These guidelines are based on experiences from V i e t n a m . Induced abortion is legal in Vietnam and the number ofwomen obtaining abortions has increased dramatically in recent years, reaching a level of over 1.3 million procedures in 1995. In response, the Ministry Of Health decided to undertake a strategic assessment of abortion service, with the goal of understanding :

(i) how to reduce the recourse to abortion among Vietnamese women and
(ii) how to improve the safety and quality of abortion services being provided.

Service-delivery is more than just ‘Dispensing Tablets’. The Service Delivery Guidelines need to meet the technical standards, be relevant to women’s needs, ensure proper monitoring systems and incorporate training needs and ensure access to services of medical abortion.

The important steps are:

(1) Meeting Technical Standards

Guidelines need to keep in mind a minimum common denominator and need to be applicable across service-delivery points i.e. use of ultrasound, home administration etc. Ultrasound is performed at some centres to confirm intra-uterine gestation and know the completeness of abortion. For some women, home administration is a preferred option, but if it is routinely allowed, there is a danger of improper monitoring, control and quality of care. Proper counseling should be provided regarding pre-abortion decision-making, theabortion process itself and post-abortion contraception counseling. Links to contraception are more difficult to achieve with medical abortion than surgical abortion. Guidelines need to be evidence-based, flexible and with enough room for adaptation as experience accumulates.

(2) Monitoring

Counting of cases should be done including the success or failure of the procedure determined 2 weeks later. It is difficult to monitor quality of services in the context of medical abortion especially counseling. The number of patients lost to follow-up and record of adverse events should be kept for monitoring the results.

(3) Training

There are several current approaches to training of abortion-providers in Vietnam. In the initial period, guidelines should have the provision of training of existing pool of MTP certified providers. In future, medical abortion curriculum should be a part of MTP certification. Training should be to teach them to provide proper counseling to clients and also to recognize normal and abnormal bleeding patterns and the need for intervention, if required. The provincial Maternal and Child Health (MCH)/Family Planning (FP) centres act as training centres for district and community-level providers.

Training costs are also kept low. Selection of appropriate trainers is the key to changing and improving abortion practices. Both service and refresher training needs to be provided. Follow-up and a supervision of trainees should be an integral part of training and should be planned for during training courses. The training of providers to increase their knowledge and skills, and address attitudes related to abortion should be integrated within a broader focus onfamily planning and a range of other Reproductive Health (RH) issues.

(4) Meeting Women’s Needs

Women must have access to information, legal rights and guidelines. Increased attention should be given to privacy for clients receiving counseling. In considering women’s needs and perspectives, it will be necessary to consider the costs of medical abortion. The costs are likely to be higher for medical abortion than surgical abortion due to the price of mifepristone and the increased number of visits required. Unless the medical abortion is heavily subsidized, access is likely to be limited to women with the ability to pay the substantially higher costs.

(5) Increasing Access

It needs to be clarified as to at what levels of the health system the services will be provided and who can provide the services. Medical abortion to be allowed as the only method available at any service-delivery point or it needs to be linked to the existing services. Even if an individual provider provides only medical abortion, a choice of options needs to be available to the client. Medical abortion guidelines should be a part of the common set of guidelines’ for management of unwanted pregnancy. Surgical abortion services should also be easily accessible. Access must include the logistics of supply and drug procurement. Women’s ability to access and utilize health information and services depends partly on their literacy and their status in society.