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Annually, there are approximately 25 million unsafe abortions, and this remains a leading cause of maternal morbidity and mortality. In settings where abortion is restricted, women are increasingly able to self-manage abortions by purchasing abortion medications such as misoprostol and mifepristone (RU-486) from pharmacies or other drug sellers. Better availability of these drugs has been shown to be associated with reductions in complications from unsafe abortions. In Bangladesh, abortion is restricted; however, menstrual regulation (MR) was introduced in the 1970s as an interim method of preventing pregnancy. Pharmacy provision of medications for MR is widespread, but customers purchasing these drugs from pharmacies often do not have access to quality information on dosage and potential complications.
This study aimed to describe a call center intervention in Bangladesh, and assess call center use over time and how this changed when a new MR product (combined mifepristone-misoprostol) was introduced into the market.
In 2010, Marie Stopes Bangladesh established a care provider–assisted call center to reduce potential harm from self-administration of MR medications. The call center number was advertised widely in pharmacies and on MR product packaging. We conducted a secondary analysis of routine data collected by call center workers between July 2012 and August 2016. We investigated the reported types of callers, the reason for call, and reported usage of MR products before and after November 2014. We used an interrupted time series (ITS) analysis to formally assess levels of change in caller characteristics and reasons for calling.
Over the 4-year period, 287,095 calls about MR were received and the number of users steadily increased over time. The most common callers (of 287,042 callers) were MR users (67,438, 23.49%), their husbands (65,999, 22.99%), pharmacy workers (65,828, 22.93%), and village doctors (56,036, 19.52%). Most MR calls were about misoprostol, but after November 2014, a growing proportion of calls were about the mifepristone-misoprostol regimen. The most common reasons (of 287,042 reasons) for calling were to obtain information about the regimen (208,605, 72.66%), to obtain information about side effects (208,267, 72.54%), or to report side effects (49,930, 17.39%). The ITS analyses showed that after November 2014, an increasing number of calls were from MR users who had taken the complete regimen (
The high call volume suggests that this call center intervention addressed an unmet demand for information about MR medications from both MR users and health care providers. Call center interventions may improve the quality of information available by providing information directly to MR users and drug sellers, and thus reducing the potential harm from self-management of MR medications.
The most recent estimates suggest that between 2010 and 2014, there were 56 million abortions annually, of which 25 million were unsafe [
The increasing use of mobile and wireless technologies for health—known as mobile health (mHealth)—has huge potential to improve health systems in low- and middle-income countries (LMICs) through better access to knowledge and information [
In Bangladesh, abortion is legal only to save a woman’s life; however, menstrual regulation (MR), “an interim method of establishing non-pregnancy in women at risk of being pregnant,” was introduced in the country in 1972 as a strategy to reduce morbidity and mortality from unsafe abortion [
The most recent study of MR incidence in Bangladesh showed that in 2014, an estimated 430,000 MR procedures (using MVA or medication) were performed in health facilities nationwide, whereas an estimated 1,194,000 induced abortions occurred and 257,000 women were treated for complications from abortion [
Marie Stopes Bangladesh (MSB) is a sexual and reproductive health service provider, operating through 600 service delivery outlets across all 64 districts of Bangladesh, including static centers, outreach teams accessing hard-to-reach and underserved rural communities, public sector support, and social marketing channels. To address the lack of access to accurate information about MR medications, MSB set up a call center in 2010 with the goal of preventing potential harm for individuals who purchase MR medications from pharmacies and drug shops. This study uses routine data to investigate the changing use of the call center over a 4-year period (2012-2016). The objectives of the study were to (1) describe the characteristics of call center users and their reasons for calling and (2) assess whether the introduction of a mifepristone-misoprostol combined regimen into the market led to a change in the usage of the call center. It is hoped that the results can inform future programming for information provision about mifepristone and misoprostol in Bangladesh and other LMICs. The term pharmacy can refer to a range of businesses of various sizes and legal statuses, and in this paper, we refer to pharmacies and drug shops as any outlet whose business is selling medicines, regardless of their training, staff qualifications, or legal status. We refer to mifepristone-misoprostol and misoprostol alone as
This call center initiative is one of 27 reproductive health call centers supported by Marie Stopes International worldwide [
Examples of call centre promotional materials.
This study retrospectively analyzed routine data collected by MSB call center operators between July 2012 and August 2016. In June 2012, a 15-item monitoring form was designed to collect information on the profile of callers and their reasons for calling. All operators were trained to administer the questions from the monitoring form during every call, to record responses on paper during the call or immediately after, and to enter the data into an Epi Info 7 database (developed by the Centers for Disease Control and Prevention) between calls. No identifying information such as the caller’s name or address was collected. Each caller was asked if they had called before but repeat callers are treated as distinct individuals and their records from previous calls are not matched. Data collection commenced in July 2012 and is ongoing.
