visit, she makes a
notation on the client's family file and checks
off the appropriate box on a service summary
sheet kept in the file. At the end of every day,
the information from each family file is used to
update the clinic's weekly summary sheet. In
this way it is possible to assess patterns of clinic
use from the information provided by the sum-
mary sheet as well as to know the total number
of services provided by the clinic. Weekly sum-
mary sheets from all the clinics are used to pre-
pare a monthly report for the central office.

The new record system provides BWHC
staff with such information as the number of
women rejected for MR, and for what reasons;
how many women who were first introduced to
the clinics through concern for their children's
health return for reproductive health care; how
many women return for repeated MRs, and how
many fail to return for post-MR check-ups.
These data have implications for counseling and
for management of client flow within each
clinic. BWHC's Deputy Director for Research,
with the help of her assistant director, is respon-
sible for analyzing this data under the guidance
of the Executive Director.
The record system also helps reveal com-
plex management problems. At one of the
urban clinics, for example, the number of MRs
declined more than 50 percent during a two-
year period, despite increases in other services.
At first, staff thought this was a result of compe-
tition from private practitioners. A review of cli-
ent records, however, showed that an unusually
large number of women were being turned
away because too much time had elapsed since
their last menstrual period. Two university stu-
dents were hired by BWHC to follow-up the
rejected clients, using a short interview proto-
col and a questionnaire prepared by BWHC.
Their study revealed that the decline in services
actually was due to a senior paramedic who was
restricting the work of a junior co-worker with
the result that many women who were within
the ten week cut-off period were not being
served. The senior paramedic was docked two
weeks salary and soon the number of MR cli-
ents was back to its previous level.

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Portrait of a Typical Urban
MR Client at the Dhaka Clinic
Rokeya lives in Dhaka, in a compound with
her husband and their two children, her hus-
band's parents, and two brothers and their fami-
lies. She is 20 years old and has completed
primary school. She and her husband want their
children to have a good education and the kind
of opportunities they themselves have not had.
But Rokeya fears she may be pregnant and
knows that a third child at this time would jeop-
ardize these dreams. She has heard that there is a
BWHC clinic in old Dhaka, about two miles from
her home, which provides MR services.
Accompanied by a friend, Rokeya travels to
the clinic by rickshaw. Located on the ground
floor of an old house, down a narrow roadjust off
a main thoroughfare, the clinic is identified by a
prominent BWHC sign board posted on a high
wall that screens it from the street. Most of the
women who come to the clinic are from neighbor-
ing sections of the city. Their education, income
and social status vary.
Rokeya walks through a long veranda to
the private registration room while her friend
waits in a room outside. The registration room
has a separate waiting area, with curtains and
screens helping to provide privacy. The recep-

tionist invites Rokeya to be seated and asks for
her name and address. As this is Rokeya's first
visit, a registration card is filled out, she is given
a registration number and afile is opened for her.
The file contains medical and family planning
history forms and will become Rokeya's perma-
nent record at the clinic. After about 15 minutes,
the project coordinator, who is also the counselor
at this clinic, invites Rokeya into her office where
they can talk privately.
The counselor describes the MR procedure
and explains to Rokeya the various contraceptive
methods available for her to choose from after
the MR. With the aid of charts, three-dimen-
sional models and a specially designed pamphlet
suitable for both non-literate and literate women,
she helps Rokeya understand how her body func-
tions and how the various contraceptives work.
The session continues until the counselor is cer-
tain that Rokeya understands the MR procedure
and the contraindications and side effects of the
contraceptive methods they have discussed.
From the counseling room, Rokeya is taken
by a paramedic to a room where her medical
history and vital signs are taken. The paramedic,
who will perform the MR, also explains the pro-
cedure for Rokeya and answers any additional
questions she may have. Next, Rokeya is escorted
into the MR procedure room. Screens are used to
create a post-procedure rest area and there is a

