Second trimester abortion service is a very important component of safe abortion service. This is a very successful program in Nepal,

1. Establishing second
trimester abortion services:
Nepal’s experience
Dr. Chanda Karki
Prof and Head
Department of Ob/Gyn
Kathmandu Medical College Teaching Hospital

2. Abortion was strictly Many women were seeking
illegal and considered as unsafe abortion clandestinely
crime in unsafe environment.
Before 2003….
Abortion was not
accepted from
social, cultural
and religious
aspect
• Deaths (15-30% of MMR)
• Several years imprisonment (6 months- more than 5
years)
• Serious body injuries

3. TCIC produced a
series of national
Background standards and
guidelines that cover
Based on WHO Nepal’s
first- and second-
initial set of guidelines on
trimester abortion as
SAS was approved in
well as medical
2003.
abortion.
After 2002, an
Abortion Task
Force drafted a set The task force was
of strategies to ↑ then replaced by
access to safe TCIC.
abortion.

4. • Today, first trimester abortion care is
available in all 75 districts (MVA) and MA
in 16 districts .
• Transformation possible -development
and implementation of comprehensive
standards and guidelines for safe abortion
care
• Providers and facility managers
understand what standard of care is
expected
• They know they have a government
mandate to provide that care.

5. • Nearly 500,000 women have had safe, legal abortion care
in Nepal since passage of the 2002 law.
• In 2010,
Nepal received a Millennium Development Goal award
from the United Nations for its achievement in reducing
maternal mortality and morbidity.
• From 2000 to 2010, Nepal’s MMR dropped from 415 to
229 per 100,000 LB.
• The nationwide introduction of safe abortion care is
credited with being one of the major reasons for that

6. Legal Indications
• Up to 12 weeks by request
• Up to 18 weeks in the case of rape or
incest
• Any gestational age
1. Life threatening conditions mental or physical
conditions
2. Fetal abnormalities/malformation

7. National, facilitybased
Background study 2006 - 4,245
women (13% of those
Procedural order seeking abortion) were
allowing SAS denied abortion
published on services because they
December 2003 were more than 12
weeks pregnant.
First trimester
service started from
Country code Received the year 2004- 75
Royal Assent on districs/487 sites
September 2002

8. The key steps
• Advocacy efforts are often required to raise
awareness among key governmental and
health system stakeholders.
• Securing the necessary approvals- to
introduce or expand second trimester
services
• Selecting abortion methods,
• organizing facilities,

9. The key steps
• Obtaining necessary equipment and supplies
• Training Service providers including values
clarification;
• Monitoring and support -prevents burn-out
and ensures quality of care.
• Setting up and managing services, and
• Ensuring quality.

10. Advocacy, Approvals, Method
selection, site selection

11. Background STA sites were
The DDA approved MA identified
drugs (mifepristone
and misoprostol) for
induction
The protocols were
In 2008 the FHD, developed on both Trained senior Gyn &
decided that both surgical and medical Obs on abortion
medical abortion and induction as
D&E should be services
recommended by
offered at all tertiary the WHO
care facilities.

12. How to successfully provide high-quality
second-trimester abortion care?
• Site that offers 7 days 24 hour
CEOC services
• At least two obs/gyn competent
in CEOC and 1st trim CAC
• Provision of USG and WHO
recommended D&E set
• Provision of Incinerator, Pit for
waste management disposal

13. How to successfully provide high-
quality second-trimester abortion care?
• Providers receive two weeks of ‘’hands
on’’ training in MH & in KMC
• Each trained providers receive three
follow ups post training (at 6 weeks, 6
month and 12 month)
• Nursing staff receive orientation on FP
counseling, scheduling clients, IP &
waste disposal, recording/reporting and
follow up

14. VCAT workshop
• Essential requirement for sec tri training
• VCAT- whole site orientation on regular basis
to most of the facilities- on going program.

