An important service–Second-trimester abortion
Provider profile: Dr.Meera Thapa Upadhyay
Dr. Meera Thapa Upadhyay is a practicing ob/gyn at Paropakar Maternity and Women’s Hospital in Kathmandu, Nepal. In early October, she sat down with Ipas to talk about her experience providing abortion care—particularly second-trimester abortion.
Ipas began training providers in second-trimester abortion in 2007, recognizing that women were being denied such services due to lack of training. Dr. Thapa was among the first group of providers to go through this training.
Early in her career, she was in a government job working outside of Kathmandu. “Women would come to me; particularly since I was the only female doctor. They’d come to ask about abortion in my private practice.”
Then and now, she says, women often come for abortion in the second trimester. “They are sometimes uneducated, they live in remote areas and by the time they know they can get an abortion, they’re at 14 weeks or more. So many times, they just don’t know where to go,” she says.
Despite the fact that abortion is legal and provided through the government health services in Nepal, many women, she notes, don’t realize that they can use medical abortion or even that mid-level providers like nurses and midwives can safely perform abortions in the first trimester.
Though second-trimester abortions account for a small percentage of abortions globally, second-trimester abortions disproportionately affect the most vulnerable women, including young women, women facing financial and logistic barriers to health care, victims of violence, and women with pregnancy complications or fetal anomalies. Where abortion is restricted, women often resort to unsafe abortion in the second trimester resulting in more severe complications.
“In cases of incest and rape, it’s really hard for women to come to us. Sometimes they are re-traumatized just by the thought of seeking services. Usually, these women and girls show up between 16 and 18 weeks pregnant,” says Dr. Thapa. And, she adds, most women who are raped often cannot go home due to the stigma and shame associated with rape. “We do a lot of work with rescue homes and community organizations that provide shelter for these women.” Independent research has demonstrated that increasing the accessibility of safe, high quality second-trimester abortion care has decreased the number of severe complications being seen at hospitals in Nepal.
The provision of second-trimester abortion presents more challenges than first-trimester abortion services. “Second-trimester sites and providers require a higher level of technical and emotional preparation and support in order to improve the likelihood of ongoing provision of care.Although evidence-based techniques are safe, the complication rates for dilation and evacuation are directly related to the experience and skill of the provider. Additionally, these providers face discrimination from colleagues, friends, and family due to the sensitivities related to abortion in the second trimester,” says Dr. Ali Edelman, Ipas clinical consultant.
“You really must have trained providers; this isn’t an easy skill and there is very limited availability because of a lack of trained providers and because geographically, Nepal has a lot of very hilly and rural areas where there are no facilities equipped for second-trimester services,” adds Dr. Thapa. “It’s so important and yet for women, it can be difficult to get to these services.”
Ipas has begun to train some providers in the more rural mountainous areas of Nepal in provision of second-trimester abortion with medical abortion—or abortion with pills. Though this method requires similar skills to obstetrical care and can be performed in facilities with lower patient volume, notes Dr. Alice Mark, Ipas clinical consultant. “However, these teams need specialized training and the facilities require close monitoring for safety and quality.”
Nepal has methodically scaled up abortion services, including second-trimester abortion, ensuring that different cadres of providers can perform abortion in the first trimester and thus shifting some of the caseload out of urban hospitals and clinics—making services more accessible to women in rural areas. Second-trimester abortion in Nepal, Dr. Thapa notes, is still restricted to cases of rape and incest, fetal abnormality or conditions that threaten the woman’s health.
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