bathroom nearby. The paramedic gives Rokeya a
pelvic exam to determine that she has no infec-
tion and that gestation is no more than 10 weeks.
Rokeya is then made as comfortable as possible
on the table and the MR is performed using a
hand held plastic syringe and cannula. (No anes-
thesia is used, but a light sedative or painkiller
may be given orally if a client is anxious.) The
counselor or another staff member stays with
Rokeya during the procedure to comfort and
reassure her and to help her relax by talking to
her, holding her hand and stroking her forehead.
After resting for about ten minutes, Rokeya
is taken to the post-MR rest area where she again
lies down. She requests that her friend join her
there and she is offered a cup of tea. In the mean-
time, the paramedic writes the details of the pro-
cedure in Rokeya's family file and sends it back
to the counselor.
About 30 minutes later, Rokeya again talks
to the counselor about the pill, the contraceptive
method she has chosen to use. The counselor
reminds her how it should be taken and how to
manage any side effects she might experience.
She gives Rokeya only one cycle of pills so she
can have a trial period to determine whether she
experiences any side effects. Rokeya is urged to
return for a follow-up visit in two weeks, or ear-
lier if she has any concerns. After a visit of about
two hours, Rokeya leaves the clinic with her
friend, taking with her the cycle of pills and her
registration card (which she will bring back with
her on every visit).

Profile of Shamima, a Typical Rural
Client at the Bolora Clinic
The Bolora clinic, established in November
1984, is located in the countryside 45 miles due
west of Dhaka. To get there from Dhaka, one
takes a jeep for one and a half hours, a rickshaw
for another half hour and then a country boat for
one to two hours, depending on whether or not
the boat has a motor. Still ahead is another rick-
shaw ride over a bumpy road, frequently inac-
cessible during the rainy season. The road winds
through fields, past clusters of mud and tin
houses and down lanes lined with palm trees.
The clinic, located at the intersection of two
lanes, is one of the few brick buildings in the
entire area. White, with blue doors and shutters
and a front veranda with a BWHC sign board,

the building has been rented to BWHC at very
low cost by the chairman of the local village
council. It is surrounded by a garden of flowers
and vegetables, and enclosed by a split bamboo
fence with an archway of flowers growing over it.
On busy days when immunizations are given,
200 to 300 women and children sit under nearby
trees on rush mats, or in a waiting room erected
across from the clinic, providing a brisk business
for the fruit and puffed rice vendors.
Shamima is 24 years old and has given
birth to six children, two of whom died before
their first birthday. Married at 12, Shamima
didn't live with her husband and his family until
she was 14 years old. She completed only three
years of primary school because she was needed
at home to help with household chores. Her first
child was born when she was 15 and she has
horne a child every two years since then. Now
her youngest, not quite a year old, is not gaining
weight and Shamima is concerned. Accompanied
by all of her children, Shamima set out by foot
from her village at dawn for the six-mile journey
to Bolora.
Shamima enters the clinic and is invited by
the receptionist to sit down. The clinic consists of
one large room with a smaller room at one side.
Hardboard partitions and curtains divide the
main room into four sections which are used for
registration, medical history, counseling/adminis-
tration and clinical procedures such as pelvic
examinations, IUD insertions and MR. As with
all new clients in any BWHC clinic, a registration
card is filled out for Shamima, recording her
name and address and the names of each of her
children. A family file is also opened in her name.
Shamima tells the receptionist she has
come to seek help for her youngest son. While she
waits with her children for about half an hour
(the average wait, which varies depending on
how crowded the clinic is that day), Shamima
learns that the woman sitting next to her is wait-
ing for something called family planning. The
woman tells Shamima that the clinic can give her
pills which will prevent her from having more
children. Just as she is about to ask the woman
more about these pills, Shamima's name is called
by the physician.
The room where the physician sees clients
is simply furnished and has an examination table
and a small kerosene stove for sterilizing instru-
ments. The male doctor asks Shamima about her

son's medical history and also inquires about her
other three children. After examining Shamima's
son, and while the nurse's aid dispenses appro-
priate medication, the doctor tells Shamima how
to prepare certain foods her son needs to eat.
Shamima leaves the clinic with medicine for her
son and the date of her next visit written on the
back of her registration card. Next time, she
thinks to herself, she will ask someone at the
clinic for more information about family plan-

Management Structure
All seven BWHC clinics are managed by a
central office staff consisting of an executive
director, a medical director and assistant, and
four deputy directors for administration,
finance and accounts, research, and community
development. Overall policy is the responsibil-
ity of an executive council of six prominent
Bangladeshi women committed to issues of
women's development. They include a social
scientist, a professor of gynecology, a lawyer, a
researcher and an educator.

