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.