The variables in the monitoring form are as follows. Callers were asked about their location (one of several divisions of Bangladesh), the age range of the MR user (in 5-year groups), and whether they were a repeat caller (yes or no). Operators recorded the caller’s relationship to the MR user with the following response options: pharmaceutical representative, pharmacist, pharmacy worker, village doctor, woman herself (MR user), husband, mother, and other relative or friend of MR user). All callers were asked the general reason for calling, and the call center operator could select multiple responses from a list of 12 (including misoprostol for medical MR, misoprostol for other conditions, combination regimen for medical MR, family planning, other reproductive or general health questions, or information on the nearest clinic or hospital). If the call was MR related, the specific queries of the caller were recorded (including whether misoprostol can be used for medical MR, correct dosage for medical MR [timing, dosage, or route], questions about side effects and complications, experience of side effects, experience of complications, taken the wrong dose, pain medications, and accessing the clinic or hospital). If the reason for calling was that the end user was experiencing side effects or suspected complications, the types of side effects and suspected complications were recorded. Complications are reported as
Some adaptations were made to the monitoring form after the initiation of data being recorded: the repeat caller variable was only included from July 2013, whether the MR drug had already been purchased was only available from November 2014, brand data were available only from September 2013, and under general reasons for calling, the response options
We conducted descriptive analyses of the number of calls, profiles of call center users, and their reported reasons for calling over time, using aggregate monthly data.
To assess whether the introduction of the combination regimen was associated with differences in call center use, we compared caller characteristics before and after November 2014. This month was chosen because it was when the call center number started to be printed on a combination pack, so although the combination regimen was available on the market from March 2013, the call center was unlikely to receive calls until the call center number was widely advertised through product packaging. Interrupted time series (ITS) analysis was used [
We also compared characteristics of calls related to misoprostol only and the combination pack using bivariate crosstabulations.
A total of 344,827 calls were made to the call center between July 2012 and August 2016, and the number of calls per month increased from 2778 in July 2012 to a peak of 11,157 calls in March 2016, falling to 8516 in August 2016 (
Number of calls received by the Marie Stopes Bangladesh call center, July 2012 to August 2016. MR: menstrual regulation.
The number and proportion of calls that were for non-MR queries also increased after November 2014, and by August 2016, they accounted for a quarter of all calls. Non–MR-related reasons for calling included questions about accessing the nearest clinic or hospital (28,554/344,827, 8.28%), family planning (6403/344,827, 3.10%), other reproductive or general health topics (7156/344,827, 3.47%), misoprostol for other indications (1518/344,827, 0.49%), and other reasons (21,114/344,827, 10.06%). Non–MR-related calls are excluded from the subsequent analysis.
The characteristics of MR-related calls are shown in
Just under half of MR calls (110,635/250,814, 44.94%) were from repeat callers. We cross-tabulated repeat callers with other characteristics (results available on request) and found that repeat callers were more likely to be MR users or pharmacy workers compared with calls from first-time callers, but there were no other significant differences in the characteristics of repeat callers and first-time callers. We also cross-tabulated the reason for calling with the type of caller, which showed that that calls about misoprostol for indications other than MR (eg, related to postpartum hemorrhage) were more likely to be made by a provider (predominantly driven by calls from village doctors) than an MR user or their family.
Of 287,095 calls, 109,429 (64.50%) calls were made when the MR user had already purchased the drug, and 68,732 (23.95%) of the MR users had taken MR medications before calling. The most common MR-related reasons for calling were to ask if medications could be used for MR (161,145/169,453, 96.75%), to obtain regimen information (208,605/287,095, 72.66%), and to get information about side effects (208,267,287,095, 72.54%). Overall, 49,930 of 287,095 people (17.39%) called because they were experiencing side effects, 21,207 (7.39%, 21,207/218,738) called to ask about pain medication, 6745 (3.08%, 6745/218,738) suspected they had taken the wrong dose, and 11,207 (3.90%, 11,207/287,095) wanted information on accessing the nearest clinic or hospital. The most common side effects reported were cramps (7.26%) followed by bleeding (4.06%) and diarrhea (4.10%), fever (2.84%), and vomiting (1.14%; data not shown). In addition, 2.83% of MR callers said they thought they were experiencing complications, and almost all of these were suspected to have incomplete MR. Only 3 callers reported excessive blood loss. Most callers called for more than one reason.
