Evaluation of a Toolkit to Assess Medical Abortion Eligibility and Success

Abstract

Background: In Nepal, Ipas is working to expand medical abortion (MA) services as a promising strategy for providing safe abortion in low-resource settings. Safe abortion services are available in public health facilities but many women obtain medical abortion directly from medical sellers without consulting a healthcare provider. To provide a strategy for safely expanding medical abortion availability to the community level, Ipas has developed tools for assessing medical abortion eligibility and another for determining whether or not the medical abortion was successful. This Toolkit has been designed for use by women or community intermediaries, such as female community health volunteers (FCHVs). The purpose of the study is to examine the ability of this Toolkit to correctly assess medical abortion eligibility and success when compared with comprehensive abortion care (CAC) providers offering standard care. Methods: The study was conducted at seven facilities from six districts in Nepal for six months in 2013-14. Sites included both public and NGO facilities that provide care to both urban and rural women. All women who came to study facilities seeking safe abortion services were eligible for the study if they had a positive pregnancy test, were 16 years of age or older, were able to read and write, demonstrated comprehension of one of the study checklists, and provided informed consent. The study was conducted in two phases — one to assess medical abortion eligibility and the other to assess medical abortion success (outcomes) two weeks later. For each phase, a Toolkit was developed in English and translated into Nepali and was tested for ease of use and understanding through focus groups with FCHVs and women. FCHVs who were selected randomly from a district-level listing, demonstrated ability to read and write, and consented to participate were posted at each study facility for one to two weeks. Results: Most women correctly assessed their eligibility for medical abortion. Most women returning two weeks after medical abortion correctly determined the outcome of medical abortion. Female Community Health Volunteers (FCHVs) correctly assessed medical abortion eligibility and medical abortion outcome for most women. Use of the medical abortion toolkit was successful in determining women’s eligibility for and outcomes with medical abortion. Risk of complications from using medical abortion based on the Toolkit alone was very low. Conclusions: The medical abortion Eligibility and Success Toolkits are a promising strategy for improving safety of medical abortion use outside the health system. A small percentage of women approximately 2% had potential increased clinical risk if they had used medical abortion based on only their assessment and without seeing a health-care provider. Minor adjustments to the toolkit will be made to improve usability and better screen out women ineligible for medical abortion. Implementation of the toolkit on a more widespread scale has the potential to increase women’s access to safe abortion at the community level, further advancing the goal of improved maternal health in Nepal. Keywords: eligibility; medical abortion; success; toolkit.