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Establishing second trimester abortion services: :
Nepal’s experience
Dr. Chanda KarkiDr. Chanda KarkiProf and HeadProf and Head
Department of Ob/GynDepartment of Ob/GynKathmandu Medical College Teaching HospitalKathmandu Medical College Teaching Hospital
Abortion was strictly illegal and considered as crime
Be
fore 2
003 …
.Many women were seeking unsafe abortion clandestinely in unsafe environment.
• Deaths (15-30% of MMR)
• Several years imprisonment (6 months- more than 5 years)
• Serious body injuries
Abortion was not Abortion was not accepted from accepted from social, cultural social, cultural and religious and religious aspectaspect
BackgroundBackground
After 2002, an Abortion Task Force drafted a set of strategies to ↑ access to safe abortion.
Based on WHO Nepal’s initial set of guidelines on
SAS was approved in 2003.
The task force was then replaced by TCIC.
TCIC produced a series of national
standards and guidelines that cover
first- and second-trimester abortion as
well as medical abortion.
• Today, first trimester abortion care is available in all 75 districts (MVA) and MA in 16 districts .
• Transformation possible -development and implementation of comprehensive standards and guidelines for safe abortion care
• Providers and facility managers understand what standard of care is expected
• They know they have a government mandate to provide that care.
• Nearly 500,000 women have had safe, legal abortion care in Nepal since passage of the 2002 law.
• In 2010, Nepal received a Millennium Development Goal award from the United Nations for its achievement in reducing maternal mortality and morbidity.
• From 2000 to 2010, Nepal’s MMR dropped from 415 to 229 per 100,000 LB.
• The nationwide introduction of safe abortion care is credited with being one of the major reasons for that progress.
Legal IndicationsLegal Indications
• Up to 12 weeks by requestUp to 12 weeks by request
• Up to 18 weeks in the case of rape or Up to 18 weeks in the case of rape or incestincest
• Any gestational ageAny gestational age1.1. Life threatening conditions mental or physical Life threatening conditions mental or physical
conditionsconditions
2.2. Fetal abnormalities/malformationFetal abnormalities/malformation
BackgroundBackground
Country code Received Royal Assent on September 2002
Procedural order allowing SAS published on
December 2003
First trimester service started from the year 2004- 75 districs/487 sites
National, facilitybased study 2006 - 4,245
women (13% of those seeking abortion) were
denied abortion services because they
were more than 12 weeks pregnant.
The key steps
• Advocacy efforts are often required to raise awareness among key governmental and health system stakeholders.
• Securing the necessary approvals- to introduce or expand second trimester services
• Selecting abortion methods,
• organizing facilities,
The key steps
• Obtaining necessary equipment and supplies
• Training Service providers including values clarification;
• Monitoring and support -prevents burn-out and ensures quality of care.
• Setting up and managing services, and
• Ensuring quality.
Advocacy, Approvals, Method selection, site selection
BackgroundBackground
In 2008 the FHD, decided that both medical abortion and D&E should be offered at all tertiary care facilities.
The DDA approved MA drugs (mifepristone and misoprostol) for
induction
The protocols were developed on both
surgical and medical induction as
recommended by the WHO
STA sites were identified
Trained senior Gyn & Obs on abortion
services
How to successfully provide high-quality How to successfully provide high-quality second-trimester abortion care?second-trimester abortion care?
• Site that offers 7 days 24 hour CEOC services
• At least two obs/gyn competent in CEOC and 1st trim CAC
• Provision of USG and WHO recommended D&E set
• Provision of Incinerator, Pit for waste management disposal
How to successfully provide high-How to successfully provide high-quality second-trimester abortion care?quality second-trimester abortion care?
• Providers receive two weeks of ‘’hands on’’ training in MH & in KMC
• Each trained providers receive three follow ups post training (at 6 weeks, 6 month and 12 month)
• Nursing staff receive orientation on FP counseling, scheduling clients, IP & waste disposal, recording/reporting and follow up
VCAT workshop
• Essential requirement for sec tri training• VCAT- whole site orientation on regular basis
to most of the facilities- on going program.
