Getting to hard to reach places: expanding access to rural Nepal through nurse provision of first trimester medical abortion
Alison Edelman1, Kusum Thapa2, Deeb Shrestha Dangol2, Indira Basnett2 1Ipas, Chapel Hill, North Carolina, USA, 2Ipas Nepal, Kathmandu, USA - firstname.lastname@example.org
In Nepal, abortion was legalized in 2002. It is permitted for any reason 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. However, Nepal is a country of extremes with mountainous regions that are challenging to access and areas that are impassable at certain times of the year. Health care services are also limited by the number and type of provider. Creating access for women seeking life-saving care such as safe abortion and contraceptive services entails innovative strategies including task sharing. The Nepali Ministry of Health and Ipas have been working to increase abortion access in these hard to reach places. A pilot project was performed in 2010-2012 to train auxiliary nurse midwives (ANMs) from primary health centres/health posts in first trimester medical abortion (MA). As of June 2012, 216 ANMs were trained. Following training, 89% (233) have provided MA with 6056 women served [mean 4.6 women/month (SD=3.3)]. Overall service quality was high; 100% of women received pain management and 88% received postabortion contraception. Perceived enabling factors for MA provision identified by providers and facility managers included community awareness through media and volunteers, well-established referral mechanisms, support by facility administration and clients' beliefs about MA. Similarly, perceived barriers included a stable supply of MA drugs and equipment, insufficient counselling areas, inability to manage severe complications, medication costs and service disruption due to transfer of trained providers. Overall, 98% of women reported being very/mostly satisfied with services. Expanding the abortion provider base to include ANMs has increasing availability of safe services to Nepal's predominantly rural population. With the success of this pilot project, the Nepali government has incorporated the training of ANMs in MA into their national curriculum.
The quest for the optimal regimen for pain control for first trimester surgical abortion is ongoing. The desired characteristics of an optimal regimen include safety, efficacy, relatively inexpensive cost, and easy to administer. Although paracervical blocks and nonsteroidal anti-inflammatory medication in combination with non-pharmacologic methods (heating pad, support person) fulfil these criteria - many women still experience significant levels of pain during their procedure. To complicate matters, many clinicians have strong feelings that their pain regimen approach is best but as clinicians have been shown to underestimate the amount of pain women are experiencing, rigorous testing of these regimens are needed.
Finally, a woman’s perception of pain is complex with both physical and psychosocial elements that have been associated with higher levels of pain including parity, age, and anxiety levels. The current literature will be discussed as well as a brief review of the pathophysiology of abortion-related pain, patient characteristics associated with increased levels of pain, a practical approach to care and research gaps.
Abortion in women with haematological disease
Oregon Health & Science University, Portland, Oregon, USA
Controversy exists regarding the management of haematological diseases in women undergoing abortion. However, the overall risk of either haemorrhage or thrombosis is extremely rare in women undergoing abortion; as such, little change is likely to be necessary in the management of these women other than increased vigilance. Consideration of clinical setting, availability of emergency resources and gestational age may influence clinical management but will vary with the type and severity of the disorder and its risk of "bleeding" or "clotting". Anecdotally clinicians prefer aspiration or surgical abortion over medical in women at risk for bleeding because of the ability to control and monitor bleeding directly. As pregnancy exponentially increases the risk of thrombosis, a woman's choice to end the pregnancy returns her risk back to baseline. Measures to prevent bleeding and clotting and the evidence behind them will also be included. Finally, one of the most important aspects of the care for women with haematological diseases is the prevention of and planning for the next pregnancy as well as the non-contraceptive benefits that can be obtained from the use of a contraceptive method for these women. The current literature will be discussed as well as a brief review of the common haematological disorders likely to be encountered and a practical approach to the clinical management of these patients.