a country with one of the world’s most restrictive abortion laws, Nepal
today offers safe and legal abortion services in each of its 75
districts. The expansion of safe abortion care is one of several
strategies that helped Nepal nearly halve its maternal mortality ratio
between 2000 and 2010.
A key factor in this transformation is the provision of abortion
services by a broad range of health workers. Access to health services
is a critical issue in Nepal, where many people live in geographically
remote areas where nurses, auxiliary nurse-midwives and community health
workers provide the bulk of reproductive health care.
“Most people here live in villages where
there are no private health services; they are marginalized. The only
providers in these villages are auxiliary nurse-midwives and
paramedics,” says midwife Meena Kumari Shrestha, Ipas Nepal program
advisor.
The evidence
is clear that the safety and effectiveness of abortion care by
providers such as nurses, nurse-midwives, clinical officers and other
cadres is equivalent to or sometimes better than care provided by
physicians. According to WHO,
“Abortion care can be safely provided by any properly trained
health-care provider, including midlevel (i.e. non-physician)
providers…Abortion care provided at the primary-care level and through
outpatient services in higher-level settings is safe, and minimizes
costs while maximizing the convenience and timeliness of care for the
woman.”
Ipas recognizes the concerns raised by the term
“midlevel,” which can be wrongly interpreted as implying that these
clinicians provide care that is of a lower standard than the care
rendered by physicians. Whenever possible, we refer to the specific
cadres under discussion, and use the term “midlevel” only when
discussing these providers collectively or to be consistent with
terminology used by some international bodies.
Worldwide, the number of unsafe abortions
continues to rise and is currently estimated at 21.6 million annually.
The Millennium Development Goals (MDGs) adopted by world leaders in 2000
recognize the need to address unsafe abortion under Goal 5 and achieve a
three-quarters reduction in maternal mortality by 2015. But a recent report from the United Nations
says progress in achieving MDG 5 is falling short and that “accelerated
interventions” are needed. One of the major barriers preventing women
from getting safe services is a lack of providers. Given the much higher
ratio of nurses, midwives and other cadres of providers to clients
compared with physicians to clients, expanding the number and type of
providers offering abortion-related care is key to ensuring women’s
access. These types of cadres far outnumber doctors in developing countries and are more likely to provide services to rural, poor or otherwise vulnerable women.
“We need to strengthen the capacity of health workers at all levels
of the health system to be able to provide life-saving abortion care for
women. It’s not just a matter of upgrading the skills of existing
providers; we also need to expand the number and types of providers
offering abortion,” says Virginia Chambers, Ipas health systems senior
advisor. “By expanding the base of abortion providers, countries can
reduce maternal mortality and provide broader access to universal
reproductive health, moving us toward achieving the MDG 5 goal.”
The need to expand the base of health workers was underscored in a
2013 report by WHO’s Global Health Workforce Alliance noting that the
world needs at least seven million more health workers, especially in
Africa and Asia, where abortion-related mortality is high. The report
specifically recommends “maximizing” the role of midlevel and community
health workers.
In Nepal, India, Nigeria and many other countries, Ipas is working to
find ways to expand the base of providers offering abortion-related
care and to include abortion care in academic training programs for
nurses, midwives, nurse practitioners, clinical officers and other
cadres of health workers.
One successful example is in Nigeria, which has the world’s second-highest rate of maternal mortality and where unsafe abortions are common.
Since 2003, Ipas has provided technical assistance to midwifery
training institutions throughout the country and trained hundreds of
midwifery educators to increase the capacity of nurse-midwives to
provide life-saving postabortion care. Graduates of university and
tutorial college nurse-midwifery programs in Nigeria now have accurate
information and skills on reproductive health, including safe abortion.
Building the capacity of tutors, midwives and other midlevel providers
in this way is crucial to improving women’s health.
“The full spectrum of health workers must be appropriately trained
and utilized in order to expand access to safe abortion services,”
according to a recent Ipas assessment of pre-service training programs
for midlevel providers in India, Nepal, Pakistan and Bangladesh. The
findings underscored that midlevel providers are essential for meeting
the demand for abortion care, in part because they are more numerous and
available than physicians in rural areas and in community-level health
facilities.
“Interventions at the community level have been shown to be
especially effective,” says Ipas’s Chambers. In Bangladesh, for
instance, where menstrual regulation (MR) has been part of the national
family planning program since 1979 as a method for establishing
“nonpregnancy after a missed period,” MR can be performed by
community-level Family Welfare Visitors and by trained paramedics. The
availability of MR throughout Bangladesh has contributed to a marked
decline in national maternal mortality. An Ipas assessment recommends
incorporating MR and postabortion care into pre-service training for
additional cadres to further contribute to improvements in maternal
health goals.
Ipas also is working for legal changes to expand the base of
providers of safe services. In India, for example, where a woman dies
every two hours from unsafe abortion, the current law basically permits
only physicians to provide abortion care. The base of providers could be
significantly increased by authorizing medical practitioners with
bachelor’s degrees in Unani, Ayurveda or Homeopathy to provide abortion
care. Studies in India in 2012 and 2011 demonstrate that manual vacuum aspiration and medical abortion can be provided as safely by nurses and ayurveds as physicians.
“Allowing midlevel providers to legally perform abortions is the next
big policy change that will significantly reduce needless deaths and
injuries resulting from unsafe abortion,” says Vinoj Manning, Ipas India
country director. “They are already involved in providing a range of
reproductive health services. Their existing technical skills can easily
be built upon to expand the availability, accessibility and quality of
early abortion care.”
At the upcoming International Confederation of Midwives Triennial Congress 2014, which will be held this June in Prague, the conference theme is maternal health, reflecting the challenge of meeting MDG 5. Ipas will be represented by a delegation of midwives from countries where Ipas offices and programs are located and also will sponsor a group of six young midwives who are committed to the inclusion of comprehensive abortion care as a part of midwifery practice. As one of those young women, a midwife in Nigeria, sums it up: “All hands must be on deck to fight the devastating enemy of unsafe abortion.”
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