15. First batch of Training

17. National trainers

18. Service status(2008-2012)
18 sites listed for
providing services
48 Providers (Ob/Gyn & GP) trained as a
service providers
Instruments
provided to 10 sites
Within first one year around 474 women
were reported receiving safe and legal
abortion services (with around 90% of
contraceptive acceptance rate)

19. Site D&E MI Total
SZH 64 56 120
KMCTH 152 59 211
NMCTH 17 22 39
Bharatpur hospital 80 35 115
WRH, Pokhara 50 21 71
Lumbini Z H 75 30 105
Maternity Hospital 270 65 335
Model Hospital 33 102 135
Om Hospital 12 22 34
Surkhet Hospital 27 30 57
BPKIHS 75 98 173
Baglung Hospital 5 7 12
B and B Hospital 9 4 13
Medicare 0 8 8
18 sites 869 (61%) 559 (39%) 1428

20. Challenges
Information Reach Fees
Still many women do not have
Not able to reach poor women
information about services
Expensive
Value clarification
Equipments
and attitude
transformation
Delayed in getting
Developing local equipment
expert trainers takes
time
Follow up of trainees
can be difficult and
Transfer of trained time-consuming and
providers capacity to do so is
limited

21. Challenges
Regular Services Judgmental
Many sites services are not routine attitudes from staff
members
Prioritization of services
Least prioritized service
Waste disposal
management
Availability of illegal 2nd
trim providers Complications referral
Difficult for pvt sites
Bottom line: time and
resource intensive!

22. KMC-Service Status (2009-2012)
Safe abortion services
Total – 1848
First trimester -1611
Second
trimester - 237 (13%)
Service Provider – 5
Training Conducted - 4

23. D & E= 70%
Duration of D&E Medical Total
gestation (70%) induction
(wks)
12+ - 14 96% (91) 4% (4) 100% (95)
15-18 73% (76) 27% (28) 100% (104)
19 and 0% (0) 100% (38) 100% (38)
more

24. Indications
• Maternal: 217(91.56%)
Physical Health -15
Mental Health -152 (64%)
Rape/Incest -12 (5%)
• Foetal: 20 (8.43%)
IUFD -11
Foetal malformation -9

25. B. Mental health -152 (64%) ( by mental
health scoring)
Reasons for mental problem were-
•Multi parity 108
Failed calendar method 49
Failed family planning 17
Financial 31
Age factor 5
Failed CAC 3
Failed MA 3
•Unmarried 10
•Conceived when husband was away 8
•Came with referral slip from psy 9
•Miscellaneous 17
(Divorce, Got Visa, Last child is very small)

26. Age Distribution
Age Percentage Gravida Percentage
Primi gravida 24.89
13- 19 yrs 9.29 Sec gravida 13.08
20 – 29 yrs 47.26 Third gravida 27.84
30 – 39 yrs 41.35 4th gravida 29.11
≥40 yrs 2.10 Grand Multip 5.06
Total No 100 Total No 100

27. Where did they come from?
Medical No. Percent
Kathmandu valley 157 66.24
Other Districts 80 33.76
Pokhara, dharding, kavre, kailali,
biratnagar, sindhupalchowk, janakpur,
dolkha, bhojpur, sankhuwasabha
taplejung etc

28. Education Status

29. Gestational Age by Clinical Assessment

30. Contraceptive Use after Procedure
Contraceptive After procedure
None 8.40%
D. provera 48.03%
Pills 12.25%
CuT 10.84%
Norplant 4.81%
Condom 12.25%
Permanent 3.51%
Total 100

31. Complications
No major complication
blood transfusion- 1 (0.4%)
USA case series from 1971  Transfusion- 0.2%
 1981 (11,993)  Cervical laceration- 1.0%
 11,747 women receiving  Perforation- 0.4%
D&E from 13-26 weeks  (suspected or proven)
 20-21 weeks: 219 women
 Re-suction 0.2%
 22-26 weeks: 27 women
 Unplanned 1.0%
Hospitalization

32. Conclusion
• Nepal seems to be a GLOBAL success
story
• The strong working relationship between
the MoH, Ipas and other national and
international partners with Strong
government support- key to making safe
abortion care a reality in Nepal.
• Coordination and strategic role of TCIC-
program planning, monitoring, quality,
national data - linkages with all
government units

33. Conclusion
• Development of national guideline is critically important
in any country, especially in settings where there is
stigma surrounding abortion.”
• Good quality second trimester abortion services are
achievable in even the most low-resource settings.
• Ultimately, improvements in second trimester abortion
services will help to reduce abortion-related morbidity
and mortality.
• More challenges ahead but seems to be a good
beginning – need to work more with partners to meet
the target.