Time Life

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Time Life
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Reducing Maternal Mortality Through Increased
Access to Safe AbortionThe Rights the Wrongs
Dr. Nozer K. Sheriar Treasurer Past
Chairperson, MTP Committee Federation of
Obstetric Gynecological Societies of
India Member, Governing Council International
Planned Parenthood Federation Member, Medical
Advisory Panel Family Planning Association of
India
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The Tragedy of Amrita Shergill
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Unintended Pregnancy A Worldwide Menace

• Each year over 75 million women experience an
  unintended pregnancy
• UNFPA, State of World Population , 1997
• About two thirds of these unintended
  pregnancies end in induced abortions
• WHO, 1998

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Unsafe AbortionsA Global Epidemic

• Some 20 million unsafe abortions take place
  annually worldwide, 55 thousand each day
• These result in more than 80,000 maternal deaths.
• WHO, Unsafe Abortion, 1998
• About a fifth of this burden is borne by India
• Meenakshi Datta Ghosh, Crossroads at the
  Millenium, 2000

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Unsafe AbortionsA Senseless Risk

• Developing Regions
• 330 deaths in contrast to 1 death per 100,000
  procedures in developed countries
• Complications of unsafe abortions
• Responsible for 13 of maternal deaths
• In some regions more than a third of maternal
  deaths associated with unsafe abortions
• WHO, Unsafe Abortion, 1998

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• Deaths from unsafe abortion are the most
  preventable of all maternal deaths
• In many countries the goal of reducing
• maternal mortality by 50 would have
• been wholly achieved by simply eliminating
• deaths due to unsafe abortions
• Ingar Brueggemann, Secretary General, IPPF

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The Indian Millennium Scenario Where We Were At

• Estimated 6.7 million induced abortions annually
• Unsafe abortions responsible for 15000 maternal
  deaths
• Estimated 10 illegal abortions for each reported
  MTP
• Inadequate availability awareness of legalized
  abortions
• Registered centres nationwide in 1995 - 8511
• Centre registration - Delay 56.8, ignorance
  11.9
• Underutilization of contemporary techniques
• MVA use limited medical abortion unavailable
• Sheriar, MTP Factfile, FOGSI, 2000

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Propagating Early Abortion Services

• Increase geographic spread enhance
  affordability
• Adopt updated safe, easy simple technologies
• Eliminate cumbersome registration of centres
• Establish additional training centres
• National Population Policy, Action Plan, 2000

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Advocacy for Safe AbortionIncreasing Access
Affordability

• Do not go where the path may lead.
• Go instead where there is no path leave a
  trail.
• Ralph Waldo Emerson

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Amendment of MTP Rules Regulations

• Significant amendments
• Formulation of district level committees
• Time frame for registration process
• Bifurcation of 1st 2nd trimester terminations
• MTP Act amended in 2002 Rules in 2003
• Operational Guidelines for MTP Facilities
• Check list to facilitate centre registration
• Developed by FOGSI gazetted in 2003

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MTP Act, 2002 MTP Rules, 2003

• A rational correction towards demedicalization
• Rule 5 of the MTP Rules
•  First trimester terminations
• Gynecology / labour table, backup for treating
  shock facilities for transportation
• Second trimester terminations
• OT table instruments for abdominal
  gynecological surgery, anesthetic equipment
• The Gazette of India - Extraordinary, December
  2002

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Advocacy for Safe AbortionUpdated Technologies

• Any sufficiently advanced technology
• is indistinguishable from magic.
• Arthur C Clarke

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Safe Abortions - Earlier the Better

• Four fold rise in complications with late
  abortions
• Lack of awareness feeds unsafe practices
• WHO, Tech Report, 1997

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ComplicationsMetaanalysis of 13 Studies

• Greensdale et al, MVA, IPAS 1993

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Vacuum AspirationThe New Gold Standard

• ICPD 5, Brazil 1997 endorsement
• Properly equipped hospitals should abandon
  curettage and adopt the aspiration methods -
  selecting MVA and /or EVA
• WHO FIGO Task Force, 1997

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Manual Vacuum Aspiration Features

• MVA syringe (60 ml) with double valve adapter
• Flexible plastic cannulae (EasyGrip)
• Colour coded cannulae
• Diameters 4 to 12 mms
• Dismantled for versatile cleaning sterilization

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Loading the Syringe
Close the pinch valve of an assembled syringe
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Creation of Vacuum
Withdraw plunger till catcher arms locked
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MVA Procedure
Pinch valve released to create intrauterine vacuum
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Evacuation of Uterus
Back forth rotatory movements of cannula
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FOGSI - Ipas Multicentric Study

• Creating contemperory locally relevant evidence
• Prospective series of 1686 procedures in 27
  clinics
• Period of gestation
• Below 8 weeks 64 8 - 12 weeks 35.1
• Anesthesia
• Sedation paracervical block 55.9
• General Private 58 Vs Government 16.8
• Successful in 98.2 with complications in 2.8
• Sheriar, Tank Ganatra, J Obs Gyn India, For
  publication, 2006

