Implementation of legal abortion in Nepal: a model for rapid scale-up of high-quality care

Unsafe abortion's significant contribution to maternal mortality and morbidity was a critical factor leading to liberalization of Nepal's restrictive abortion law in 2002. Careful, comprehensive planning among a range of multisectoral stakeholders, led by Nepal's Ministry of Health and Population, enabled the country subsequently to introduce and scale up safe abortion services in a remarkably short timeframe. This paper examines factors that contributed to rapid, successful implementation of legal abortion in this mountainous republic, including deliberate attention to the key areas of policy, health system capacity, equipment and supplies, and information dissemination. Important elements of this successful model of scaling up safe legal abortion include: the pre-existence of postabortion care services, through which health-care providers were already familiar with the main clinical technique for safe abortion; government leadership in coordinating complementary contributions from a wide range of public- and private-sector actors; reliance on public-health evidence in formulating policies governing abortion provision, which led to the embrace of medical abortion and authorization of midlevel providers as key strategies for decentralizing care; and integration of abortion care into existing Safe Motherhood and the broader health system. While challenges remain in ensuring that all Nepali women can readily exercise their legal right to early pregnancy termination, the national safe abortion program has already yielded strong positive results. Nepal's experience making high-quality abortion care widely accessible in a short period of time offers important lessons for other countries seeking to reduce maternal mortality and morbidity from unsafe abortion and to achieve Millennium Development Goals

A prospective study of complications from comprehensive abortion care services in Nepal

<p>Abstract</p> <p>Background</p> <p>In March 2002, Nepal's Parliament approved legislation to permit abortion on request up to 12 weeks of pregnancy. Between 2004 and 2007, 176 comprehensive abortion care (CAC) service sites were established in Nepal, leading to a rise in safe, legal abortions. Though monitoring systems have been developed, reporting of complications has not always been complete or accurate. The purpose of this study was to report the frequency and type of abortion complications arising from CAC procedures in different types of facilities in Nepal.</p> <p>Methods</p> <p>A total of 7,386 CAC clients from a sample of facilities across Nepal were enrolled over a three-month period in 2008. Data collection included an initial health questionnaire at the time of abortion care and a follow-up questionnaire assessing complications, administered two weeks after the abortion procedure. A total of 7,007 women (95%) were successfully followed up. Complication rates were assessed overall and by facility type. Multivariable logistic regression was used to assess the association between experiencing a complication and client demographic and facility characteristics.</p> <p>Results</p> <p>Among the 7,007 clients who were successfully followed, only 1.87% (n = 131) experienced signs and symptoms of complications at the two-week follow up, the most common being retained products of conception (1.37%), suspected sepsis (0.39%), offensive discharge (0.51%) and moderate bleeding (0.26%). Women receiving care at non-governmental organization (NGO) facilities were less likely to experience complications than women at government facilities, adjusting for individual and facility characteristics (AOR = 0.18; 95% CI: 0.08-0.40). Compared to women receiving CAC at 4-5 weeks gestation, women at 10-12 weeks gestation were more likely to experience complications, adjusting for individual and facility characteristics (AOR = 4.21; 95% CI: 1.38-12.82).</p> <p>Conclusions</p> <p>The abortion complication rate in Nepali CAC facilities is low and similar to other settings; however, significant differences in complication rates were observed by facility type and gestational age. Interventions such as supportive supervision to improve providers' uterine evacuation skills and investment in equipment for infection control may lower complication rates in government facilities. In addition, there should be increased focus on early pregnancy detection and access to CAC services early in pregnancy in order to prevent complications.</p

Community Based Maternal and Child Health Care in Nepal : Self-Reported Performance of Maternal and Child Health Workers

The performance of a sample of 112 refresher trained Maternal and Child Health Workers (MCHW) was assessed over a nine-month period, using a self-reporting questionnaire. The findings show that the MCHWs are providing obstetric services, including antenatal care, birth attendance and postnatal and newborn care, at community level and identifying complications for referral, but their productivity levels are very low, particularly in the remote hill areas, where they are most needed. In order to increase their effectiveness, greater emphasis needs to be placed on the creation of an enabling environment, both in terms of professional support and recognition at community level. This requires more technical and logistical backup and the promotion of greater awareness amongst women and their families about the importance of midwifery care and skilled birth attendance. Key Words: Skilled attendance, enabling environment, performance

