Expanding comprehensive abortion care into the second trimester: Challenges and successes

Thursday, March 12, 2015

health-care providers

Provision of safe, high-quality second-trimester abortion care would save the lives of thousands of women each year. While second-trimester abortions are only a small percentage of all abortions worldwide, the majority of abortion-related deaths and injuries occur in the second trimester of pregnancy. Yet, in many parts of the world, safe second-trimester services remain limited or nonexistent.

“Second-trimester service provision comes with a unique set of issues, such as the technical expertise needed and the heightened stigma of second-trimester abortion,” says Alison Edelman, an obstetrician/gynecologist and technical consultant with Ipas. 

In addition, Edelman says, women most likely to need second-trimester care are among the most vulnerable and disenfranchised—poor, young, uneducated, suffering from severe medical issues, living in remote areas, or survivors of sexual violence. They are not able to overcome the many barriers to getting safe, first-trimester care--such as prohibitive costs, timely recognition or disclosure of a pregnancy, or lack of knowledge about the availability of safe services--and often do not arrive at health-care facilities until they have passed the 12-week mark.

“Young women, in particular, are more likely to need second-trimester services compared to older women because they may not realize they are pregnant in the early stages or may be hiding the pregnancy out of fear and shame,” she says.

As Dr. David Grimes, former chief of the abortion surveillance branch at the Centers for Disease Control in the United States, has written: “Late abortion concerns women in difficult circumstances.”

Ipas is committed to making second-trimester abortion services available to all women who need them and has developed second-trimester programming in accordance with the World Health Organization’s safe abortion guidance.  Ipas also has developed a second-trimester abortion toolkit for service delivery, which is available online.

Ipas’s successful second-trimester programs include programs in Ethiopia and Nepal, where Ipas has worked with the national ministries of health to design and implement comprehensive, structured programs that have significantly increased women’s access to second-trimester care. These programs are highlighted in articles recently published in Contraception and the International Journal of Gynecology and Obstetrics

Second-trimester medical abortion in Ethiopia

Ethiopia has one of the highest maternal mortality rates in the world, with unsafe abortion as a major contributor. The Guttmacher Institute reported in 2010 that almost 60 percent of abortions in Ethiopia are unsafe.  The country liberalized its abortion law in 2005 to combat maternal mortality by expanding access to safe abortion care. Abortion is legal through 28 weeks for several indications, including rape, incest, fetal anomaly and endangerment of the health of the mother. 

study of abortion-related complications in Ethiopia, published in International Perspectives on Sexual and Reproductive Health, estimates that, in 2008, 100 women died in health facilities from abortion complications, with 87 of the deaths occurring among women in the second trimester of pregnancy.

In 2010, Ipas began working with the federal Ministry of Health (FMOH) to expand second-trimester medical abortion using the WHO-recommended regimen of mifepristone and misoprostol. The program included technical trainings, needs assessments and meetings with key stakeholders.

“This systematic approach has allowed us to successfully introduce second-trimester medical abortion services into all major states and regions of Ethiopia,” says Dr. Yonas Getachew, senior advisor for Ipas Ethiopia. “Because we focused on medical abortion, we were able to achieve rapid service introduction without extensive changes to facilities, equipment or staffing.”

During the period from October 2010 to December 2013, the program provided eight clinical trainings for health professionals from 23 hospitals—opening the way for more than 7,000 women to access second-trimester medical abortion services.

“Second-trimester services are part of the continuum of abortion care. Comprehensive care means serving the needs of women as early as possible and as late as necessary,” says Getachew.

Rapid expansion in Nepal

In Nepal, abortion was illegal for any reason as recently as 15 years ago. Women who sought abortions were sometimes prosecuted and imprisoned. In 2002, Nepal legalized abortion, including services for up to 18 weeks for rape or incest, and at any gestational age for maternal mental or physical health or fetal health indications.  Despite the decrease in restrictions, however, at least 13 percent of the women presenting for safe abortion in 2006 were turned away due to lack of training and support to safely provide second-trimester care.

Since 2007, Ipas has worked with the Nepali Ministry of Health, Family Health Division to increase the availability of second-trimester services, both dilation and evacuation (D &E) and medical abortion (mifepristone-misoprostol). Between 2007 and 2012, 19 second-trimester sites were established, with a total of 46 providers. Services were provided to 1,848 women during that period, and service is ongoing today. Independent research has documented a decline in major morbidity and mortality for women since the introduction of this program—and notes that “the steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access.”

As the Contraception commentary on the Nepal program notes,  this successful expansion of second-trimester services, which grew by eight-fold over the five years, is due to “the comprehensive, structured design of the program, the close collaboration between the Nepali government and Ipas, and the dedication of the providers to decrease Nepal’s maternal morbidity and mortality.” The program included creating support teams for providers at each site and clinical mentors who provided direct support for clinical concerns.

Since mental health is one legal indication for second-trimester services in Nepal, development of the program included convening a group of physicians, lawyers, women’s advocates and policymakers to generate a mental health checklist for providers to use in deciding which women do or do not qualify. (That checklist is included in the handouts accompanying the Ipas second-trimester toolkit.)

While recognizing the need for strengthening second-trimester abortion services, Ipas is equally committed to programs and strategies for access to abortion early in pregnancy. The Nepal program also included training female community health volunteers to test for pregnancy in an effort to identify pregnancies earlier and reduce the need for second-trimester services. 

For further reading, see: "An Unmet Need for the World's Women: Safe Second-Trimester Abortion."