{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,23]],"date-time":"2026-04-23T19:13:26Z","timestamp":1776971606057,"version":"3.51.4"},"update-to":[{"DOI":"10.12688\/gatesopenres.12920.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2019,6,28]],"date-time":"2019-06-28T00:00:00Z","timestamp":1561680000000}}],"reference-count":58,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2019,6,28]],"date-time":"2019-06-28T00:00:00Z","timestamp":1561680000000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["OPP1181398"],"award-info":[{"award-number":["OPP1181398"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]},{"name":"international Planned Parenthood Federation"}],"content-domain":{"domain":["gatesopenresearch.org"],"crossmark-restriction":false},"short-container-title":["Gates Open Res"],"abstract":"<ns4:p>\n                    <ns4:bold>Background:<\/ns4:bold>\n                    Bangladesh is exposed to natural hazards such as floods, cyclones and droughts. As such, its health systems and health infrastructure are exposed to recurrent disasters. Research studying the impacts of natural disasters on reproductive health in particular is lacking. This research contributes to this knowledge gap by studying the challenges related to menstrual regulation and post-abortion care at both the facility and community levels, and the care-seeking patterns of pregnant women during the 2016 flood in Belkuchi, Bangladesh.\n                  <\/ns4:p>\n                  <ns4:p>\n                    <ns4:bold>Methods:<\/ns4:bold>\n                    Six government-run primary health care facilities were assessed using a structured assessment tool prior to the flood of 2016. In total, 370 structured interviews were conducted with women in three unions of Belkuchi (Belkuchi Sadar, Daulatpur and Bhangabari) 4 months after the 2016 flood.\n                  <\/ns4:p>\n                  <ns4:p>\n                    <ns4:bold>Results:<\/ns4:bold>\n                    The main challenges at the facility level are a lack of services and a shortage of medicines, equipment and trained health workers. The main challenges at the community level are displacement, high rates of self-diagnosed spontaneous abortion and a lack of treatment for post-abortion complications. A majority of the interviewed women (48%) sought menstrual regulation from the residence of a nurse or family welfare visitor. In total, 73.2% of the women who experienced post-abortion complications sought medical care.\n                  <\/ns4:p>\n                  <ns4:p>\n                    <ns4:bold>Conclusion:<\/ns4:bold>\n                    To overcome the challenges at the facility level, it is important to construct flood-resistant health infrastructure and train health workers in menstrual regulation and post-abortion care, so that these services can be made available during a flood. At the community level, more research is required to understand the reasons for spontaneous abortions so that these, and the subsequent chronic conditions\/complications women experience, may be avoided. Context specific interventions that can overcome local challenges (both at the community and facility levels) are required to promote disaster resilience at primary health care facilities.\n                  <\/ns4:p>","DOI":"10.12688\/gatesopenres.12920.2","type":"journal-article","created":{"date-parts":[[2019,9,4]],"date-time":"2019-09-04T08:00:07Z","timestamp":1567584007000},"page":"788","update-policy":"https:\/\/doi.org\/10.12688\/gatesopenres.crossmark-policy","source":"Crossref","is-referenced-by-count":5,"title":["Understanding reproductive health challenges during a flood: insights from Belkuchi Upazila, Bangladesh"],"prefix":"10.12688","volume":"3","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8448-5567","authenticated-orcid":false,"given":"Nibedita S.","family":"Ray-Bennett","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7822-1693","authenticated-orcid":false,"given":"Denise M. J.","family":"Corsel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nimisha","family":"Goswami","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Aditi","family":"Ghosh","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2560","published-online":{"date-parts":[[2019,6,28]]},"reference":[{"key":"ref-1","doi-asserted-by":"publisher","first-page":"118-128","DOI":"10.1016\/j.ijdrr.2013.10.002","article-title":"A semi-quantitative risk assessment model of primary health care service interruption during flood: Case study of Aroma locality, Kassala State of Sudan.","volume":"6","author":"H Abbas","year":"2013","journal-title":"Int J Disaster Risk Reduct."},{"key":"ref-2","article-title":"Community support group: A sociable approach for improving maternal health in rural Bangladesh.","author":"A Ahmed","year":"2011","journal-title":"Centre for Reproductive Health."},{"key":"ref-3","first-page":"601-605","article-title":"Primary health care and the Midwest flood disaster.","volume":"109","author":"C Axelrod","year":"1994","journal-title":"Public Health Rep."},{"key":"ref-4","doi-asserted-by":"publisher","first-page":"190-199","DOI":"10.1007\/s13753-013-0020-z","article-title":"Flood-induced vulnerabilities and problems encountered by women in northern Bangladesh.","volume":"4","author":"A Azad","year":"2013","journal-title":"Int J Disaster Risk Sci."