The Executive Director is responsible for
basic program planning, program monitoring,
fund raising, public relations and on-going liai-
son with the government and other voluntary
agencies. She knows each of her 170 staff mem-
bers by name and her management style is par-
ticipatory. Management and medical workshops
are held periodically with project coordinators
and medical staff to discuss progress and resolve
problems, and all staff are encouraged to con-
tribute their ideas and suggestions during these
meetings. This ensures a sense of team spirit
and encourages the kind of smooth working
relationships essential to maintaining high stan-
dards of morale, commitment and performance.

Other members of the management team
The Medical Director, who is responsible
for maintaining medical standards at all
BWHC clinics, which she visits regularly.
She gives in-service training to the medical
staff, arranges for outside training when
required and oversees inventories of medi-
cal equipment and medicine. She is

assisted by a senior FWV.
The Deputy Director for Research, who
analyzes clinic data and undertakes special
studies on relevant issues such as contra-
ceptive continuation after MR and patterns
of clinic use. An assistant director works
with her.
The Deputy Director for Finance and
Accounts, who oversees bookkeeping, pre-
pares financial reports, and assists in prepa-
ration of budgets for each clinic and for
BWHC's central office.
The Deputy Director for Administration,
who runs the central office, makes regular
visits to all the clinics, helps staff solve
administrative problems, and is responsible
for training administrative staff. An impor-
tant part of her job is to ensure that sup-
plies reach the clinics and that inventories
are properly maintained.
The Deputy Director for Community
Development (this is a relatively new post),
who supervises and monitors the social
workers and their supervisors and oversees
the women's literacy program. She is also
responsible for BWHC's Cottage Printing
Project (see below).
While the central office determines over-
all policy, the project coordinators in each clinic

are encouraged to make suggestions and take
initiative on issues specific to their situation.
The central office staff, however, try to relieve
the project coordinators of much of the man-
agement burden by assuming responsibility
for raising money, ordering and distributing
medical supplies, arranging for acquisition of
supplies that may not be available locally
and preparing general reports and program
Keeping seven clinics functioning
smoothly in Bangladesh demands excellent
management skills plus an extra dose of energy,
imagination, creativity and commitment. Three
of the clinics have no telephone, and telephones
in the other clinics often do not work. Problems
must be dealt with on the spot. Information is
relayed to the central office by messenger, or
saved for discussion with the central office staff
during their regular clinic visits.
One important element in the success of
the clinics has been the development of good
relationships with community leaders. Local
advisory committees have been set up for each
clinic to help establish and maintain good rap-
port with the local community. In Bolora, for
example, community support was instrumental
in finding a suitable accommodation for the
clinic, and in Palash, northeast of Dhaka, com-
munity support was essential in gaining accep-

tance of reproductive health services in an area
where conservative religious leaders initially
disapproved of both contraception and MR.
Even though the government supplies
contraceptives (other than condoms) free of
charge to NGOs, maintaining sufficient supplies
and equipment is an on-going problem for
BWHC, as it is for all family planning NGOs in
Bangladesh. BWHC's project coordinators
must carefully estimate their needs in advance
to ensure that their clients can have an ade-
quate choice of contraceptive methods.
Networking with other health outlets in
the community helps to provide sources of
referral for supplies on the few occasions when
BWHC supplies run out. A case in point is the
supply of injectable contraceptives, which are
imported by the government for distribution to
health organizations. At Narayanganj clinic,
which has a large client load and a high demand
for injectables, supplies periodically run short
due to bureaucratic delays in distribution. This
can be extremely problematic for clients who
often must travel considerable distances to
reach the clinic for their next injection. Since it
is very difficult for them to return the next day,
or even the next week, they are faced with
going without the injection and risking an
unwanted pregnancy, finding an alternative
source of supply or changing their contra-
ceptive method. To prevent this situation
from occurring, the project coordinator tries
to anticipate such shortages and locate sup-
plies of injectables at other family planning

Costs of Services
BWHC's experience has proved that qual-
ity need not be costly. In two urban clinics (the
original clinic in Old Dhaka and the clinic in
Narayanganj), women who can afford to do so
pay for services on a sliding scale according to
their means. These clinics are now about 35
percent self-sufficient. The top fees at the
Dhaka and Narayanganj clinics are 100 taka
(U.S. $3.13) for MR, 10 taka (U.S. $.31) for a
pelvic examination, 15 taka (U.S. $.47) for an
IUD insertion, and 25 taka (U.S. $.78) for
pathology tests for prenatal clients. (Weekly
income for an unskilled worker in Dhaka is
about 250 taka; weekly income for an FWV is

