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

Ipas, Chapel Hill, NC, USA.
Reproductive Health (Impact Factor: 1.88). 04/2012; 9(1):7. DOI: 10.1186/1742-4755-9-7
Source: PubMed


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.

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Available from: Alyson Hyman, Aug 05, 2015
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    • "A considerable proportion of these abortions are unsafe according to the World Health Organization (WHO) criteria [5]. In Nepal, where legal reforms were introduced in 2002, almost 500 000 safe abortions were performed between 2004 and 2011 [6]. "
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    ABSTRACT: Since 2008, the FIGO Initiative for the Prevention of Unsafe Abortion and its Consequences has contributed to ensuring the substitution of sharp curettage by manual vacuum aspiration (MVA) and medical abortion in selected hospitals in participating countries of South-Southeast Asia. This initiative facilitated the registration of misoprostol in Pakistan and Bangladesh, and the approval of mifepristone for “menstrual regulation” in Bangladesh. The Pakistan Nursing Council agreed to include MVA and medical abortion in the midwifery curriculum. The Bangladesh Government has approved the training of nurses and paramedics in the use of MVA to treat incomplete abortion in selected cases. The Sri Lanka College of Obstetricians and Gynaecologists, in collaboration with partners, has presented a draft petition to the relevant authorities appealing for them to liberalize the abortion law in cases of rape and incest or when lethal congenital abnormalities are present. Significantly, the initiative has introduced or strengthened the provision of postabortion contraception.
    Full-text · Article · Jul 2014 · International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics
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    • "Legalized abortion in Nepal has presented an unprecedented opportunity for dispensing contraceptives to women at risk of unintended pregnancy. Considerable progress has been made to provide comprehensive family planning services after abortion [1], yet important challenges remain. Efforts to increase the range of methods discussed might improve uptake. "
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    ABSTRACT: Objective To assess the contraceptive information received and methods chosen, received, and used among women having abortions one decade after legalization of abortion in Nepal. Methods We examined postabortion contraception with questionnaires at baseline and six months among women obtaining legal abortions (n = 838) at four facilities in 2011. Multivariate regression analysis was used to measure factors associated with method information, choice, receipt, and use. Results One-third of participants received no information on effective methods, and 56% left facilities without a method. The majority of women who chose to use injectables and pills were able to do so (88% and 75%, respectively). However, only 44% of women choosing long-acting reversible contraceptives and 5% choosing sterilization had initiated use of the method by six months. Levels of contraceptive use after medical abortion were on par with those after aspiration abortion. Nulliparous women were far less likely than parous women to receive information and use methods. Women living without husbands or partners were also less likely to receive information and supplies, or to use methods. Conclusion Improvements in postabortion counseling and provision are needed. Ensuring that women choosing long-acting and permanent contraceptive methods are able to obtain either them or interim methods is essential.
    Full-text · Article · Jan 2014
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    • "At a social level, examples from Nepal showed the success of widespread advocacy campaigns and information about where to access safe-abortion services and a national logo was developed that was displayed on all facilities offering the services [49]. Political will and widespread provider support were also key to achieving this in Nepal; however, these are currently lacking in Ghana. "
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    ABSTRACT: Unsafe abortion is a major public health problem in Ghana; despite its liberal abortion law, access to safe, legal abortion in public health facilities is limited. Theory is often neglected as a tool for providing evidence to inform better practice; in this study we investigated the reasons for poor implementation of the policy in Ghana using Lipsky's theory of street-level bureaucracy to better understand how providers shape and implement policy and how provider-level barriers might be overcome. In-depth interviews were conducted with 43 health professionals of different levels (managers, obstetricians, midwives) at three hospitals in Accra, as well as staff from smaller and private sector facilities. Relevant policy and related documents were also analysed. Findings confirm that health providers' views shape provision of safe-abortion services. Most prominently, providers experience conflicts between their religious and moral beliefs about the sanctity of (foetal) life and their duty to provide safe-abortion care. Obstetricians were more exposed to international debates, treaties, and safe-abortion practices and had better awareness of national research on the public health implications of unsafe abortions; these factors tempered their religious views. Midwives were more driven by fundamental religious values condemning abortion as sinful. In addition to personal views and dilemmas, 'social pressures' (perceived views of others concerning abortion) and the actions of facility managers affected providers' decision to (openly) provide abortion services.In order to achieve a workable balance between these pressures and duties, providers use their 'discretion' in deciding if and when to provide abortion services, and develop 'coping mechanisms' which impede implementation of abortion policy. The application of theory confirmed its utility in a lower-middle income setting and expanded its scope by showing that provider values and attitudes (not just resource constraints) modify providers' implementation of policy; moreover their power of modification is constrained by organisational hierarchies and mid-level managers. We also revealed differing responses of 'front line workers' regarding the pressures they face; whilst midwives are seen globally as providers of safe-abortion services, in Ghana the midwife cadre displays more negative attitudes towards them than doctors. These findings allow the identification of recommendations for evidence-based practice.
    Full-text · Article · Jul 2013 · Health Research Policy and Systems
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