Second trimester abortion in Nepal ------------------------

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Second trimester abortion in Nepal--------------
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• Dr. Veena Shrivastava
• President Elect
• Nepal Society Of Obstetricians Gynaecologists
• Nepal

Global Safe Abortion Conference , London 23rd
24th October, 2007
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Objectives

• Highlight current status of second trimester
  abortion in Nepal
• Share experience of the only training on
  comprehensive second trimester abortion services
  in Nepal

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Map of Asia
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Map of Nepal
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Legalization of abortion in Nepal

• Abortion became legal in 2002 (restrictive
  abortion).
• From March 2004 CAC service was started.
• 167 listed sites giving CAC service.

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Abortion Law according to 11th amendment of
Muluki Ain Sept ,2002

• On request- up to 12 weeks
• .
• Rape and incest, - up to 18 weeks
• Anytime with the approval by an authorized
  physician - foetus is abnormal
• - pregnancy posses the danger
  to the life of the pregnant woman or to her
  physical or mental health

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Case History

• Maya had been happily married for six
  months, when suddenly her husband disappeared .
  She realized that she is pregnant, but did not go
  for an abortion hoping that her husband would
  come back. After a couple of months she learnt
  that he cheated on her and already had a family.
  Devastated, she went to a chemist to get
  medicines for abortion. The chemist referred her
  to the maternity hospital where CAC was available
  at an affordable price.
•  
• The doctors at the maternity hospital found
  Maya to be over 20 weeks pregnant and denied to
  perform abortion on her. No one cared to
  understand the mental trauma she was undergoing.
  She had no option .She was ready to commit
  suicide rather than have the baby. Eventually a
  paramedic referred her to a private clinic who
  provided service at higher price. However, she
  started having torrential bleeding after the
  procedure. Again, she was referred to the
  maternity hospital, where she had to undergo
  hysterectomy.
• If only people had understood her situation....
•  
• If service providers were capable to assess
  her mental status for the indication of
  termination pregnancy, Maya would have been
  enjoyed her rights to safe abortion services.

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Post legalization of abortion status in Nepal

• MMR dropped from 539 to- 278/100,000 live
  births.
• 
  (NDHS-2006)
• No imprisonment of women due to induced abortion.
• Hospital admission for abortion complications
  unchanged (CAC PAC understanding
  complications NJOG Dr Sudha Dr Indira Dr
  Kasturi ).
• Report of four deaths due to abortion in news
  paper.

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Post legalization status

• 13-22 denied because their pregnancy was beyond
  12 weeks (National baseline survey CREHPA-2006).
• 61 of patients admitted with complication of
  abortion had 2nd trimester induced abortion
  (Study on maternal mortality morbidity among
  induced septic abortion 2006 ,Dr Achala).

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• Second trimester induced abortion is still a big
  health issue in Nepal.

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Second trimester abortion, where are we ?.

• Eighty three first trimester trainings have been
  conducted
• ( 374 Trained providers ).
• No second trimester abortion training - been
  organized.
• Providers not very clear about indications of
  late abortion.
• Clinicians are reluctant to perform second
  trimester abortion.
• Those who do perform - use old methods.

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• Need for second trimester abortion training was
  recognized by the government.

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First mid -trimester abortion TOT

• Training was organized by FHD, MOH with the
  support of TCIC on 10 -22 June 2007 in Maternity
  Hospital CAC Unit.

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Data During Mid-Trimester Training

• Total no of mid trimester abortions done during
  the training - 23
• Total no of first trimester abortions - 107

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Demographics of Mid trimester abortion

• Age distribution 14- 45 yrs
• Parity Nulliparous- 17
• Grand multi - 17
• Economic condition- poor (2-4 Per day)
• Education- 70 no education
• Home - 40 from remote
  area

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Reasons for abortion
Reason Number Percentage
Family. complete 17 73
Unmarried 2 8.6
Unwanted 1 4.3
Failed abortion (H) 1 4.3
Rape 1 4.3
Neurological Prob. 1 4.3
Total 23 100
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Duration of time from insertion of Misoprostol
to evacuation
Number No.of doses of Misoprostol Induction abortion interval
13 1 4-5hrs
5 2 7-9 hrs
1 3 12.5 hrs
Total No- 19
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Time taken for evacuation

• 15-20 minutes (one case - 30 minutes)

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Complications

• No major complications
• Minor - 3
• High Fever - 1 (1020F) admitted discharged next
  day
• Bleeding - 2 (1- cervical injury, 1- atony)

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Follow up

• No problem

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• First mid- trimester abortion training was
  successful.

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Future Plan

• Five mid trimester abortion trainings will be
  organized each year .
• All seventeen Zonal Hospitals will have trained
  doctors (Gynaecologists/ General practitioners )
• The training will follow Value Clarification
  workshop.
• Necessary instruments and medicines will be made
  available to them.

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Conclusion

• Second trimester abortion services has not been
  given priority so far in Nepal and is a major
  challenge in ensuring reproductive health rights
  of Nepalese women
• It also highlights that provision of law without
  implementation will not solve the problem
• Competency based training in second trimester
  abortion is very much feasible to implement and
  save womens lives from unsafe abortion

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Acknowledgment

• Marie Stopes International Specially Ms Rodica
  Comendent
• TCIC Nepal specially Dr Indira Basnet

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Thank you