about 500 taka.) BWHC rates are very low in
comparison with the fees charged by private
doctors and clinics, which can be as high as 500
taka for an MR procedure. In rural areas, most
women are so poor that they pay only a token
clinic registration fee of one taka (U.S. $.03),
and a nominal service fee of three taka (U.S.
$.10) for general health or family planning ser-
vices; 25 taka (U.S $.78) is charged for MR, if
the client is able to afford it. Mirpur clinic, in a
suburban slum area at Dhaka, charges five taka
for each health and family planning service, and
100 taka for MR.
Low overhead, high volume and multiple
services make BWHC's care affordable by
Bangladeshi standards. It costs U.S. $4.78 to
serve an MR client who adopts contraception
following the procedure and then returns for a
follow-up visit. If the cost to the client of mak-
ing the trip to and from the clinic (i.e., income
forgone while at the clinic and transportation
costs) is included, the cost rises to U.S. $5.68.
Initially it was hoped that eventually
BWHC would become self-sufficient from fees
received for services. However, given the pov-
erty of the majority of its clientele, self-suffi-
ciency is an unrealistic goal. BWHC continues
to depend primarily on grant funds (at a level of
U.S. $300-350,000 per year), and on contribu-
tions of medical supplies and contraceptives
from government and private sources.
BWHC received support from the Popu-
lation Crisis Committee, the International
Women's Health Coalition (IWHC) and the
Ford Foundation for its earlier work. Currently,
the Coalition receives support from the Ford
Foundation, the Swedish International Devel-
opment Authority (SIDA), the British Overseas
Development Agency (ODA) and the Danish
International Development Agency (DANIDA).
The International Women's Health Coalition
(IWHC) provides technical assistance and
moral support.
In 1987, BWHC started an income-gener-
ating project, with support from CIDA and
NORAD, with the intention of reducing
BWHC's dependency on outside donors. The
Coalition's Cottage Printing Project now
employs 25 people who silk screen fabrics for
Dhaka businesses and design and produce
greeting cards, tie-dye saris, and silk screened
or block printed tablecloths, napkins and bed-

spreads. This project is now operating without
outside assistance and should begin to generate
profits in the next year.

BWHC as a Training Resource for
the Government
Since BWHC clinics serve only a tiny
fraction of Bangladeshi women, the Coalition
provides free clinical training in family planning
service delivery for paramedics (FWVs)
enrolled in government training programs and
in-service refresher training programs. This ser-
vice, which has been in operation since 1982,
not only helps BWHC maintain a cordial rela-
tionship with the government but serves to
introduce government health workers to high
quality, comprehensive care.
Every year initial training for approxi-
mately 60 government FWVs, and refresher
training for 100 FWVs, is provided at the clinic
in old Dhaka and at the Narayanganj, Tangail
and Mirpur clinics. The training covers MR pro-
cedures, IUD insertions, pelvic examinations
and associated pathological tests. All trainees
are introduced to BWHC's counseling
approach and basic principles for high quality
care. Teaching is based on the BWHC experi-
ence and is provided by the senior paramedic,
the project coordinator and the doctor in each

clinic. The two to three-week training program
The importance of counseling in effective
family planning-qualities of a good coun-
selor, goals of contraceptive counseling, the
most common mistakes made by coun-
selors, how staff can help clients select the
best options and "how do I know if I am a
good counselor?"
Methods of family planning-how different
methods work; side effects and contraindi-
cations of the pill, IUD, injectables, con-
doms, vaginal spermicides, periodic
abstinence, female sterilization and vasec-
tomy, withdrawal and hormonal implants.
MR-the procedure and possible side
Female reproduction-what every woman
should know about her body including the
monthly cycle, conception and the course
of pregnancy.
Referrals, resources and aftercare.
BWHC also works to strengthen the poli-
cies and programs of other health and family
planning service providers, especially govern-
ment sponsored programs, since even small
changes can greatly improve women's access to
services. For example, it is important to let


women know not only that MR services are
available, but that they must not delay in going
to a clinic once they determine that their period
is late. There is a substantial network of govern-
ment FWVs who could provide this important
information to village women, but they need to
be trained and motivated.

