1. 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.

2. 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.

3. 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.

4. … 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

5. 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

6. 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
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

7. 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

8. Counseling and IEC materials
Counseling materials
Client & stakeholder brochures

9. 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

10. 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

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

12. Post MA complications & USG
Pilot (n= 1718
Dec 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

13. Lessons learned
System related: (MA pilot findings 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

14. Lesson learned
Client’s perspectives: (client exit interview in 36 MA pilot sites 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)

15. Lessons learned
Service provider’s (physicians and nurses) perspectives: (interview with 68 trained providers on MA 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 ??

16. 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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