First batch of Training
National trainers
Service status(2008-2012)Service status(2008-2012)
Within first one year around 474 women were reported receiving safe and legal abortion services (with around 90% of contraceptive acceptance rate)
18 sites listed for providing services
48 Providers (Ob/Gyn & GP) trained as a service providers
Instruments provided to 10 sites
Site D & E MI TotalSZH 64 56 120
KMCTH 152 59 211
NMCTH 17 22 39
Bharatpur hospital 80 35 115
WRH, Pokhara 50 21 71
Lumbini Z H 75 30 105
Maternity Hospital 270 65 335
Model Hospital 33 102 135
Om Hospital 12 22 34
Surkhet Hospital 27 30 57
BPKIHS 75 98 173
Baglung Hospital 5 7 12
B and B Hospital 9 4 13
Medicare 0 8 8
18 sites 869 (61%) 559 (39%) 1428
ChallengesChallenges
Follow up of trainees can be difficult and time-consuming and capacity to do so is
limited
ExpensiveEquipments
Value clarification and attitude
transformation
Developing local expert trainers takes
time
Transfer of trained providers
Delayed in getting equipment
Information ReachStill many women do not have information about services
FeesNot able to reach poor women
ChallengesChallengesJudgmental
attitudes from staff members
Availability of illegal 2nd trim providers
Waste disposal management
Regular Services Many sites services are not routine
Complications referral
Difficult for pvt sites
Prioritization of services Least prioritized service
Bottom line: time and resource intensive!
Safe abortion services Total – 1848 First trimester -1611 Second trimester - 237 (13%)Service Provider – 5Training Conducted - 4
KMC-Service StatusKMC-Service Status (2009-2012)(2009-2012)
D & E= 70%Duration of gestation
(wks)
D & E (70%)
Medical induction
Total
12+ - 14 96% (91) 4% (4) 100% (95)
15-18 73% (76) 27% (28) 100% (104)
19 and more
0% (0) 100% (38) 100% (38)
Indications Indications
• Maternal: 217(91.56%)
Physical Health -15 Mental Health -152 (64%) Rape/Incest -12 (5%)
• Foetal: 20 (8.43%) IUFD -11 Foetal malformation -9
B. Mental health -152 (64%)( by mental
health scoring)
Reasons for mental problem were-
•Multi parity 108Failed calendar method 49
Failed family planning 17
Financial 31 Age factor 5 Failed CAC 3 Failed MA 3
•Unmarried 10•Conceived when husband was away 8•Came with referral slip from psy 9•Miscellaneous 17
(Divorce, Got Visa, Last child is very small)
Age DistributionAge DistributionAge Percentage Gravida Percentage
Primi gravida 24.89
13- 19 yrs 9.29 Sec gravida 13.08
20 – 29 yrs 47.26 Third gravida 27.84
30 – 39 yrs 41.35 4th gravida 29.11
≥40 yrs 2.10 Grand Multip 5.06
Total No 100 Total No 100
Where did they come from?Where did they come from?
Medical No. Percent
Kathmandu valley 157 66.24
Other DistrictsPokhara, dharding, kavre, kailali,
biratnagar, sindhupalchowk, janakpur, dolkha, bhojpur, sankhuwasabha
taplejung etc
80 33.76
Education StatusEducation Status
Gestational Age by Clinical AssessmentGestational Age by Clinical Assessment
Contraceptive Use after ProcedureContraceptive Use after Procedure
Contraceptive After procedure
None 8.40%
D. provera 48.03%
Pills 12.25%
CuT 10.84%
Norplant 4.81%
Condom 12.25%
Permanent 3.51%
Total 100
ComplicationsComplicationsNo major complication No major complication
blood transfusion-blood transfusion- 1 (0.4%) 1 (0.4%)
USA case series from 1971 1981 (11,993) 11,747 women receiving
D&E from 13-26 weeks 20-21 weeks: 219 women 22-26 weeks: 27 women
Transfusion- 0.2% Cervical laceration- 1.0% Perforation- 0.4% (suspected or proven) Re-suction 0.2% Unplanned 1.0%
Hospitalization
ConclusionConclusion• Nepal seems to be a GLOBAL success
story• The strong working relationship between
the MoH, Ipas and other national and international partners with Strong government support- key to making safe abortion care a reality in Nepal.
• Coordination and strategic role of TCIC- program planning, monitoring, quality, national data - linkages with all government units
Conclusion• Development of national guideline is critically important
in any country, especially in settings where there is stigma surrounding abortion.”
• Good quality second trimester abortion services are achievable in even the most low-resource settings.
• Ultimately, improvements in second trimester abortion services will help to reduce abortion-related morbidity and mortality.
• More challenges ahead but seems to be a good beginning – need to work more with partners to meet the target.