Scaling Up MA within the Context of SA Services in Nepal
description
Transcript of Scaling Up MA within the Context of SA Services in Nepal
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.