Vietnam has a very high abortion rate and a liberal abortion law (on request). The high levels of induced abortion in Vietnam reflect an unmet need for effective contraception, and the findings of this assessment confirm the need to improve the quality of care in the National Family Planning Programme. The MMR is 160-180/100,000 live-births and abortion-related mortality is relatively low (5%). Early terminations are a norm with 60% of terminations occurring within the first six weeks and 80% within first eight weeks. Vietnam has a very high female literacy rate (90%).

It has a well-developed primary health infrastructure. Surgical abortion services exist at all levels, even down to the lowest level of healthcare system i.e. the commune equilent to PHC or sub centre though quality of care may vary. The service-providers for surgical abortion are doctors, assistant doctors (physician assistants with three-year training), secondary midwives (college graduates with two year training and special training in MVA up to six weeks) and private sector personnel. Midlevel providers are also allowed. They have an extensive research experience with medical abortion.

The development of National Reproductive Health Guidelines in 2002 preceded the development of the strategic assessment of abortion in 1997. The strategic assessment was cautiously optimistic about the introduction of medical abortion. They suggested that the government should look into the service-delivery issues of medical abortion but also recommended that, as a priority, improvement of quality around surgical abortion be their prime objective. The Government decided to introduce medical abortion as a part of National Reproductive Health Guidelines. Subsequent to the approval of guidelines in October, 2002, MOH asked for an assessment (Pre-Introduction Assessment 2003) related to the issues regarding introduction of these guidelines into the existing services.

The National Guidelines on medical abortion include early pregnancy termination up to 49 days from LMP. Dosage recommended is 200µg mifepristone administered on day 1, followed 48 hours later by 400mg oral misoprostol and follow-up visit 2 weeks later. Research on other routes of misoprostol and misoprostol only regimens is also going on. Contraindications for subject selection include adrenal gland pathologies, bleeding disorders, patients on corticosteroids or anticoagulants, breast-feeding and known allergy to misoprostol or mifepristone.

The guidelines recommend that gestational age estimation be based on LMP, pregnancy test (mandatory) and ultrasound (if required) and signed informed consent. USG is the most contentious among providers. It may not be very accurate in very early pregnancy and requires great skill. Reliance on history, clinical signs and symptoms, followed by USG as a complementary investigation in suspected cases is adequate. Similarly, ultrasound to diagnose the completeness of abortion is not necessary as a routine, and may, in fact, increase the risk of unnecessary surgical intervention.While USG should be available for the selected cases that require it, its use as a mandatory part of the medical abortion procedure is not required and may only restrict access and increase the cost and inconvenience for women.

The guidelines recommend that drugs be administered under medical supervision at the clinic, with 15 minutes and 4 hours observation period formifepristone and misoprostol respectively. Abortion caseload in Vietnam is very high, large hospitals do up to 200 cases a day and waiting period of four hours following misoprostol administration completely clogs the system. A likely change in guidelines is reduction of the observation period of misoprostol to half an hour.

Guidelines recommend the following to be checked during the follow-up visit:

• If the products have been expelled and there is no bleeding, follow-up is complete.

• If the products have been expelled, there is still bleeding, continue to follow up.

• If the pregnancy is still viable, use aspiration method for abortion.

Counseling plays a vital role in the decision-making of the client to undergo medical abortion. It should provide information about the available abortion methods, advantages and disadvantages of medical abortion, complications and side- effects, danger signs, normal signs when taking the medicine, normal signs of health and fertility-recovery, importance of follow-up at 2 weeks and post-abortion contraception advice.

The guidelines suggest that medical abortion service be provided at central, provincial levels by obstetric and gynaecology doctors trained in medical abortion. Midlevel practitioners are not allowed to provide services. There is no mention of private sector personnel providing services. Thus, guidelines for medical abortion are more restrictive than surgical abortion guidelines.The distance between the client’s home and health facility should not be more than 30 minutes travel by any means.

Mifepristone is not yet registered and licensed in Vietnam, and has, therefore, limited availability. It is available only as bulk supply for certain public hospitals. One tablet of mifepristone costs 18 US$.

Misoprostol registration ended in 2001 and current supplies will not last beyond 2004.

Drugs are not accessible over the counter to clients but providers in private sector can obtain the drugs.

In future, the introduction of medical abortion services should be started at those sites where counseling services for surgical abortions are already established, and also that they are well functioning and adequately staffed.

There is a need for country-specific, locally-relevant training materials, counseling fact-sheets and client- information material.

Introduction in phases is a good idea, initially to introduce at those sites where well-functioning and adequately staffed surgical abortion services already exist.

Monitoring mechanisms and training programmes need to be established.

Other service-delivery issues to consider are provider compensation, role of private sector, dual service system, and contraceptive availability at abortion service-delivery points. Training of providers is another important issue.

Thus, the National Standards and Guidelines need to alter with time and experience.