},{"key":"ref-5","article-title":"Lessons Learned from Integration of Postabortion Care, Menstrual Regulation, and Family Planning Services in Bangladesh","author":"K Biswas","year":"2013"},{"key":"ref-6","doi-asserted-by":"publisher","first-page":"37","DOI":"10.1186\/s12978-017-0298-1","article-title":"Integrating postabortion care, menstrual regulation and family planning services in Bangladesh: a pre-post evaluation.","volume":"14","author":"K Biswas","year":"2017","journal-title":"Reprod Health."},{"key":"ref-7","doi-asserted-by":"publisher","first-page":"1-2","DOI":"10.1191\/146342300669830843","article-title":"Primary health care: Does it defy definition?","volume":"1","author":"R Bryar","year":"2000","journal-title":"Prim Health Care Res Dev."},{"key":"ref-8","article-title":"Flood Worsens in 6 Districts.","author":"T Dhaka","year":"2016a","journal-title":"Dhaka Tribute."},{"key":"ref-9","article-title":"Flood Victims in Dire Need of Relief.","author":"T Dhaka","year":"2016b","journal-title":"Dhaka Tribute."},{"key":"ref-10","doi-asserted-by":"crossref","DOI":"10.1596\/0-8213-5930-4","article-title":"Natural Disaster Hotspots: A Global Risk Analysis","author":"M Dilley","year":"2005"},{"key":"ref-11","doi-asserted-by":"publisher","first-page":"1366-1374","DOI":"10.1016\/S0140-6736(14)60955-7","article-title":"Maternal mortality in Bangladesh: a Countdown to 2015 country case study.","volume":"384","author":"S El Arifeen","year":"2014","journal-title":"Lancet."},{"key":"ref-12","doi-asserted-by":"publisher","first-page":"1121-1127","DOI":"10.1016\/0277-9536(89)90025-7","article-title":"Deaths from injuries and induced abortion among rural Bangladeshi women.","volume":"29","author":"V Fauveau","year":"1989","journal-title":"Soc Sci Med."},{"key":"ref-13","doi-asserted-by":"publisher","first-page":"255-270","DOI":"10.1080\/21699763.2015.1091784","article-title":"What is hindering progress? 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The language of the article is accessible to different audiences which makes its ambition to impact on policy much easier to achieve. The article explores a significant and under-researched topic of the provision of reproductive health services in the period following the natural disaster in a remote and under-resourced area in Bangladesh. Various failures in the healthcare infrastructure have been identified as the main barriers for the provision of adequate menstrual regulation and post-abortion care services to vulnerable women. The findings of the article can be framed within the debates surrounding the relationship between structural violence, gender and health in a particular context in the Global South. There are several areas where the article could be enriched:\u201d&nbsp;\n<i>- We would like to thank Eva Luksaite for reviewing our article. <\/i>&nbsp;\u201c1. There are several issues which arise from the use of the chosen methodology and the authors suggest that ethnographic research methods could be used to provide more in-depth data. I could not agree more. Firstly, the article would have greatly benefited from the inclusion of women\u2019s voices and experiences of both using healthcare services and refusing to use them. It is mentioned that some open-ended questions were included in the structured-interviews. It would be good to know if any of these questions asked women to share their experiences; if not, such questions could be included in the follow-up research projects. If such data were collected, it would be good to include direct quotations from research informants. Secondly, a long-term engagement with fewer informants which builds trust and rapport may have enabled to overcome \u2019the culture of silence\u2019 which surrounds talking about reproductive health. Issues which are surrounded by stigma and taboo require more in-depth research methods, such as ethnography or the collection of life-histories and narratives. These research methods would require a much smaller \u2018sample\u2019 but would provide much richer data, especially when investigating topics such as menstrual regulation, spontaneous abortions and post-abortion care.\u201d&nbsp;\n<i>- In regard to the reviewer\u2019s comment that \u201cthe article would have greatly benefited from the inclusion of women\u2019s voices and experiences of both using healthcare services and refusing to use them\u201d \u2013 this is one of the limitations of this paper, which we have acknowledged. <\/i>\n<i>The structured interviews did include a few open-ended questions, such as \u2018Did you experience any complications after receiving menstrual regulation?\u2019 and \u2018Why did you not receive any healthcare service for these complications?\u2019. However, the response rate was very low.<\/i>&nbsp;\n<i>- We did encourage respondents to elaborate but as mentioned in the article, we also respected their culture of silence around reproductive health. In the future and for follow-up projects, ethnographic research methods are recommended to provide more in-depth data because a key part of ethnographic research would involve a rapport and trust building, which is essential. We agree that in-depth research methods would have been very useful but unfortunately, we are unable to go back in time. Furthermore, the objectives of this entire research project were different. &nbsp;Nevertheless, we believe that the findings have provided valuable insights into the reproductive health challenges faced at the facility level and community level during a flood in Belkuchi Upazila. We anticipate that the research findings will act as baseline research for future research projects.