Implementation evaluation of ARCHES for menstrual regulation and post-abortion care clients in Bangladesh

Intimate partner violence (IPV) and reproductive coercion (RC) are forms of gender-based violence (GBV) that significantly hinder women’s reproductive autonomy and contribute to unintended pregnancies. These issues are especially severe in low- and middle-income countries (LMICs) like Bangladesh, where IPV prevalence is among the highest globally, and patriarchal norms limit women’s decision-making power in healthcare. The ARCHES (Addressing Reproductive Coercion in Health Settings) intervention is a single counseling session designed to address RC and connect clients with available IPV support services to support their reproductive autonomy. ARCHES was originally implemented in the United States and later adapted in Kenya and further adapted to the Bangladesh context for menstrual regulation (MR) and post-abortion care (PAC) clients. This paper describes the implementation fidelity and contextual effectiveness of the ARCHES intervention for MR and PAC clients in Bangladesh. A cluster-randomized controlled trial (cRCT) was conducted to evaluate the effectiveness of the adapted ARCHES intervention among MR and PAC clients in Bangladesh. The trial was registered on clinicaltrials.gov (NCT03539315) on 29/05/2018. Implementation was assessed using 1 the Consolidated Framework for Implementation Research (CFIR) to evaluate fidelity and identify factors influencing successful integration, and 2 an as-treated sensitivity analysis to determine the effect of fidelity on continuous contraceptive use. Evaluation results indicate high implementation fidelity of all components of ARCHES, increasing the odds of subsequent continuous contraceptive use twelve months after exposure. Providers found the intervention feasible and acceptable, noting its usefulness in enhancing client engagement and supporting reproductive decision-making. Key determinants of successful implementation included provider motivation, quality of training, and institutional support. The ARCHES intervention was successfully adapted and implemented in MR and PAC settings in Bangladesh with high fidelity, improving contraceptive use in context of partner/husband and/or family opposition. It was deemed acceptable and feasible by providers, highlighting its potential for empowering reproductive health choices in clinic settings. Future efforts should focus on optimizing the scalability of the ARCHES intervention, ensuring alignment with client preferences, and improving acceptability and accessibility of referral pathways within the local context.