Don't Ask,Don't Tell

The youth in Bangladesh (ages 15-30) form almost a third of the country's population, and almost half the youth population are women. The number of women of reproductive age is estimated to be at 49.4 million by 2025. The World Health Organisation (WHO) estimates that at least a third of the 333 million new cases each year of curable sexually transmitted infections (STIs) occur among people under 25 years of age. In Bangladesh, 63% of the population is under 25.

A paper published by Campaign for Popular Education (CAMPE) and Embassy of Netherlands contends that issues related to Sexual and Reproductive Health Rights (SRHR) among young women in Bangladesh are not given enough importance by society. The association of cultural, social and religious stigma, superstitious beliefs, and little to no knowledge of matters related to Sexual and Reproductive Health (SRH) often lead to a variety of health issues. In a study that assessed young people's health concerns, Icddr,b found that of young women's SRH issues, nearly half were Sexually Transmitted Infections (STIs). Shyness or a sense of shame is a common reason why women refrain from seeking help for SRH problems.  

According to health experts, there is very little data related to STIs and reproductive tract infection (RTI) in Bangladesh. Sexual and Reproductive Health Rights are poorly understood by many policy-makers, let alone the average person, and their relevance in people's day to day lives needs to be made clearer.

"There is ample data on HIV but hardly any national data on RTI/STI as a whole" says Dr. Farzana Islam of Save the Children. For example, when we collect data on maternal health, RTI/STI is not held as an indicator and therefore not recorded. Unsafe sex practices contribute largely to STIs. Hepatitis B and HIV seem to be most prevalent when it comes to STIs." 

But sexual and reproductive health rights is a human rights issue and not just a women's issue. Men's sexual health behaviours affect women just as much and vice versa. 

"Sex without protection and male unawareness needs to be addressed when talking about sexually transmitted infections. A lot of men don't seek treatment for STIs, or have multiple sexual partners which exposes other women who come into sexual contact with these men, to infections," says Dr. Farzana Islam.  

Menstrual Regulation (MR) is a procedure that has been in the family planning programme in Bangladesh since 1979. It uses manual vacuum aspiration (MVA) to ensure non-pregnancy after a missed period. Despite available MR services, unsafe abortions are still on the rise. 

"Unsafe abortions, while they don't fall under the umbrella of sexually transmitted diseases, can cause reproductive tract infections because of a lot of reasons including unsterilised equipment and other unhygienic practices. A committee has been formed to oversee the prevention of unsafe abortions but it's still at the nascent stage. There are services and standards for abortion but implementation is poor, especially in terms of the legal aspect," notes Dr. Farzana Islam.

An estimated 646,600 induced abortions were performed in Bangladesh in 2010, the majority of which were unsafe. The increase in unsafe abortions may be explained by the barriers present to MR services: One-third of facilities that could potentially provide MR services lack either basic MR equipment or trained professionals, an estimated 26% of women seeking MR services are turned away by facilities each year, and more than 3 in 10 facilities reported rejecting women's requests for MR for social or cultural reasons.

It has been a month since 29-year-old Nabila (not her real name) recently had an abortion. For Nabila, interactions with doctors were far from pleasant. "Doctors can be so judgmental sometimes. They ask unnecessary questions that add to the mental burden. For me, the psychological pressure was so much worse than the physical aspect of it. Doctors need to be more supportive of women seeking abortion."

Rashedul Anwar, Research Physician at Icddr,b sheds some light on the vulnerability of adolescent girls to SRH problems: "Girls usually hit puberty somewhere between ages 13-19. Urban middle-class adolescent girls are generally educated but they are likely at a higher risk of contracting STIs than older women because of high-risk behaviour."

"The health needs of adolescent girls and women are least researched. Reaching out to this age group can be challenging. Collecting health information of infants and mothers, especially new ones, isn't tough since they usually have health concerns of their own. But in the case of teenagers, you have to seek out SRH data for yourselves. You have to ask: would he/she be willing to participate in a certain health study? Because more often that not, they may not feel comfortable talking about such issues," observes Rashedul Anwar. 

Maya.com.bd (hereafter referred to as Maya) has emerged as the go-to solution for Bangladeshi women (and even men) with regard to health concerns. The hugely successful anonymous Q&A platform "Maya Apa Ki Bole" on Maya's website encourages both men and women to speak out on their SRH concerns.

Shahana Siddiqui, Head of Content and Communications of Maya, talks about the SRH provisions and information catering to the needs of young urban middle-class women: "There is a huge gap in the health service sector resulting in the under servicing of health needs of educated, middle-class women. These women have become very fearful of their own body because of the culture of silence around this entire issue. There's a complacency among parents who think their daughters and sons will find solutions to health problems on their own as they grow older," she claims. 

Siddiqui recalls a story of a woman patient who discovered a massive tumour in her uterus much later than she should have. She only went for a check up until the pain became unbearable. Often women have little knowledge of the human anatomy which results in the patient going to the doctor when it is too late. 

"She was too ashamed to go to the doctor since she's a traditional married woman. Even our ma's and khala's who are educated have a tough time talking about their health issues, especially when it's concerning SRH. This widespread stigma is a huge reason why well-educated urban women refrain from seeking healthcare services," states Siddiqui.   

Dr. Khairul Islam, a public heath expert and Country Representative of WaterAid Bangladesh, talks about urban trends of healthcare services. "The word 'urban' itself has a lot of variation. Urban may include upazilas, townships and other municipalities, many of which have rural characteristics. In that context, it's been observed that in upazilas, the public health system works relatively well (compared to that at the district level) because of better access to public health complexes and medical resources. There's also the 'elite' factor at play as those with political affiliations have the advantage of avoiding bureaucratic processes to access health services. At the district level however, the public health system is overcrowded, especially with low income patients. The middle class, therefore, makes more use of the private healthcare system."

Out-of-pocket health expenditure (part of private spending) by households as a percentage of total health expenditure in Bangladesh stands at an overwhelming 63.31. This means more than 63 percent of a household's total health expenditure is paid out of its own pocket -- one of the highest in the region. Bangladesh is far from achieving universal health coverage as public health expenditure remains dismally low at 23.09 percent, leaving people with burdensome treatment expenses. 

"Those belonging to the age group 18-35 tend to be the most productive and healthy and this is when one starts a family. This cohort usually seeks reproductive or neo-natal health services. Young mothers usually seek counselling services or information related to family planning. Most problems have to do with a lack of information, societal attitudes and availability of services. New mothers usually seek help of private practitioners who then tag them to clinics or hospitals that are awfully expensive. At every step, young urban middle-class women are faced with societal, economic or other conditions when it comes to SRH," concludes Dr. Islam.