Looking to the Future
As part of its attempt to better serve
women, BWHC continually looks for ways to
improve its effectiveness both through expan-
sion of clinical services and experimentation
with new activities aimed at improving the
quality of women's lives. As Bangladeshi women
develop the courage to use health care services,
as they come to expect quality care and learn to
make choices about their health, they will grow
in strength and dignity. They can hope-and
work for-better lives for themselves and their
Although knowledge of the health ser-
vices BWHC provides spreads quickly by word-
of-mouth (clinics are well-utilized within a few
months of opening), BWHC has recently added
four social workers and a community supervisor
to the staff of each clinic. Their job is to
increase community awareness of clinic ser-

vices, escort clients to the clinic when neces-
sary, help women understand the importance of
timely and regular use of health services and,
when possible, visit clients in the immediate
area who have missed a scheduled follow-up.
Social workers also carry out surveys in the sur-
rounding community to assess health and fam-
ily planning needs and, when appropriate, refer
people to other community resources.
As a result of demand from clients,
BWHC also provides adult literacy classes in all
seven clinic areas. These classes are held daily
for groups of 15 women over a six-month
period, and are taught by BWHC community
development staff. Other services offered by
BWHC include saving schemes and loans for
individual income-generation projects, such as
opening a food stall or buying a milk goat.
Lectures are held once a week in each com-
munity where there is a BWHC clinic on topics
such as nutrition, family planning and legal
rights. Staff members also give periodic lectures
in the clinics to waiting clients on health related
topics such as infant care, breast feeding or

Lessons Learned
One of the real strengths of BWHC has
been its willingness to learn from experience
and to continually modify its range of services
and mode of service delivery to better address
the needs of its clients. BWHC clinics are not
intended to be models for replication, but are
examples of what can be done to develop high
quality services with limited resources.
Some specific lessons that can be drawn
from BWHC's experience include the following.
1. High quality services are not a luxury.
BWHC has clearly demonstrated that quality
care can be attained at per capital costs consid-
erably below those of standard family planning
clinics, many of which are under-utilized. Sav-
ings accrue in part from: the attractiveness of
the services and settings, which keep attend-
ance high and spread fixed costs over larger
numbers; from providing a mix of services so
that clients can use a visit for more than one
purpose, which lowers the cost per service; and
from using well trained paramedical personnel
instead of physicians for pelvic examinations,
IUD insertions and MR. In addition, simple
gestures such as treating clients with respect,
keeping clinics clean and cheerful and ensuring
privacy, cost very little yet are highly valued by
2. The role of counseling goes beyond just
giving information. The availability of empa-
thetic counseling creates an environment of
choice for all clients. Women are encouraged to
care about their own health needs and to
understand that their health is also important
for their children's well-being.
3. When clients are satisfied with one ser-
vice, they'll return to try others. BWHC clinics
expose many women coming for child health
care to family planning information that other-
wise might not be available to them. As these

women gain confidence in utilizing the child
health services, their initial hesitation about
reproductive health care is overcome. Similarly,
family planning clients are encouraged to seek
child health care.
4. The availability of MR, along with contra-
ception, makes family planning and health ser-
vices accessible to more women. The inclusion
of MR means that women who fear they are
pregnant can feel welcome at BWHC clinics,
and those women who decide to terminate an
unwanted or badly timed pregnancy are able to
do so safely and in an atmosphere of emotional
support. Client records show that most MR cli-
ents are first-time visitors to BWHC clinics and
have never used contraceptives. If MR was not
available, many of these women would resort to
dangerous, clandestine abortions. Almost all
women receiving MR leave with a contracep-
tive method and a follow-up appointment, thus
facilitating a long-term commitment to family
5. Positive treatment of clients begins with
positive treatment of staff. Good management
means creating an environment where staff feel
they have a voice in making decisions and
where they are treated with respect. This, in
turn, has a positive effect on the way staff inter-
act with clients. BWHC's participatory man-
agement style engenders responsiveness to and
communication with clients, both of which are
essential to the provision of quality health care
6. Client-centered record keeping is essen-
tial to quality care. Records, though simple,
must be well designed and properly used to
facilitate monitoring initial and follow-up care
for each client. BWHC's experience demon-
strates that records can serve client needs and
improve program performance. Service statis-
tics are also a valuable research tool for program
planning and evaluation.

For more information about BWHC, write to the Bangladesh Women's Health Coalition,
House 46-A, Dhanmondi Rd., Dhaka 1205, Bangladesh. To learn more about the work of the
International Women's Health Coalition, write to IWHC, 24 East 21st Street, New York, N.Y.
10010, U.S.A.
For additional information about menstrual regulation, contact IPAS, 301-303 East Main
Street, Carrboro, N.C. 27510, U.S.A.

