Scaling Up MA within the Context of SA Services in Nepal Indira Basnett, MD, MPH Ipas/Nepal Country Director Expanding Access to Medical Abortion: Building on Two Decades of Experience Lisbon, Portugal March 2-4, 2010 Namaste and thank you very much for giving me this opportunity to share our experiences on scaling up MA within the context of SA serivces in Nepal.

Background in Nepal Maternal Mortality Ratio was 539/100,000 live births in 1996 The abortion was legalized in 2002 Before legalization, 50% of all maternal deaths were due to abortion related complications The latest MMR (2008) is 281/100,000 Nepal’s target is to reduce MMR to 134 by 2015 The road to reform very strict and decade old law was a long one - spanning over three decades. The primary rationale for liberalization of the law was to improve maternal health and well being. The new law permits termination of an unwanted pregnancy abortion on ‘’all grounds’’ thus making Nepal one of the 55 countries in the world where abortion ‘’ on request’’ is permitted, here in this slide we can see the impact of abortion legalization on high MMR in Nepal.

Our working modality is public-private partnership and you can see there within seven yrs of post legalization we have 245 government approved sites for offering MVA, 10 sites for 2nd trim, and in 36 sites we have introduced. Our population is 27 mln and according to Ipas SAC indicators, we have achieved the minimum recommended amount of SA care sites. However, mostly of them are located in urban and the semi urban areas so the distribution of sites are not equitable in terms of rural and urban population. Our government recongnised the gaps and urged all stakeholders working in the areas of abortion to develop a strategy to reach to the unreached women.

… Services – public & private Female CH Volunteers - 48,000 Sub Health Posts – 3126 MA Health Posts- 677 Primary Health Center -35/209 Public hospitals- 89, NGOs & private clinics =106 MVA 2nd Tri This is our health structure. The blue areas show the number of health facilities offering 1st and 2ndtrim abortion while the yellow areas are not offering any abortion services. On the top there are female community health volunteers helping women to confirm their pregnancy, counseling and making timely referral. Specialized hospitals-14 Tertiary level maternity hospital-1 Ce

All listed CAC service providers Advocacy MoHP Training curriculum development MoHP Policy MOHP Professional obs/gyn society Ipas IEC materials development MoHP Service delivery Regional/district health authorities Project management Ipas/TCIC PSI and Ipas All listed CAC service providers Public & private Training Operations Research So in 2008 the MoHP invited all concerned stakeholders and requested to develop an introductory strategy on MA, an agreement was developed on the roles/responsibilities. Gynuity MoHP Product availability Sun Pharma Ipas CREHPA PSI, Concept

An incremental and systematic approach to scaling up MA Integrating MA to all approved centres (public, NGOs and private) Community midwives -SBAs & CEM for EE FCHVs - counselors Clinical trial & Introductory Period 2007-2009 This slide shows an incremental and systematic approach to scaling up MA. In 2009 August MoHP conducted a workshop with the purpose of reviewing introductory period findings and recommending a scale up strategy. We are thankful to CF, Gynuity and WHO for supporting us to make our MA scale up strategy inclusive and evidence based. 1st-all approved sites will offer both ( MVA and MA), the focus of health system is to train SBAs only on MA who are located in the community, they are also skilled in using MVA for PAC. CEM-Community engagement & mobilisation ( pregnancy detection and early referrals through FCHVs). Private sector and pharmacists

FCHVs –counselors Key points: FCHVs found training relevant to their job They felt UPT- is easy to use and have sustainable approach to resupply the product Aim of preparing FCHVs to confirm pregnancy by using low technology urine pregnancy tests and to refer women for appropriate services Enables women to make timely decisions through the following approaches: - first step - confirm that they are pregnant, - second step - counsel them for early antenatal care in the case of wanted pregnancy or, - third step - counsel them for early abortion in the case of confirmed unwanted pregnancy, however, - fourth step - if not pregnant then to refer them for family planning services FCHVs learning how to use urine tests for early detection of pregnancy Training materials for FCHVs

Counseling and IEC materials Counseling materials Client & stakeholder brochures

Referral Card and Safe Abortion Logo Key Points: This referral card was provided to FCHVs and referral was made according to the choices of women. This logo is a branding symbol of safe abortion care

Post pilot (June 15-Dec 15’09) % of MA v/s MVA Medical abortion scale up strategy approved in November 2009 Among women having abortion, the % of women choosing medical abortion rose impressively. Client chose MA Pilot (Dec 15’08-June 15’ 09) Post pilot (June 15-Dec 15’09) 1718 2563 Source: HMIS/MoHP 2008-2009

Outcomes of medical abortion The success rate was more during the post pilot period, as the service providers gained confidence. Source: HMIS/MoHP 2008-2009

Post MA complications & USG Pilot (n= 1718 Dec 2008- June 2009) Post Pilot (n= 2563 June –December 2009) Number and percent of clients requiring blood transfusion 2(0.1%) Number and percent of clients with suspected infections 8(0.5%) 4(0.15) Number and percent of clients with ultrasound 2(1%) The complications were minor during the both periods pilot and post pilot, and I would like to highlight here that during post pilot there was no USG. Source: SA logbook & client profile record 2008-2009

Lessons learned System related: (MA pilot findings 2008-2009 in six districts) Government leadership encourages public-private-NGOs partnership Approved protocol protects providers for any adverse events Training MLPs (RN and ANMs) ensures women friendly clinic Female community health volunteers empower women to make timely decision for their RH needs MA drug availability & distribution is possible through the public-private system ‘’No blame approaches’’ for auditing AEs inspires team spirit and strengthens the capacity of health facility to handle complicated cases

Lesson learned Client’s perspectives: (client exit interview in 36 MA pilot sites 2008-2009 in six districts) Consulting FCHVs to confirm their suspected pregnancy MA service delivery closer to their community Telephonic conversation for assessing abortion status (complete/incomplete) Women with Prolapse Uterus prefer (non vaginal route)

Lessons learned Service provider’s (physicians and nurses) perspectives: (interview with 68 trained providers on MA 2008-2009 from six pilot districts) Feel confident minimum with 20 MA cases Understanding a difference between ‘’process’’ vs ‘’procedure’’ is critical Training should be combined with clinical practicum and with real clients How to handle women seeking TOP with HIV positive and undergoing TB treatment ??

Conclusion The success rate without USG and routine hemoglobin test in a population with high prevalence of anemia is an example of great importance for MA implementation in other low resource countries.

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