<\/i>&nbsp;\u201c2. The methods section could include some more information on the interview process. It would be good to include how many field research assistants interviewed 370 women (6 field research assistants are mentioned in the acknowledgements only), how long each interview lasted and how long it took to interview 370 women. This would provide more information on the research process and the reliability of data collected.\u201d&nbsp;\n<i>- We have updated the manuscript with the details of the field research assistants who interviewed the 370 women. Please see the third paragraph in the sub-section: \u2018Methods: Interviews\u2019. As requested, we have specified how long each interview lasted (approximately 30 minutes to 2 hours) and how long it took to interview the 370 women (January-February 2019). <\/i>&nbsp;\u201c3. More context could have been provided for readers who are not familiar with this particular area of South Asia. For instance, the article mentions different health workers (medical officer, sub-assistant community medical officers, family welfare visitors), but their different roles in the local health infrastructure remain unclear to those unfamiliar with the healthcare provision in Bangladesh. More information on the social, economic and political context of the area where research was carried out would have provided a more nuanced understanding of research findings and their implications for policy.\u201d&nbsp;\n<i>- The Methodology section has been amended to provide some demography and disaster data of Belkuchi. We have also provided the role description of the health workers in a footnote. <\/i>&nbsp;\u201cThe article states that \u2018untrained health workers continue to provide menstrual regulation and post-abortion care services and this malpractice has huge consequence in decreasing patient safety, satisfaction and good practices\u2019. This statement needs more context on who these untrained health workers are, what they do and why they are so prevalent. The presence of such untrained personnel often points to the failure of the public health system, the distrust in government services, the presence of traditional health care practices which have not been incorporated\/integrated into public health infrastructure or a configuration of other social, cultural, economic and political conditions. Exploring these local conditions would provide a more in-depth understanding of pathways of care for women seeking reproductive health services.\u201d&nbsp;\n<i>- The untrained health workers included some of the nurses and family welfare visitors who were providing menstrual regulation without being trained. Through this project and as a result of our findings, these health workers received training<\/i>\n<i> (Ray-Bennett, Corsel and Goswami, 2019a, 2019b).<\/i>&nbsp;\u201c4. Some statements made in the article are presented as facts or realities but could have been problematised. Practices of untrained health workers are labelled as \u2018malpractice\u2019 but little explanation is provided as to why. Local health practices which fall outside of biomedicine should be explored on a case-by-case basis before being labelled as inappropriate precisely because they fall outside of the contours of biomedicine. The article reports that \u2018hygiene is sometimes not maintained\u2019 in some of the healthcare centres. What does this statement really mean? Ideas about hygiene and regulation of hygiene standards are socio-political practices which are constructed in institutional settings and implemented in locally specific ways. Peoples\u2019 and institutions\u2019 ideas about hygiene are different. It would be good to specify which particular set of guidelines are used here and to acknowledge that these guidelines are arbitrary and socially constructed.\u201d&nbsp;\n<i>- We agree that peoples\u2019 and institutions\u2019 ideas about hygiene are different. Therefore, in the section about \u2018hygiene\u2019, we have provided some further information based on the first two authors\u2019 observations during a field visit.<\/i>&nbsp;\u201c5. Finally, and probably most importantly, the discussion on the status of women in the region would have been particularly welcome in order to inform the understandings of health-seeking behaviour and delays in seeking care. This includes the discussion on the economic situation of households and whether women have control over financial resources, restrictions on women\u2019s physical mobility and whether women are allowed to travel to healthcare settings on their own, gender relations within the household and in the community and how reproductive decisions are made. In other words, the discussion on how women are embedded in local relations of power, status and kinship would contextualise research findings in significant ways.\u201d&nbsp;\n<i>- We appreciate these insightful comments. We feel these issues could be studied through in-depth qualitative research. This has not been the objective for this IPPF-Funded research project. The research project was geared towards how to improve the quality and availability of post-abortion care during a flood at facility level.<\/i>","URL":"https:\/\/gatesopenresearch.org\/articles\/3-788\/v2#referee-comment-3184","order":2,"name":"referee-comment-3184","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"This research was sponsored by The Bill & Melinda Gates Foundation (OPP1181398) and International Planned Parenthood Federation\u2019s (IPPF) \u2018Innovation Programme\u2019 and IPPF-South Asia Region Office\u2019s \u2018SPRINT Initiative\u2019.","order":3,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}