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Manual Vacuum AspirationIndias Special Needs

• Low tech rural
• Limited access to medical facilities
• Non availability of reliable equipment
• Poor maintenance of available resources
• Erratic electricity supply
• High tech urban
• Sensitive urine pregnancy tests serum ? hCG
• Transvaginal ultrasound
• Appreciation of minimally invasive concept

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Marie Stopes Clinic Dhaka
DWHC Centre - Palash
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Introduction of Medical Methods

• Date of Approval - February 13, 2002
• Concerns raised about the possible resistance by
  professionals exclusively providing surgical
  abortions
• For medical termination of pregnancy through 49
  days of pregnancy
• To be sold by retail outlets on the prescription
  of a gynecologist only
• Drug Controller of India, Government of India,
  2002

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Approval of Mifepristone WorldwideA Growing
Family of Nations

• 2000
• Norway Russia
• Taiwan Tunisia
• Ukraine US
• 2001
• New Zealand South Africa
• 2002
• Azerbaijan Georgia
• India
• Latvia Uzbekistan
• Vietnam

• 1988
• France China
• 1991
• UK
• 1992
• Sweden
• 1999
• Austria Belgium
• Denmark Finland
• Germany Greece
• Israel Luxembourg
• Netherlands Spain
• Switzerland

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Mifepristone-MisoprostolClinical Effects
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Updated Technologies Medical Abortions

• Creating a clinical space, practical guidelines
  legal validation of medical abortion
• Expert Group Meeting Guidelines for RU 486
• Participated into the formulation of National
  Guidelines, October 2002
• Medical methods introduced in the MTP Rules
• May be prescribed by a registered medical
  practitioner as prescribed under MTP Act
• Having access to a place approved by the
  Government under MTP Rules

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FOGSI Population Council Survey

• Assessment of clinical practices with an
  evaluation of attitudes future needs
• Mail-in telephonic survey conducted starting
  March 2003
• Scientifically selected national representative
  sample of 1000 members of FOGSI societies
• Total of 440 completed responses received
• Elul, Sheriar, Anand Philip, J Obs Gyn India,
  56340, 2006

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Practice Protocols of Medical Abortion

• Interesting commentary on clinical behaviour
• Mifepristone current use
• Users 69
• Mifepristone use
• Commonest dose 200 mg 50
• Misoprostol use
• Commonest dose 400 ?g 73
• Oral administration 75
• Home based administration 30
• Elul, Sheriar, Anand Philip, J Obs Gyn India,
  56340, 2006

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Mifepristone Doses for Early Abortion

• Randomised double blind multicentric trial with
  1589 cases in 17 centres
• Oral mifepristone 200 or 600 mg followed by oral
  misoprostol 400 ?g after 48 hrs
• Complete abortion rates 89.3 88.1
• Lower dose as effective in pregnancies upto 8
  weeks gestation
• Von Hertzen, Br J Obs Gyn, 107524, 2000

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Safe Abortion in IndiaPromise of Mifepristone

• Mifepristone-misoprostol use in rural Indian
  villages between 1995 and 1998
• 294 cases with 95.9 success
• Feasible, safe effective in all settings
• Promise of medical methods with MVA backup to
  promote widespread availability of safe abortions
• Coyaji, J Am Med Womens Assoc, 55191, 2000

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Late Abortion Practice in an Indian Teaching
Hospital

• Second trimester abortions in 2055Represented
  15 of abortions over 10 years
• Overall complication rate 11
• Abortions in adolescents (lt 18 years)
• All abortions - 5.5
• Second trimester abortions - 18.6
• Bhathena, Sheriar Guillebaud, J Obs Gyn,
  10(4)299, 1990

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Second Trimester TerminationsEthacridine Lactate

• Extraamniotic ethacridine lactate in 315 cases
• Supplementary extraamniotic 15 methyl PGF2? 250
  ?g after 6 hours
• Bhathena, Sheriar, Walvekar Guillebaud, Br J
  Obs Gyn, 97, 1990

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Second Trimester TerminationsMisoprostol
Recommendations

• US Preventive Services Task Force Grades
• A Good consistent scientific evidence
• Mifepristone 200 mg followed 36-48 hours later by
  600 ug vaginal misoprostol then by 400 ug
  vaginal / oral misoprostol 3 hrly (5 doses)
• B Limited or inconsistent evidence
• Misoprostol 200 600 ug vaginally 12 hrly
• Misoprostol 400 ug 3 hrly
• Goldberg et al, N Eng J Med, 344(1)38, 2001

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FOGSI - ICOG Clinical Practice Guidelines

• Consensus Group Meeting supported by Ipas
• 1 FOGSI acknowledges the magnitude of the
  problem of
• unsafe abortion. It promotes the services
  offered for safe
• abortion in India wherever legally
  permitted abroad
• 2.1 Determining the length of pregnancy
• Bimanual pelvic examination recognition
  of symptoms
  
• of pregnancy is usually adequate
• Lab / USG to confirm pregnancy or
  gestational age is not
• mandatory but may be used as per
  clinicians discretion
• 2.2 Hb, Bl group, Rh type, urine sugar protein
  testing may be
• the minimum investigations that are to be
  performed

