Introduction of second trimester medical abortion to rural Nepal: a demonstration project
ESC Congress Library. Edelman A. 05/28/14; 50455; A-038 Disclosure(s): The research was support by Ipas; the authors are either employees or consultants of Ipas. Dr. Edelman otherwise has no disclosures specific to this research but is a consultant to the U.S. CDC, WHO, and FDA; receives grant funding from USAID, Gates Foundation, and the NIH; receives royalties as an author for UpToDate; and is a trainer for Merck (Nexplanon).
Assoc. Prof. Alison Edelman
Assoc. Prof. Alison Edelman
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Abstract
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Objectives:  In Nepal, abortion was legalized in 2002 permitting it for any reason up to 12 weeks, for rape or incest up to 18 weeks and for maternal or fetal indications at any gestational age.  First trimester abortion services became more readily available in 2004 but second trimester services remained extremely limited.  In 2007, Ministry of Health and Population, Nepal and Ipas Nepal collaborated to increase access to safe second trimester services [dilation and evacuation (D&E) and medical (mifepristone followed by misoprostol)].  To this day, twenty one second trimester abortion sites have been established; however, all of these sites are in the hill and lowland regions.  Expansion to remote, mountainous sites with lower patient volume has not been attempted due to concerns regarding the ability to safely provide D&E.  Modeled after Ipas's successful second trimester medical abortion-only program in Ethiopia, we sought to pilot a similar program at one site in the remote mountainous region of Nepal.  


Methods: A standardized medical abortion regimen utilizing mifepristone and misoprostol (WHO 2012) was introduced at one site in Nepal.  The program consisted of a site assessment, whole site values clarification workshop,   team-based clinical training, and post-training follow-up and supportive supervision. Patient characteristics, success rates and complications were tracked using logbooks and findings were augmented through an onsite support and quality assurance visit.  Key findings are presented here.


Results: Prior to this pilot, no routine second trimester services were being offered in this region and women were told to cross into India to receive care.  The hospital team (1 physician and 1 nurse) underwent training in March 2013.  Over a 6 month period, the team cared for 25 women.  The characteristics of the women seeking care were as follows: mean age 28 years old (SD 6.8), 72% were parous, mean gestational age 16.6 weeks (SD 3.5), and the most common indication for abortion was mental health (72%).  Twenty four women (96%) experienced successful uncomplicated abortions while one woman desired D&E and was referred following no expulsion in 48 hours. The median time to expulsion was 6.5 hours (range 3.25 to 66.25 hours) with an average of 2 doses of misoprostol. 


Conclusions: Introduction of second trimester medical abortion can increase access in areas where D&E may not be feasible.  Women offered this service had high success and low complication rates. 


 

Objectives:  In Nepal, abortion was legalized in 2002 permitting it for any reason up to 12 weeks, for rape or incest up to 18 weeks and for maternal or fetal indications at any gestational age.  First trimester abortion services became more readily available in 2004 but second trimester services remained extremely limited.  In 2007, Ministry of Health and Population, Nepal and Ipas Nepal collaborated to increase access to safe second trimester services [dilation and evacuation (D&E) and medical (mifepristone followed by misoprostol)].  To this day, twenty one second trimester abortion sites have been established; however, all of these sites are in the hill and lowland regions.  Expansion to remote, mountainous sites with lower patient volume has not been attempted due to concerns regarding the ability to safely provide D&E.  Modeled after Ipas's successful second trimester medical abortion-only program in Ethiopia, we sought to pilot a similar program at one site in the remote mountainous region of Nepal.  


Methods: A standardized medical abortion regimen utilizing mifepristone and misoprostol (WHO 2012) was introduced at one site in Nepal.  The program consisted of a site assessment, whole site values clarification workshop,   team-based clinical training, and post-training follow-up and supportive supervision. Patient characteristics, success rates and complications were tracked using logbooks and findings were augmented through an onsite support and quality assurance visit.  Key findings are presented here.


Results: Prior to this pilot, no routine second trimester services were being offered in this region and women were told to cross into India to receive care.  The hospital team (1 physician and 1 nurse) underwent training in March 2013.  Over a 6 month period, the team cared for 25 women.  The characteristics of the women seeking care were as follows: mean age 28 years old (SD 6.8), 72% were parous, mean gestational age 16.6 weeks (SD 3.5), and the most common indication for abortion was mental health (72%).  Twenty four women (96%) experienced successful uncomplicated abortions while one woman desired D&E and was referred following no expulsion in 48 hours. The median time to expulsion was 6.5 hours (range 3.25 to 66.25 hours) with an average of 2 doses of misoprostol. 


Conclusions: Introduction of second trimester medical abortion can increase access in areas where D&E may not be feasible.  Women offered this service had high success and low complication rates. 


 

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