Richard Smith: Menstrual regulation and the sacra rosa—escaping religious rigidity

Richard SmithCountries that are strongly Muslim or Roman Catholic find abortion unacceptable, but Bangladesh, a Muslim country, has found a clever way of helping women who might be pregnant and don’t want to be.

In Bangladesh induced abortion is illegal unless a woman’s life is threatened. But a woman who has missed a period may in the next eight to ten weeks undergo menstrual regulation to ensure that she is not pregnant. Menstrual regulation has been undertaken with manual vacuum aspiration, but increasingly drugs are being used. It is very important not to do a pregnancy test: if it was known that the woman was pregnant then the procedure would be an abortion and so illegal.

In 2010 some 650 000 women had menstrual regulation performed, but there were also 640 000 induced abortions, most of them illegal. Around 570 000 of the women suffer complications, and about 1%—some 6400—die. Women undergo unsafe abortions because they are unaware of menstrual regulation, lack access to the procedure, or don’t understand the difference between menstrual regulation and unsafe abortion. Unsurprisingly poor and rural women are more likely to undergo unsafe abortion.

Menstrual regulation, which seems to me a very clever idea, has been available in Bangladesh since 1979. It’s been suggested to me that it became acceptable because of the systematic raping of women during the War of Liberation, when what was East Pakistan fought off the dominance of West Pakistan and became Bangladesh, still a Muslim country, but steeped in the richness of Bengali culture.

As far as I know, other countries that are opposed to abortion on religious grounds don’t allow menstrual regulation—but perhaps they should.

I’m impressed by the ingenuity of menstrual regulation, and I was describing it to an Italian friend, who said that it reminded him what he called the sacra rosa. The way he described it even a married couple who had had children could be allowed a divorce by the Catholic Church on the grounds that one or other or both of the couple had not been thinking of sex while conceiving the children. For my friend it was a form of corruption, and the Church would need generous payment for allowing such a divorce.

I can’t find mention of the sacra rosa online, but I have learnt about the “declaration of nullity.” The Church, it seems, can’t allow separation of a couple whom God have joined, but it can accept that there are circumstances in which true marriage never took place even though the couple went through the ceremony in a church. Non-consummation is the best known cause, and both the Church and God expect sex to occur. But it also seems that “not intending, when marrying, to remain faithful to the spouse (simulation of consent)” can mean that true marriage never took place.

This would seem to be a marvellous out for the world’s many philanderers, but it leaves me wondering why all the fuss around Henry VIII and why we need the Church of England. I know the answer: it was all about politics, power, and money.

Perhaps with more of the mental ingenuity that has given us menstrual regulation and the declaration of nullity we could avoid the considerable pain and suffering that result from ideological and religious rigidity.

Competing interest: RS is the chair of the board of trustees of ICDDR,B (formerly International Centre for Diarrhoeal Disease, Bangladesh), which has studied and promoted menstrual regulation in Bangladesh.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.