Background

Despite the availability of numerous methods of contraception, the need for termination of pregnancy will continue to exist. It is essential to have a safe, effective, widely-available and acceptable method for abortion. Having undergone extensive research, medical abortion has been considered a safe and effective method for termination of early pregnancy under supervision. It avoids the need for an invasive procedure and anaesthesia in majority of the patients.

Thus, early medical abortion can attract new health-care providers for abortion services at all levels
with proper training and emergency back up.

QUESTIONS TO BE ANSWERED

A. Who should be the trained for medical abortion services ?
B. What will be the duration and curriculum of training ?
C. What should be the place of training ?
D. What should be the criteria for refresher training?

VIEWS OF THE GROUP

Safe abortion is a reproductive health measure that enables a woman to opt out of an unwanted pregnancy in certain specified circumstances without endangering her life and well being.

At present, lack of trained doctors in providing comprehensive abortion services is a major hurdle in increasing the accessibility of safe abortion services to women, especially in the rural areas. 1992 estimates indicate that there were only 3000 trained doctors available compared to the 21,000 required to serve all rural PHCs.

In 1997, there were only 163 designated MTP training centres in the country, with a capacity of only 20 doctors per centre per year.

Recognising the need for increasing access to safeabortion and the need to improve training of serviceproviders, the National Population Policy 2000 has laid down 10 operational strategies in its Action Plan for Safe Abortion Services.

The group needed to focus on the training of healthcare providers. It includes duration and curriculum of training, place of training and the criteria for refresher training.

A. Healthcare providers to be trained

There are four levels of healthcare-providers :
• Certified MTP providers
• Basic MBBS doctors
• Paramedics
• Grassroot level workers.

According to MTP Act, a registered medical practitioner as prescribed by the Act will only be authorised to provide medical abortion. However, to increase the access to abortion services, there is a need to increase the number of providers.

Under the current legislation, medical abortion is to be provided by certified MTP providers only, but others can be trained for medical abortion under superivision of a certified provider as well as for counseling and awareness of medical abortion. Primary Health Centre (PHC) doctor, Lady Health Visitor (LHV), Auxillary Nurse Midwife (ANM) are important healthcareproviders in the RCH Programme. All of them need to be trained in medical abortion before making it available for wider use, specially for the rural masses where the trained providers are currently unavailable.

B. Duration and curriculum of training

• Two days orientation training including lectures for certified MTP providers
• 14 days training for fresh M.B.B.S. doctors who will be incorporated in the programme
• 6 days training for mid-level workers (midwives and ANMs)
• 2 days training for grassroot-level workers.

Contents of curriculum can be divided into four training modules:

1. Introduction

• Defining the mechanism of medical abortion
• Highlighting the usefulness of this method
• Safety and efficacy of the method
• Complications and side-effects of medical abortion
• Legal and policy provisions
• Health effects of unsafe abortion

2. Counseling of the patient

• Pre-abortion counseling
• Post-abortion counseling
• Contraception counseling
• Privacy and confidentiality

3. Implementation training for providers who will give the drugs includes

• Consent
• Dating of pregnancy (confirmation of period of gestation)
• Regimen and technique of medical abortion
• Management of side-effects and complications

4. Follow-up

C. Place of Training

This has to be government recognised MTP training centre with surgical and emergency back up. It includes:
• District hospitals
• Teaching hospitals and
• Approved training centres.

Another important area is training of interns who spend at least 2 month in Obstetrics and Gynaecology departments during their internship. During this period, interns should be trained in the technique of early medical abortion. But this will be only possible if the drugs are made available free of cost to the medical colleges.

All healthcare providers may be authorized to prescribe medical abortion if they have observed at least 5 cases, upervised 5 cases and performed 5 cases of medical abortion independently.

The strategies can include:
• Adopt updated and simple technologies that are safe and easy, not dependent upon anaesthesia and use of surgical techniques that are non-invasive.
• Simplify and facilitate the establishment of additional training centres for safe abortions in the public, private and NGO sectors.

Under the RCH project of Ministry of Health & Family Welfare, Government of India, the National Institute Of Health & Family Welfare (NIHFW) has been identified as the nodal agency for Specialized Skill Training, which also includes MTP training. NIHFW has now identified 240 MTP training centres in the country.

D. Referesher Training
This is required for doctors already registered under MTP Act. These doctors require only 2 days on site training to provide safe medical abortion services.

The training and supervision of providers of medical abortion may help to overcome the barriers of accessibility and availability and actualize the potential of medical abortion in women’s healthcare.

E. Unresolved Issues

• MTP rules need to be modified to take MBBS doctors into the fold of medical abortion providers.