Characteristics of individuals calling the Marie Stopes Bangladesh call center about menstrual regulation (MR) from July 2012 to August 2016.
Characteristic of the call or caller | July 2012-October 2014, % | November 2014-August 2016, % | Total, n (%) | ||
<.001 | |||||
Pharmaceutical representative | 0.51 | 0.59 | 1603 (0.56) | ||
Pharmacist or pharmacy worker | 21.83 | 23.70 | 65,828 (22.93) | ||
Village doctor | 20.76 | 18.67 | 56,036 (19.52) | ||
MR user (woman) | 21.70 | 24.74 | 67,438 (23.49) | ||
Husband of MR user | 28.19 | 19.39 | 65,999 (22.99) | ||
Mother or other relative of MR user | 4.08 | 7.27 | 17,115 (5.96) | ||
Friend of MR user | 2.61 | 5.54 | 12,466 (4.34) | ||
Don’t know, refuse and missing | 0.33 | 0.10 | 557 (0.19) | ||
<.001 | |||||
<20 | 20.20 | 25.85 | 67,579 (23.54) | ||
20-24 | 40.04 | 35.03 | 106,453 (37.08) | ||
25-29 | 25.67 | 21.18 | 66,074 (23.01) | ||
30 or older | 9.24 | 14.35 | 35,188 (12.26) | ||
Don’t know, refuse and missing | 4.85 | 3.60 | 11,801 (4.11) | ||
<.001 | |||||
Dhaka | 28.47 | 27.27 | 79,700 (27.76) | ||
Rajshahi | 10.72 | 12.54 | 33,870 (11.80) | ||
Rangpur | 9.01 | 10.37 | 28,175 (9.81) | ||
Chittagong | 22.21 | 20.84 | 61,448 (21.40) | ||
Sylhet | 8.80 | 11.25 | 29,422 (10.25) | ||
Khulna | 8.44 | 7.73 | 23,017 (8.02) | ||
Barisal | 6.58 | 7.09 | 19,758 (6.88) | ||
Out of country, don’t know, refuse and missing | 5.76 | 2.91 | 11,705 (4.08) | ||
<.001 | |||||
Don’t know and refuse | 12.44 | 8.21 | 23,450 (9.53) | ||
Yes | 45.69 | 44.61 | 110,635 (44.94) | ||
No | 41.87 | 47.18 | 112,085 (45.53) | ||
—c | |||||
Don’t know and refuse | — | — | 1070 (0.63) | ||
Yes | — | — | 109,429 (64.50) | ||
No | — | — | 59,158 (34.87) | ||
<.001 | |||||
Taken complete regimen | 12.38 | 17.80 | 44,745 (15.59) | ||
Started the regimen | 10.17 | 7.10 | 23,987 (8.36) | ||
Not taken | 72.78 | 72.35 | 208,211 (72.52) | ||
Don’t know and other | 4.67 | 2.75 | 10,152 (3.54) | ||
Whether misoprostol used for MRe | — | 96.75 | 164,145 (96.75) | — | |
Correct MR dosage and regimenf | 73.11 | 72.35 | 208,605 (72.66) | <.001 | |
Information on side effects and complications | 72.82 | 72.35 | 208,267 (72.54) | <.001 | |
Experiencing side effects | 15.12 | 18.96 | 49,930 (17.39) | <.001 | |
Caller suspects complications | 2.04 | 3.37 | 8118 (2.83) | <.001 | |
Caller thinks they have taken the wrong doseg | 4.22 | 2.75 | 6745 (3.08) | <.001 | |
Questions about taking pain medication | 6.75 | 7.83 | 21,207 (7.39) | <.001 | |
Questions about accessing clinic or hospital | 1.04 | 5.88 | 11,207 (3.90) | <.001 | |
Total | 40.91 | 59.09 | 287,095 (100.00) | — |
aQuestion introduced in July 2013.
bMissing data due to question being introduced in November 2014.
cNot applicable.
dMultiple responses allowed, so column percentages can total more than 100.
eMissing data due to question being introduced in November 2014.
fCombined responses to queries about timing, dosage, and route.
gQuestion not asked in September 2013-October 2014.
The brands of MR medications reported to have been purchased by call center users varied over time, and details of the most commonly mentioned brands are shown in
Time series plots showed that over the 4-year reference period, the mean number of MR users who reported they were under 20 years increased. Over time, there was a steady decrease in calls from husbands of MR users, and slight increases in calls from MR users and pharmacists or pharmacy workers. There was a noticeable increase in the proportion of callers who reported having taken the complete regimen and decrease in those who had called the call center when they had only started the regimen.
