No abstract

CONTEXT Although abortion has been legal under broad criteria in Nepal since 2002, a significant proportion of women continue to obtain illegal, unsafe abortions, and no national estimates exist of the incidence of safe and unsafe abortions. METHODS Data were collected in 2014 from a nationally representative sample of 386 facilities that provide legal abortions or postabortion care and a survey of 134 health professionals knowledgeable about abortion service provision. Facility caseloads and indirect estimation techniques were used to calculate the national and regional incidence of legal and illegal abortion. National and regional levels of abortion complications and unintended pregnancy were also estimated. RESULTS In 2014, women in Nepal had 323,100 abortions, of which 137,000 were legal, and 63,200 women were treated for abortion complications. The abortion rate was 42 per 1,000 women aged 15–49, and the abortion ratio was 56 per 100 live births. The abortion rate in the Central region (59 per 1,000) was substantially higher than the national average. Overall, 50% of pregnancies were unintended, and the unintended pregnancy rate was 68 per 1,000 women of reproductive age. CONCLUSIONS Despite legalization of abortion and expansion of services in Nepal, unsafe abortion is still common and exacts a heavy toll on women. Programs and policies to reduce rates of unintended pregnancy and unsafe abortion, increase access to high-quality contraceptive care and expand safe abortion services are warranted.

In Nepal, despite policy restrictions, both registered and unregistered brands of mifepristone and misoprostol can easily be obtained at pharmacies. Since many women visit pharmacies for abortion information, ensuring that they receive effective care from pharmacy workers remains an important challenge. We conducted an operations research study to examine whether trained pharmacy workers can correctly provide information on safe use of mifepristone and misoprostol for early first trimester medical abortion. Pharmacy workers in one district were given orientation and training using a harm-reduction approach, and compared with a non-equivalent comparison group in the second district. Overall, trained pharmacy workers' knowledge increased substantially, but no increase was found in the comparison group. Compared to the baseline (65%), 97% of trained pharmacy workers knew up to what stage of pregnancy and how women should use mifepristone and misoprostol. A higher percentage of pharmacy workers in the intervention group (77%) compared to the comparison group (49%) were knowledgeable at follow-up about determining whether an abortion was successful, implying a need for improving this aspect of training. As many mid-level health providers run their own pharmacies and offer medical abortion pills, it is important for the government to consider training these providers and registering their pharmacies as safe medical abortion service outlets.

The role of pharmacy workers as providers of correct and complete information on safe and effective use of MA needs to be recognized and policies formulated to allow them to provide MA drugs for first trimester use.

Medical abortion was introduced in Nepal in 2009, but rural women's access to medical abortion services remained limited. We conducted a district-level operations research study to assess the effectiveness of training 13 auxiliary nurse-midwives as medical abortion providers, and 120 female community health volunteers as communicators and referral agents for expanding access to medical abortion for rural women. Interviews with service providers and women who received medical abortion were undertaken and service statistics were analysed. Compared to a neighbouring district with no intervention, there was a significant increase in the intervention area in community health volunteers' knowledge of the legal conditions for abortion, the advantages and disadvantages of medical abortion, safe places for an abortion, medical abortion drugs, correct gestational age for home use of medical abortion, and carrying out a urine pregnancy test. In a one-year period in 2011-12, the community health volunteers did pregnancy tests for 584 women and referred 114 women to the auxiliary nurse-midwives for abortion; 307 women in the intervention area received medical abortion services from auxiliary nurse-midwives. There were no complications that required referral to a higher-level facility except for one incomplete abortion. Almost all women who opted for medical abortion were happy with the services provided. The study demonstrated that auxiliary nurse-midwives can independently and confidently provide medical abortion safely and effectively at the sub-health post level, and community health volunteers are effective change agents in informing women about medical abortion.