scaling up ma within the context of sa services in nepal indira basnett, md, mph ipas/nepal country...
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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.