ITS analyses using November 2014 as the intervention point are shown in
Details of the most commonly mentioned menstrual regulation medications.
Product | Date registered in Bangladesh | Date call center number first printed on product |
Misoprostol brand 1 | September 2011 | September 2011 |
Misoprostol brand 2 | 2002 | Not printed |
Combination brand 1 | February 2013 | January 2015 |
Combination brand 2 | October 2014 | October 2014 |
Number of calls by month according to brand of menstrual regulation drug purchased (September 2013-August 2016).
Interrupted time series regression results comparing the number of calls pre- and post-November 2014, overall, by type of caller, and reason for calling.
Characteristic of the call or caller | Mean calls per month at start of time series | Time trend (calls per month) before November 2014 (95% CI) | Step change at November 2014 (95% CI) | Change in time trend after November 2014 (95% CI) | |
Overall | 2641.5 | 115.0 (87.3 to 142.8) | 1866.6 (1064.5 to 2668.8) | −1.6 (−0.73 to 70.0) | |
Pharmacist or pharmacy worker | 352.2 | 41.7 (32.2 to 51.2) | 277.5 (10.6 to 544.5) | 2.8 (−15.5 to 21.2) | |
Menstrual regulation (MR) user (woman) | 732.4 | 13.1 (−5.5 to 31.8) | 632.7 (60.8 to 1204.8) | 16.5 (−21.3 to 54.5) | |
<20 | 362.7 | 35.8 (28.1 to 43.7) | 391.8 (75.0 to 708.6) | 22.3 (−2.8 to 47.4) | |
Taken complete regimen | 362.7 | 11.6 (3.1 to 20.1) | 360.8 (46.8 to 674.8) | 30.9 (4.4 to 57.4) | |
Correct MR dosage and regimen | 1775.7 | 95.6 (77.2 to 114.0) | 1510.5 (771.1 to 2250.0) | −36.9 (−96.8 to 23.7) | |
Information on side effects and complications | 1733.8 | 97.8 (79.2 to 116.5) | 1490.5 (754.2 to 2226.9) | −36.5 (−96.8 to 23.7) | |
Experiencing side effects | 503.5 | 9.7 (2.4 to 16.9) | 300.3 (−24.2 to 624.9) | 36.9 (10.7 to 63.2) | |
Caller suspects complications | 24.2 | 4.5 (3.4 to 5.7) | 70.6 (−23.3 to 164.6) | 3.7 (−4.3 to 11.6) | |
Questions about pain medication | 256.2 | 2.0 (−4.8 to 8.8) | 133.1 (−11.0 to 278.2) | 15.1 (3.3 to 26.9) |
Plotted time series data and fitted regression lines considering pre- and postintroduction of the combination regimen (November 14) for selected outcomes.
Differences between combination drug and misoprostol-only purchasers (November 2014-August 2016, N=169,619).
Characteristic of call or caller | Combination regimen (n=95,447), n (%) | Misoprostol only (n=74,210), n (%) | ||
.001 | ||||
Pharmaceutical representative | 523 (0.55) | 481 (0.65) | ||
Pharmacist or Pharmacy worker | 21,993 (23.05) | 18,207 (24.54) | ||
Village doctor | 17,920 (18.78) | 13,740 (18.52) | ||
Menstrual regulation (MR) user (woman) | 25,648 (26.88) | 16,315 (21.99) | ||
Husband of MR user | 17,156 (17.98) | 15,741 (21.22) | ||
Mother and other relative of MR user | 6919 (7.25) | 5411 (7.29) | ||
Friend of MR user | 5163 (5.41) | 4236 (5.71) | ||
Don’t know, refuse and missing | 103 (0.11) | 63 (0.08) | ||
.001 | ||||
<20 | 25,625 (26.85) | 18,232 (24.57) | ||
20-24 | 32,454 (34.00) | 26,973 (36.35) | ||
25-29 | 20,127 (21.09) | 15,799 (21.29) | ||
30 or older | 13,748 (14.40) | 10,593 (14.27) | ||
Don’t know, refuse and missing | 3493 (3.66) | 2613 (3.52) | ||
42,855 (44.90) | 32,821 (44.23) | .001 | ||
.001 | ||||
Taken complete regimen | 18,099 (18.96) | 12,106 (16.31) | ||
Started the regimen | 5097 (5.34) | 6947 (9.36) | ||
Not taken | 70,224 (73.57) | 52,519 (70.77) | ||
Don’t know and other | 2027 (2.12) | 2638 (3.55) | ||
Whether misoprostol or combination pack used for MR | 93,468 (97.93) | 70,677 (95.24) | .001 | |
Correct MR dosage and regimen | 70,224 (73.57) | 52,523 (70.78) | .001 | |
Information on side effects or complications | 70,224 (73.57) | 52,523 (70.78) | .001 | |
Experiencing side effects | 18,750(19.64) | 13,422 (18.09) | .001 | |
Caller suspects complications | 2942 (3.08) | 2783 (3.75) | .001 | |
Thinks they have taken the wrong dosec | 2024 (2.12) | 2650 (3.57) | .001 | |
Questions about pain medication | 6854 (7.18) | 6431 (8.67) | .001 | |
Accessing clinic or hospital | 4739 (4.97) | 5245 (7.07) | .001 | |
Nausea | 757 (0.79) | 508 (0.68) | .01 | |
Vomiting | 1489 (1.56) | 1308 (1.76) | .001 | |
Diarrhea | 4136 (4.33) | 3376 (4.55) | .03 | |
Headache | 1937 (2.03) | 589 (0.79) | .001 | |
Cramps | 6850 (7.18) | 6379 (8.60) | .001 | |