Resumt en Frangais

La Coalition pour la Sant6 des Femmes du
Bangladesh (Bangladesh Women's Health Coalition,
BWHC) est une initiative important dans l'6volu-
tion vers un mode de distribution des services de
planification familiale plus personnalis6. Depuis son
ouverture en 1980, comme clinique sp6cialis6e oi
les femmes en situation de d6tresse du fait de leur
6tat de grossesse pouvait obtenir une regulationn
menstruelle" (c'est-A-dire, I'aspiration par le vide de
l'ut6rus au moyen d'une seringue de succion
actionn6e soit manuellement, soit par une pompe
electrique) la Coalition n'a cess6 de croitre et com-
prend a present sept cliniques, r6parties en milieu
urbain et rural, offrant une game 6tendue de ser-
Bien que sa structure administrative et finan-
cibre soit similaire a celle de toute autre clinique
priv6e, la BWHC se distingue nettement des autres
cliniques par sa philosophies, sa conception, et sa
determination a traiter les femmes avec dignity. Les
cliniques de la BWHC sont des endroits accueillants,
ou les clients sont mis a l'aise, se sentent respects et
compris. Un des objectifs principaux 6tant de leur
donner la possibility de faire un choix avis6, notam-
ment en mettant A leur disposition un large 6ventail
de m6thodes contraceptives, y compris l'interruption
volontaire de grossesse a un stade peu avanc6. Une
autre particularity des cliniques de la BWHC reside
dans le fait que la planification familiale n'est pas
s6par6e des autres services de protection de la santh
des femmes et des enfants. En effet, des services
destin6s a traiter d'autres problems de sant6 impor-
tants, tels que les problems gyn6cologiques et les
maladies infantiles y sont 6galement dispenses.
Des le depart, le personnel de la BWHC a 6t6
compose presque exclusivement par des femmes.
Leur principle de base a toujours 6t6 que la quality
de la communication entire le conseiller et le client
occupe une place tout aussi important dans un pro-
gramme en sant6 reproductive que la prevention
m6dicale et I'acces aux services. En effet, il convient
de traiter chaque femme avec respect, de discuter
avec elle de ses besoins, et de lui foumir le plus
d'informations possible pour lui permettre de faire
son propre choix en matihre de sant6 reproductive.
A la Coalition, poss6der des connaissances
techniques approfondies ne suffit pas; en effet, les
membres du personnel doivent 6galement faire preu-
ve d'aptitudes interpersonnelles. Les augmentations
de salaires et les promotions ne sont pas uniquement
function de la quantity de soins prodigues mais
dependent surtout de la quality. Informer et donner
des conseils sont une composante essentielle des ser-
vices fournis par la BWHC, l'objectif 6tant de mettre
le client a l'aise et de l'encourager a poser des ques-
tions et a se confier au conseiller.
Au course de l'ann6e budg6taire 1989-90, les
cliniques de la BWHC ont trait environ 97,000

