Two models for national standards and guidelines: Nepal and Vietnam
Thursday, March 01, 2012
Two countries in particular—Vietnam and Nepal—stand out as models of how national standards and guidelines on abortion care can be developed, reviewed and put into practice. In each instance, Ipas worked with the ministries of health and other partners to produce standards and guidelines that would help ensure that women get the abortion care they are entitled to under the law.
As recently as the mid-1990s, women in Nepal were imprisoned for abortion-related offenses. Today, safe abortion care is available in all 75 districts of the mountainous nation.
This transformation would not have been possible without the development and implementation of comprehensive standards and guidelines for safe abortion care, says Dr. Indira Basnett, Ipas Nepal Country Director. “I have seen firsthand, at the service delivery level, what a difference it makes to have clear technical guidelines in place,” says Basnett. “Not only do providers and facility managers understand what standard of care is expected—they know they have a government mandate to provide that care. This is critically important in any country, especially in settings where there is stigma surrounding abortion.”
After Nepal’s abortion law was liberalized in 2002, an Abortion Task Force was established to draft a set of strategies to increase access to safe abortion. Based on the World Health Organization’s guidelines for safe abortion care, Nepal’s initial set of guidelines was approved in 2003.
The task force was then replaced by a Technical Committee for Implementation of Comprehensive Abortion Care (TCIC). Made up of government representatives and civil-society and non-governmental organizations such as Ipas, Marie Stopes International and the Safe Motherhood National Federation, the TCIC has produced a series of national standards and guidelines that cover first- and second-trimester abortion as well as medical abortion. These model documents not only provide for wide accessibility, but have taken the step of providing specific language dealing with reproductive rights in the context of youth services and in response to sexual violence.
The Medical Abortion Clinical Protocol issued in 2008 specifies, for example, that special counseling should be provided to unmarried adolescents and HIV-infected women, as well as to women “suspected of experiencing coercion, sexual violence or abuse.”
Over the years, Nepal’s series of standards and guidelines has resulted in an unprecedented level of safe abortion care. It is estimated that nearly 500,000 women have had safe, legal abortion care in Nepal since passage of the 2002 law.
In 2010, Nepal received a Millennium Development Goal award from the United Nations for its achievement in reducing maternal morbidity. During the decade from 2000 to 2010, Nepal’s maternal death rate dropped from 415 to 229 per 100,000 live births. The nationwide introduction of safe abortion care is credited with being one of the major reasons for that progress.
The strong working relationship between the Ministry of Health, Ipas and other national and international partners has been key to making safe abortion care a reality in Nepal.
The director of Nepal’s National Health Center, Laxmi Narayan Deo, says that helping abortion care providers become confident and competent in their work “is a big challenge.” Standardized training materials, especially those emphasizing youth-centered approaches, have been a big assistance, he adds.
Nepal’s service guidelines on second-trimester abortion care, introduced in 2011, for example, were greatly informed by Ipas’s Clinicians’ Guide for Second-Trimester Abortion.
Dr. Naresh Pratap, KC, Director of the Nepali Family Health Division, says the second-trimester guidelines were developed in order to standardize training and service delivery. “I am very much confident that these guidelines will contribute to ensuring quality second-tri services in government as well as in the private health facilities,” he says.
As he noted in the written introduction to those guidelines, they provide valuable support for trainers, program managers and service providers. But most of all, he said, they make an invaluable contribution “in saving the life of Nepali women through prevention of unsafe abortion.”
Ipas was invited by the Ministry of Health (MOH) to be the lead technical agency on developing abortion standards and guidelines. The working group established by the MOH included top-level health-care providers from teaching hospitals and international experts brought in by Ipas. After the initial draft was completed, the MOH sent it to health officials in all provinces, who in turn shared it with health officials at the district level. This allowed for feedback and input from all levels of the health system.
There also was a series of regional meetings so that health-care providers at the local level—managers, administrators, midwives and others—could voice their concerns and ideas.
All of this made for an inclusive, participatory process. It gave health system staff in every province and at all levels of the health system a voice in development of the safe abortion guidelines. It also cleared the way to get the proposed guidelines disseminated and into circulation at an early stage. By the time the guidelines were adopted, many people were already familiar and in agreement with them.
A logbook for abortion services based on the guidelines has been developed and is being utilized at both reproductive health and hospital systems in Vietnam. In addition, the MOH monitoring tool has been revised to ensure that abortion services provided by both public and private providers are matched with MOH requirements.
“Thanks to Ipas, the MOH has had in hand the scientific evidence and international guidelines that are helpful in developing our national guidelines,” says Dr. Nguyen Duy Khe, director of the Mother and Child Health Department. “All of the elements of safe abortion care were first applied in our comprehensive abortion care project, which proved their appropriateness and effectiveness. That project also provided safe abortion trainers who disseminated the standards and guidelines across the nation, as well as to other countries in the region.”