Determination of medical abortion success by women and community health volunteers in Nepal using a symptom checklist

Abstract Background We sought to determine if female community health volunteers (FCHVs) and literate women in Nepal can accurately determine success of medical abortion (MA) using a symptom checklist, compared to experienced abortion providers. Methods Women undergoing MA, and FCHVs, independently assessed the success of each woman’s abortion using an 8-question symptom checklist. Any answers in a red-shaded box indicated that the abortion may not have been successful. Women’s/FCHVs’ assessments were compared to experienced abortion providers using standard of care. Results Women’s (n = 1153) self-assessment of MA success agreed with abortion providers’ determinations 85% of the time (positive predictive value = 90, 95% CI 88, 92); agreement between FCHVs and providers was 82% (positive predictive value = 90, 95% CI 88, 92). Of the 92 women (8%) requiring uterine evacuation with manual vacuum aspiration (n = 84, 7%) or medications (n = 8, 0.7%), 64% self-identified as needing additional care; FCHVs identified 61%. However, both women and FCHVs had difficulty recognizing that an answer in a red-shaded box indicated that the abortion may not have been successful. Of the 453 women with a red-shaded box marked, only 35% of women and 41% of FCHVs identified the need for additional care. Conclusion Use of a checklist to determine MA success is a promising strategy, however further refinement of such a tool, particularly for low-literacy settings, is needed before widespread use

Determination of medical abortion eligibility by women and community health volunteers in Nepal: A toolkit evaluation.

To determine if pregnant, literate women and female community health volunteers (FCHVs) in Nepal can accurately determine a woman's eligibility for medical abortion (MA) using a toolkit, compared to comprehensive abortion care (CAC) trained providers.We conducted a prospective diagnostic accuracy study in which women presenting for first trimester abortion, and FCHVs, independently assessed each woman's eligibility for MA using a modified gestational dating wheel to determine gestational age and a nine-point checklist of MA contraindications or cautions. Ability to determine MA eligibility was compared to experienced CAC-providers using Nepali standard of care.Both women (n = 3131) and FCHVs (n = 165) accurately interpreted the wheel 96% of the time, and the eligibility checklist 72% and 95% of the time, respectively. Of the 649 women who reported potential contraindications or cautions on the checklist, 88% misidentified as eligible. Positive predictive value (PPV) of women's assessment of eligibility based on gestational age was 93% (95% CI 92, 94) compared to CAC-providers' (n = 47); PPV of the medical contraindications checklist and overall (90% [95% CI 88, 91] and 93% [95% CI 92, 94] respectively) must be interpreted with caution given women's difficulty using the checklist. PPV of FCHVs' determinations were 93% (95% CI 92, 94), 90% (95% CI 89,91), and 93% (95% CI 91, 94) respectively.Although a promising strategy to assist women and FCHVs to assess MA eligibility, further refinement of the eligibility tools, particularly the checklist, is needed before their widespread use

Women’s self-assessments of their overall eligibility, eligibility based on gestational age determination using the dating wheel, and medical eligibility using the checklist for MA drug use compared to CAC-provider’s determinations of their eligibility based on standard of care.

<p>Women’s self-assessments of their overall eligibility, eligibility based on gestational age determination using the dating wheel, and medical eligibility using the checklist for MA drug use compared to CAC-provider’s determinations of their eligibility based on standard of care.</p

Clinical risk for the 482 women (15% of n = 3113) who were determined to be ineligible for medical abortion by comprehensive abortion care providers.

<p>Clinical risk for the 482 women (15% of n = 3113) who were determined to be ineligible for medical abortion by comprehensive abortion care providers.</p

FCHV’s assessments of a woman’s overall eligibility, eligibility based on gestational age determination using the dating wheel, and medical eligibility using the checklist for MA drug use compared to CAC-provider’s determinations of their eligibility based on standard of care.

<p>FCHV’s assessments of a woman’s overall eligibility, eligibility based on gestational age determination using the dating wheel, and medical eligibility using the checklist for MA drug use compared to CAC-provider’s determinations of their eligibility based on standard of care.</p

Contraindications and cautions (conditions that require further evaluation by a CAC-provider before MA drug use) reported by women or determined by CAC-provider (n = 42^a).

<p>Contraindications and cautions (conditions that require further evaluation by a CAC-provider before MA drug use) reported by women or determined by CAC-provider (n = 42<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0178248#t003fn001" target="_blank">^a</a>).</p