femmes et enfants et le nombre total de soins fouris
s'est 61ev6e 145,000. La BWHC a r6ussi L d6mon-
trer que quality nest pas forc&ment synonyme d'ont-
reux. Des frais g6n6raux peu 6lev6s, un volume
d'activit6s important, et des services multiples font
que les soins offers par la BWHC sont a la port6e
des habitants du Bangladesh. Par example, le coit
total par client qui obtient une regulationn men-
struelle", adopted une m6thode contraceptive, et
retoume a la clinique pour une visit de suivi, s'616ve
a $4,78.
A l'heure actuelle, BWHC est l'une des deux
seules ONG a pratiquer la regulationn menstruelle"
au Bangladesh. La regulationn menstruelle" est une
proc6d6 simple, peu cofiteux, qui peut ktre r6alis6
par un m6decin ou par un personnel param6dical
ayant, au pr6alable, suivi un stage de formation.
Chaque ann6e, environ 95,000 RM sont r6alis6es au
Bangladesh, la plupart d'entre elles dans des hopi-
taux publics. Au course de l'ann6e 89-90, les cliniques
de la BWHC en ont effectu6es 6525.
En raison de sa capacity d'accueil limited, la
Coalition a, depuis 1982, donn6 des course de forma-
tion gratuits sur la planification familiale a I'intention
du personnel param6dical suivant un stage de recy-
clage pour le compete du gouvernement. Ce service
permet a la BWHC de maintenir des rapports cor-
diaux avec le gouvemement et d'initier les agents de
sant6 gouvernementaux a la notion de quality des
Une autre activity de la BWHC consiste a
renforcer les politiques et programmes d'autres pre-
stataires de services de planification familiale et de
sante, notamment les programmes parrain6s par le
gouvemement, puisque des changements memes
minimes peuvent am6liorer de fagon considerable
l'acces aux services et leur quality.
En r6ponse a de nombreuses demands de la
part de leurs clients, la BWHC a d6cid6 d'offrir des
course de lecture et d'6criture, ainsi que des pro-
grammes d'6pargne et de credit pour venir en aide
aux femmes voulant se mettre a leur propre compete.
Une fois par semaine, chaque clinique organise une
conference sur des sujets tels que la nutrition ou la
planification familiale. De temps L autre, les mem-
bres du personnel donnent 6galement des conf6r-
ences sur le type de soins a prodiguer aux nourissons,
I'allaitement au sein ou la vaccination.
Dans une soci6t6 oh le r6le social et la liberty
de movement de la plupart des femmes et des
jeunes filles sont extr&mement restreints, la BWHC
s'est fix6 comme objectif ambitieux de permettre aux
femmes-quel que soit leur niveau d'education ou
leur revenu-d'apprendre a g6rer leur propre sant6
et celle de leurs enfants de faqon b pouvoir pleine-
ment s'assumer et se r6aliser en temps qu'individu.

Resumen en Espafiol

La Bangladesh Women's Health Coalition
(Coalici6n para la Salud de la Mujer de Bangladesh, o
BWHC) represent una iniciativa important en el
movimiento hacia modos de entrega de la planifica-
ci6n familiar que responded a las necesidades de la
client. Fundada en 1980 con el prop6sito de proveer
regulaci6n menstrual (RM) (que consiste en la aspira-
ci6n del utero por medio de una jeringa de succi6n
manual o una bomba el6ctrica, un procedimiento
simple y econ6mico que puede ser ejecutado por un
m6dico o un auxiliar medico entrenado) para
mujeres preocupadas por la posibilidad de un
embarazo no deseado, la BWHC actualmente cuenta
con siete clinics de servicios mtiltiples, en sectors
urbanos y rurales.
Aunque la BWHC se basa en el modelo con-
vencional de la clinica de salud independiente, se
distingue de lo traditional por su filosofia, espiritu y
compromise con el tratamiento digno de la mujer.
Las clinics de la BWHC son lugares dondes las
clients se sienten bienvenidas, c6modas, respetadas
y comprendidas. Se mantiene un 6nfasis en la elec-
ci6n informada de una amplia variedad de m6todos
de control de la natalidad, incluyendo la terminaci6n
temprana del embarazo no deseado. Las clinics de
la BWHC tambien son singulares por negarse a
separar a la planificaci6n familiar de las otras necesi-
dades de salud de las mujeres y de sus nifios. Los
servicios para otros importantes problems de salud,
como ser los problems ginecol6gicos y las enferme-
dades infantiles, se proven en el mismo local.
Desde sus comienzos, la gerencia y el personal
de la BWHC han estado integrados principalmente
por mujeres. La premisa fundamental del personal
ha sido que la elecci6n informada es tan esencial a los
programs de salud reproductive como lo son la
seguridad m6dica v el acceso a los servicios. La
BWHC ha detenninado que cada mujer debe ser
tratada con respeto, que sus necesidades particulars
deben ser cuidadosamente repasadas con ella, y que
debe ser provista de suficiente informaci6n y conse-
jeria como para que pueda hacer una elecci6n propia
sobre su salud reproductive.
La political de la BWHC require que todo
miembro del personal no s6lo est6 completamente
capacitado en los aspects tecnicos de sus tareas, sino
que tambien demuestre habilidad para las relaciones
interpersonales. Las promociones y los aumentos en
los salaries dependent no s61o de la cantidad de aten-
ci6n provista, sino de su calidad. La consejeria es el
component esencial de la entrega de todos los servi-
cios en la BWHC, ya que el objeto de los mismos es
lograr que la client se sienta c6moda y motivarla a
que haga preguntas, ademis de brindarle informa-
En el afio fiscal de 1989-1990, las clinics de la
BWHC atendieron a aproximadamente 97.000