Bleeding | 5981 (6.27) | 2041 (2.75) | .001 | |
Fever | 2009 (2.10) | 2377 (3.20) | .001 |
aQuestion introduced in July 2013.
bMultiple responses are allowed, so percentage may sum to more than 100%.
cNo data available in September 2013-October 2014.
dQuestion introduced in July 2013.
This study analyzed the usage patterns of a call center in Bangladesh that was established to reduce harm from potential incorrect use of MR medications, and the findings point to the effectiveness and feasibility of this approach. Consistent with findings from surveys of pharmacy workers undertaken in 2011 [
This study adds to the evidence on call center support for maternal and reproductive health issues [
Improving the quality of information available to women who purchase mifepristone or misoprostol from pharmacies is a challenge, and although pharmacy worker–focused interventions such as training and detailing have had some impact on pharmacy provision [
An important function of the call center is to provide referral information to women experiencing complications after taking misoprostol for MR. The WHO recommended a misoprostol-only MR regimen of 800 mcg taken sublingually up to 3 times at 6-, 12-, and 24-hour intervals [
Unsurprisingly, the introduction of the combination pack into the market was followed by a decline in the number of calls regarding misoprostol-only MR and an increase in calls about the combination regimen. As increases in calls were clearly linked to when various brands started to include the call center number on the packaging, it also suggests the efficacy of this technique to publicize call centers as a source of support for women self-administering MR medications. Unlike misoprostol, the combination regimen is packaged for MR with instructions on use. ITS analysis showed that after the call center number started to be printed on combination regimen packaging, significantly more calls were made about MR users who had taken the complete regimen and who were experiencing side effects and wanted information on pain medication. Conversely, downward trends were seen after November 2014 for enquires about dosage, regimen, and asking for information on side effects, which is logical given that the combination regimen pack prints usage instructions. This suggests that after the introduction of the combination regimen to the market, callers more often called later in the MR process and with different kinds of queries.
Our sample is likely not representative of all women who are accessing MR medications through pharmacies in Bangladesh, and preliminary analyses suggest that call center users may be younger than the general population of MR users in Bangladesh. As a crude comparison of age distribution, we used the 2014 Bangladesh Demographic and Health survey (DHS) [
Our study has some limitations and implications for further research. We collected limited data on repeat callers, and these were not linked, so the characteristics of the 45% of calls who are repeat callers are overrepresented in the data. It would be useful to understand more about repeat callers: why they called more than once and the duration between calls, for example. Further information is also needed about non-MR callers, as the numbers of these have been increasing and now account for a quarter of calls. This could suggest a further need for accessible advice for other reproductive health issues such as family planning or a change in the way the call center is promoted to better address other reproductive health needs. Further research is needed to understand the impact of this intervention on provider provision practices and client outcomes such as complete MR, use of post-MR family planning, and access to appropriate treatment for complications.
Evidence has demonstrated that availability of misoprostol can lead to a decrease in the rate and severity of abortion complications [
Demographic and Health survey
interrupted time series
low- and middle-income country
mobile health
menstrual regulation
Marie Stopes Bangladesh
manual vacuum aspiration
World Health Organization
This study was funded by the Department of International Development, UK.
All authors are employed by Marie Stopes International or Marie Stopes Bangladesh, and the call center at the focus of this study is run by these organizations.