Expansion of Safe Abortion Services in Nepal Through Auxiliary Nurse-Midwife Provision of Medical Abortion, 2011-2013.

INTRODUCTION: The termination of unwanted pregnancies up to 12 weeks' gestation became legal in Nepal in 2002. Many interventions have taken place to expand access to comprehensive abortion care services. However, comprehensive abortion care services remain out of reach for women in rural and remote areas. This article describes a training and support strategy to train auxiliary nurse-midwives (ANMs), already certified as skilled birth attendants, as medical abortion providers and expand geographic access to safe abortion care to the community level in Nepal. METHODS: This was a descriptive program evaluation. Sites and trainees were selected using standardized assessment tools to determine minimum facility requirements and willingness to provide medical abortion after training. Training was evaluated via posttests and observational checklists. Service statistics were collected through the government's facility logbook for safe abortion services (HMIS-11). RESULTS: By the end of June 2014, medical abortion service had been expanded to 25 districts through 463 listed ANMs at 290 listed primary-level facilities and served 25,187 women. Providers report a high level of confidence in their medical abortion skills and considerable clinical knowledge and capacity in medical abortion. DISCUSSION: The Nepali experience demonstrates that safe induced abortion care can be provided by ANMs, even in remote primary-level health facilities. Post-training support for providers is critical in helping ANMs handle potential barriers to medical abortion service provision and build lasting capacity in medical abortion.

Early pregnancy detection by female community health volunteers in Nepal facilitated referral for appropriate reproductive health services.

BACKGROUND: Female community health volunteers (FCHVs) are a possible entry point for Nepali women to access timely reproductive health services at the village level. This evaluation assessed the success of a pilot program that trained FCHVs in early pregnancy detection using urine pregnancy tests (UPTs), counseling, and referral to appropriate antenatal, safe abortion, or family planning services. METHODS: Between July 2008 and June 2009, the program trained 1,683 FCHVs from 6 districts on how to provide UPTs and appropriate counseling and referral; 1,492 FCHVs (89%) provided follow-up data on the number of clients served and the type of services provided. In addition, the program conducted in-depth interviews with selected FCHVs and other reproductive health service providers on their perceptions of the program. RESULTS: Of the FCHVs with follow-up data, 80% reported providing UPTs to women in the 8-month follow-up period. In total, they conducted 4,598 UPTs, with a mean number of 3.1 tests per FCHV. Among the women with a negative pregnancy test (47%), FCHVs provided 24% of them with oral contraceptive pills and 20% with condoms; referred 10% for other contraceptive services; and provided contraceptive counseling only to 46%. Among the women with positive pregnancy tests (53%), FCHVs referred 68% for antenatal care and 32% for safe abortion services. CONCLUSIONS: Providing FCHVs with the skills and supplies required for early pregnancy detection allowed them to make referrals for appropriate reproductive health services. Results of this evaluation suggest that community health workers such as FCHVs are a promising channel for early pregnancy detection and referral. As the intervention is scaled up, the focus should be on ensuring service availability and awareness of available services, UPT supply, and creating viable options for record keeping.