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Advocacy for Safe Abortion Knowledge
Dissemination Training

• The mind once stretched by an original idea,
  never regains its original dimensions.
• Oliver Wendell Holmes

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Skill Development for Training
Creating a core resource for training advocacy

• FOGSI Ipas Promotion of Safe Abortion Workshop
  Training of Trainers
• Pune, June 2001
• 55 participants
• Included FOGSI office bearers chairpersons of
  seven committees

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Training Programmes Conducted
Nationwide coverage with over 60 workshops

• North
• Agra, Ajmer, Bharatpur, Bikaner, Delhi,
  Gorakhpur, Indore, Jodhpur, Lucknow,
  Muzzafarnagar, Rajkot, Rewari, Udaipur
• South
• Bangalore, Bellary, Calicut, Chennai, Coimbatore,
  Davangere, Erode, Guntur, Hyderabad, Kurnool,
  Madurai, Raichur, Salem, Trivandrum, Vizag
• East
• Bhilai, Bhubhaneshwar , Bijapur, Calcutta,
  Dhanbad, Durg, Guwahati, Jamshedpur, Muzzafurpur,
  Patna, Raipur, Ranchi
• West
• Ahmedabad, Akola, Amravati, Baroda, Goa, Latur,
  Mumbai, Nagpur, Nasik, Pune, Solapur, Surat

Bangalore, 2001
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FOGSI Committee Publications

• Safe Abortions Save Lives - MTP Factfile 2001
• Decision makers media
• MTP Act An Overview
• Detailed presentation
• FOGSI Focus Making Abortions Safer
• Overview - clinical aspects
• Collaboration with Ipas
• Distributed to all members
• Use as training resource

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Advocacy for Safe AbortionSupporting National
Initiatives

• Be the change
• you want to see in the world.
• Mahatma Gandhi

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MTP ProvisionInadequate Inequitable
Distribution

• Estimated 6.7 million induced abortions
  annuallyReported MTPs (1998-99) - 613,879
• Approved institutions increased from 1877 in 1976
  to 8511 in 1995 nationwide
• Maharashtra - 10 population has 21
  facilitiesBIMARU states - 40 population with
  17 facilities
• Rural services minimal
• Less than 1800 of over 20,000 PHCs provide MTPs
• Chhabra Nuna, Abortion in India - Overview, 1994

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Rural Public Sector Abortion Provision
Khan et al, Abortion Services in India, CORT, 2001
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MVA Pilot Project - GOI, FOGSI WHO

• Walk the talk
• Proving feasibility developing practical
  systems
• Pioneering project to introduce MVA
• At district level in healthcare - down to PHC
  level
• Project implementation in 2 districts in 8 states
• Ten doctors trained per district along with an
  accompanying staff nurse or lady health visitor
• Over 120 doctors trained
• MVA Pilot Project, GOI, FOGSI WHO, 2004

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Advocacy for Safe AbortionWomens Reproductive
Rights Context

• Health professionals at all levels have ethical
  legal obligations to respect womens rights.
• World Health Organization

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Womens Sexual Reproductive Rights

• FIGO - Womens Sexual Reproductive Rights
  Project Bangalore, May 2003
• Integrating accepted human rights principles
  IPPF Charter
• FOGSI Right to Safe Abortion - Preamble
• Women should have the right to safe abortion with
  respect dignity
• Sexual Reproductive Rights pertaining to safe
  abortion must be supported ensured
• These rights should be upheld irrespective of
  age, education, marital status, economic status,
  religion, disability or background

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FOGSI - Right to Safe Abortion

• Right to Information Knowledge
• Right to Access Safe Abortion Services
• Right to Choice Decision Making
• Right to Quality of Care
• Right to Privacy Confidentiality
• To confidentiality, even from spouse or family if
  so desired
• To privacy during consultation, counselling,
  procedure recovery
• To complete secrecy confidentiality including
  in the maintenance of records

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Advocacy for Safe AbortionSpeaking up for the
Silent

• Too many women in too many countries speak the
  same language of silence.
• Anasuya Sengupta

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Unsafe Adolescent Abortions

• Upto 10 of all abortions occur among girls aged
  15 to 19 years
• De Bruyn, Ipas, Pioneer Factsheet, 2005
• Adolescents accounted for 53 - 74 of septic
  abortions in African studies
• Adetro, Am J Obs Gyn, 12201, 1986
• In Uganda 60 of deaths due to unsafe abortions
  occur in women under 20 years
• Unuigbe et al, Int J Obs Gyn, 26435, 1988

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The Bane of Sex Selected Abortions
Ethical concerns challenges Vs Threats
compromise

• Child sex ratio has steadily declined from 976 in
  1961 to 927 in 2001
• FOGSI represented on the apex Central Supervisory
  Panel for PNDT implementation
• Potential threat to achievements on safe
  abortions in India

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• The only way of discovering
• the limits of the possible,
• is to venture a little way past them
• into the impossible.
• Arthur C Clarke