Broadening the base of providers offering safe abortion care

Monday, April 14, 2014

04-14-14 Broadening-SAC-providers

Once 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.”