mujeres y nifios, y proveyeron mAs de 145.000 servi-
cios de salud reproductive. Las clinics han demos-
trado que la calidad no tiene que ser cara. Gastos
bajos, alto volimen, y servicios multiples hacen que
la atenci6n de la BWHC sea econ6mica en terminos
de la situaci6n de Bangladesh. Por ejemplo, la
BWHC require de s61o US$ 4,78 para servir a una
client de RM que adopta anticoncepci6n despu6s
del procedimiento y luego regresa para una visit de
En la actualidad la BWHC es una de las dos
organizaciones no-gubernamentales que ofrecen la
regulaci6n menstrual (RM) en Bangladesh. Aprox-
imadamente 95.000 procedimientos de RM se repor-
tan anualmente en Bangladesh, y la mayoria se
realizan en hospitals del gobierno. En 1989-1990, se
realizaron 6.523 procedimientos de RM en las clini-
cas de la BWHC.
Ya que las clinics de la BWHC s6lo pueden
servir a una pequefa proporci6n de las mujeres,
desde 1982 la Coalici6n ha provisto entrenamiento
clinic gratuito en la entrega de servicios de planifi-
caci6n familiar a auxiliares m6dicos inscriptos en pro-
gramas de entrenamiento del gobierno. Este servicio
permit que la BWHC mantenga una relaci6n cor-
dial con el gobierno, y avuda a introducir el concept
de la atenci6n comprehensive, de alta calidad, a los
trabajadores de salud del gobierno.
La BWHC tambi6n busca fortalecer las politi-
cas y los programs de otros proveedores de servicios
de salud y planificaci6n familiar, especialmente en los
programs patrocinados por el gobierno, ya que un
pequeno cambio puede mejorar significativamente
tanto el acceso de las mujeres a los servicios, como la
calidad de los mismos.
Como respuesta al pedido de clients, la
BWHC actualmente provee classes de alfabetizaci6n
para adults en cada una de las siete clinics, ademas
de programs sobre ahorro y pr6stamos para asistir a
las mujeres en la creaci6n de proyectos individuals
de generaci6n de ingresos. Una vez por semana, cada
clinic patrocina charlas sobre temas como la nutri-
ci6n, la planificaci6n familiar y los derechos legales.
Ademis, various miembros del personal peri6dica-
mente ofrecen charlas en las clinics sobre temas
como el cuidado del infante, la lactancia materna, y la
En el context de una sociedad que mantiene
limits estrictos sobre el papel social v la mobilidad
fisica de la mayoria de las ninfas y mujeres, la BWHC
ha adoptado el ambicioso objetivo de habilitar a las
mujeres-no obstante sus ingresos o su nivel educa-
cional-para que puedan aprender a manejar su pro-
pia salud reproductive y la salud de sus hijos, de una
manera que aumente sus sentidos de competencia y
poder personal.

About the Authors
Bonnie J. Kay, Ph.D., consultant, is a health systems analyst specializing in issues related to the
health of women and their children. Adrienne Germain, Vice President of the International
Women's Health Coalition, has worked extensively in Third World countries on women's roles in
development, reproductive health and reproductive rights. Maggie Bangser is the Asia Program
Officer at the International Women's Health Coalition and has worked on public policy and public
interest issues in the United States and the Third World.

The International Women's Health Coalition (IWHC) is an organization dedicated to improving
women's reproductive health in the Third World. IWHC serves as a catalyst for change in national
and international health and population policies and programs.

Quality/Calidad/QualitM Advisory Committee
George Brown Debbie Rogow
Judith Bruce Jill Sheffield
Ethel Churchill Lindsay Stewart
Francine Coeytaux Kerstin Trone
Adrienne Germain Nahid Toubia
Margaret Hempel Gilberte Vansintejan
Ann Leonard Cynthia Steele Verme
Margaret McEvoy Beverly Winikoff
John Paxman Margot Zimmerman


Ann Leonard
John Paul Kay
Village Type & Graphics
Graphic Impressions

We invite your comments and your ideas for projects which might be included in
future editions of Quality/Calidad/Qualite. If you would like additional copies of this
issue or would like to be included on our mailing list, please write to: Ann Leonard,
Editor, Quality/Calidad/Qualitg. The Population Council, One Dag Hammarskjold
Plaza, New York, N.Y. 10017 U.S.A.


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