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, PortugalMarch 2-4, 2010

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

… Services – public & private

Female CH Volunteers - 48,000

Sub Health Posts – 3126

Health Posts- 677

Primary Health Center -35/209

Public hospitals- 89, NGOs & private clinics

=106Specialized hospitals-14

Tertiary level maternity hospital-1

Ce

MA

MVA2nd Tri

Project managementIpas/TCIC

Policy

Advocacy

IEC materials development

Training

Service delivery

Productavailability

OperationsResearch

Sun Pharma

PSI, Concept

MoHP

All listed CAC service providersPublic & private

MoHP

MoHP

MOHP Professional obs/gyn

society

Ipas

Gynuity

CREHPA

Training curriculum

development

MoHP

Regional/districthealth authorities

Ipas

PSI and Ipas

Clinical trial&

Introductory Period

2007-2009

Integrating MA to all approved centres (public, NGOs and

private)

An incremental and systematic approach to scaling up MA

Community midwives -SBAs & CEM for EE

Private sector and pharmacists

FCHVs -counselors

FCHVs –counselors

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

% of MA v/s MVA

Client chose MA

Pilot (Dec 15’08-June 15’ 09) Post pilot (June 15-Dec 15’09)

1718 2563

Medical abortion scale up strategy approved in November 2009

Source: HMIS/MoHP 2008-2009

Outcomes of medical abortion

Source: HMIS/MoHP 2008-2009

Pilot (n= 1718Dec 2008- June

2009)

Post Pilot (n= 2563 June –

December 2009)

Number and percent of clients requiring blood transfusion

2(0.1%) 0

Number and percent of clients with suspected infections

8(0.5%) 4(0.15)

Number and percent of clients with ultrasound

2(1%) 0

Post MA complications & 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 learnedClient’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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