Application of a novel abortion care quality measurement tool (ACQTool) in Bangladesh

By Laura E Jacobson, Sarah E. Baum, Erin Pearson, Rezwana Chowdhury, Nirali M. Chakraborty, Julia M. Goodman, Caitlin Gerdts, & Blair G. Darney

Measuring and improving quality of care is an essential part of ensuring safe and effective health services; however, until recently measuring the quality of abortion care has been hampered by a lack of shared definitions and validated tools. The Abortion Care Quality (ACQTool) is a new tool that includes 29 validated indicators and the first global standard for measuring the quality of abortion care in low- and middle-income countries, for both facility and self-managed medication abortion (SMA) contexts. This is the first study to use this novel, validated abortion quality measure. 

In Bangladesh, abortion law is highly restrictive, only permitting abortion to save the life of the pregnant person; however, menstrual regulation (MR) when someone has a procedure or takes medications to bring on the return of their menses if they have not had a period for 10–12 weeks without confirmation of pregnancy, is legal. Self-managed MR (or SMA) occurs in Bangladesh where a person obtains medications and information directly from pharmacies or retail drug shops without a prescription, from staff who may or may not have adequate medication abortion training. SMA has been shown to be safe and effective, has been incorporated into global care standards, and has the potential to expand abortion access and improve health outcomes.  Recognizing SMA as a safe and effective option, it is important to examine and address any disparities in the quality of care provided to ensure that individuals’ rights to safe abortion care are upheld.


This work revealed the following key findings:

  1. Using the ACQtool, we show that in Bangladesh, the majority (11/18) of quality indicators were not different between facility-managed medication abortion and pharmacy SMA abortion modalities. Clients reported higher quality in facilities for five indicators and higher quality in pharmacies for two indicators. 
  2. When compared to facility-managed abortion care, pharmacy sourced SMA is more affordable to clients and may expand access, an important measure of quality of care, despite government subsidized public sector facility care in Bangladesh. 
  3. Our study found gaps in the quality of abortion information provision offered by pharmacies. Nearly three-quarters of pharmacy SMA clients compared to one third of facility medication abortion clients rated low information provision.  
  4. Facility clients compared to pharmacy clients had higher odds of knowing what to do for an adverse event, the only one of eight abortion care outcomes that showed differences. In addition, adolescence (age 15-19 versus 20-24 years) was associated with not knowing what to do for an adverse event.



Measuring and comparing client experience of abortion quality of care in pharmacy-based SMA and facilities reveals that generally clients rate quality highly. However, improvement is needed in important areas such as affordability of facility-based abortion services, information and education supplied by pharmacies, and informing all clients (but especially pharmacy-SMA clients and adolescents) of what to do if an adverse event occurs. Patient-centered quality of care is a human right; our results suggest that information provision can serve as a key point of intervention for quality of care in pharmacies to improve client experiences, especially in light of the lower cost. 

Read the paper here.


About the Authors 

Laura E. Jacobson, MPH is a PhD candidate of health systems and policy at OHSU-PSU joint School of Public Health in Portland Oregon USA. Her work examines abortion quality of care, medication abortion self-use,and pregnancy and birth outcomes in a global context.  

Sarah E. Baum, MPH is a Senior Research Scientist at Ibis Reproductive Health in Oakland CA, USA. 

Erin Pearson, PhD, MPH is a Research Scientist at Center on Gender Equity and Health, University of California San Diego, San Diego CA, USA. 

Rezwana Chowdhury, MDS, MPH is a Senior Research, Monitoring, and Evaluation Advisor at Ipas Bangladesh, Dhaka, Bangladesh

Nirali M. Chakraborty, PhD is Director of Research at Metrics for Management, Baltimore, MD USA. 

Julia M. Goodman, PhD, MPH is Associate Professor of Health Systems Management and Policy at OHSU-PSU joint School of Public Health in Portland Oregon USA.  

Caitlin Gerdts, PhD MHS is Vice President for Research at Ibis Reproductive Health in Oakland CA, USA. 

Blair G. Darney, PhD, MPH is an Associate Professor of Obstetrics and Gynecology, OHSU, and Health Systems & Policy in the OHSU-PSU joint School of Public Health in Portland Oregon USA. She also holds an appointment at the National Institute of Public Health (Instituto Nacional de Salud Publica/INSP) in Mexico. 


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