-Navaraj Bhattarai
The whole world is battling with the Covid-19 pandemic. No one provides an exact answer when and at what cost will this pandemic end? Health sector of Nepal was already grappling with multiple challenges even before the pandemic hit. As the country is in lockdown and putting whole effort in preventing and saving lives due to Covid-19, the other pressing health problems may receive less priority. Some projection shows that one-off lockdown is not sufficient and we may need repeated periods of physical distancing until 2022. Therefore, we need to prevent the lives from Covid-19 but at the same time need to ensure critical health services are being delivered with special attention to vulnerable groups such as women, children, pregnant, chronic disease patient, HIV infected, TB patients, etc.
Evidence shows that women and girls are disproportionately affected during any humanitarian situation and their health problems are often unmet, face violence and sometimes lead to the situation where their lives are in danger due to lack of medical care during childbirth, adoption of harmful practices in terminating unwanted pregnancies. To prevent these situations, the government should devise an alternate plan where women have full access to health service they need but at the same time have minimal contact with health facility itself so that both service providers and clients are safe. In doing so, it should lax some legal provisions, try some approaches which have been proven effective elsewhere but yet to be implemented in Nepal in such scale. There can be different avenues in delivering critical service using telemedicine, strengthening outreach with necessary precautions, recognizing the pharmacies to deliver the set of health services such as abortion and task shifting of the service to the lower facilities so that the pressure in higher facilities is reduced. Government should not hesitate in coming out from their customary practice because the situation is extraordinary and our response should commensurate it. Here, I would like discussing two critical services: family planning and abortion services.
Unsafe abortion is the third leading cause and accounts for 7% of maternal death in Nepal. Abortion service is time-sensitive service and both delay and denial will have profound negative consequences in women’s health including death. Although government recognized abortion service as an essential health service, many factors such as travel restriction, health facilities turning to Covid-19 dedicated hospital, lack of women’s autonomy in seeking reproductive health services may restrict women and girl in seeking abortion care. As per 2014 estimates, about 323,000 abortion services takes place every year and 58% of these are unsafe. However, we have to differentiate between legal abortion and safe abortion service. According to the abortion-related law, this 58 % are unsafe but if we compare against the definition of the World Health Organization (WHO), the number of unsafe abortions should be less. The current provision in Nepal allows the abortion at the listed site by the listed provider with appropriate technology and only these are considered as safe. However, WHO recognizes abortion is safe if they are done using the recommended method appropriate to the gestation and person supporting or provide service is trained. So, the provision of the listed site is unnecessary. When it comes to terminating pregnancy up to 10 weeks using pills, the listed site doesn’t add any significant benefit in the process. The idea of listed provider and listed site is dated back to 2002 when Nepal had just legalized the abortion service, medical abortion was not introduced and much evidence was not produced about the safety of other procedures. The new evidence also shows women can safely terminate early pregnancy without visiting the health facilities and without the physical presence of health workers. Health workers can virtually support via telephone basically in assessing the eligibility, right process of using the pills, assessing the termination of pregnancy and ensuring post-abortion contraceptive. If women can correctly recall her last mensuration date, then women can take pills from pharmacies and completes the abortion at home. Different pieces of evidence show that women are likely to be conservative in recalling their last menstrual date and a slight error in estimating the gestational age might not pose a big risk as the dose of pills until 10 weeks of pregnancy is same. The government should lax the law of the listed site and providers for at least during this pandemic and let the registered pharmacies run by the medical professional, paramedics, private hospital, polyclinics dispense the legally registered drugs with clear instruction of its use. Simultaneously, partners can assist in providing necessary clinical orientation and support to the service providers, orienting female community health volunteers, supplying commodities, etc. There are different online platform, apps that can guide the paramedics, pharmacy workers or even the women in providing and obtaining comprehensive abortion care.
The need for abortion service only arises when women experience an unintended pregnancy. Unintended pregnancy can be prevented by using modern contraceptive methods. As per Nepal Demographic Health Survey (NDHS) 2016, women mostly use permanent methods from government hospitals, camps and private hospitals. Considering the present situation, this service is sure to be halted for a certain period. Injectable (Depo-Provera) is the second preferred method. According to NDHS 2016, 74% of injectable services are provided from government facilities and the private sectors, mainly private clinics and pharmacies. Considering the less failure rate compared to other temporary methods, women's preference, three month protection periods, no need for specialized training, injectable continues to be the most appropriate choice in the current situation. Hence, the government should also timely think about other available alternatives within the injectable with a potential of self-use. Sayana Press can be one of "the game-changer" contraceptives with ample evidence of self-injection. Sayana Press is similar to Depo-Provera in composition, but in less dosage, comes with its needle and is injected under skin unlike in muscles in case of Depo-Provera. All these features have made Sayana Press feasible for self-injection. If Sayana Press is added in the current contraceptive basket, for the women opting injectable, the first dose of Sayana Press can be provided by health workers and at the same time instruct women on its use. For the next dose, women can self-inject, or a partner or family members can help her. Women should be fully informed on its uses, possible side effects and link with female community health volunteers for any information or help. Until now, Sayana press hasn't been part of routine contraceptives, but the government should have a plan about this option urgently and partners should leverage its resources in term of procurement and its implementation. Introducing the new product in the contraceptive basket seems a bit challenging, but again we have to realize we have to adapt with the “new normal” for an uncertain time due to threat of Covid-19 but at the same time deliver other sets of health interventions safely and effectively suggested by the science. Different countries like Uganda have prioritized to continue the innovation for community-based distribution of Sayana Press. In addition, provide counselling on fertility awareness methods in case of service and supply disruption both at the community, national and international level.
The above-suggested interventions are not free of risk for women. But weighing the risk and benefit, the benefit is much higher than placing women in risk of unintended pregnancy, using the harmful traditional method in terminating a pregnancy that will lead women either to death or other morbidities. This will on top exert the pressure on the health system that might be already overstretched in dealing the Covid-19 patients. To sum up, the reproductive health paradigm is changing. The advancement in science is making many reproductive health services possible for self-use. There are different of contraceptives being developed considering the self-removal such as IUD. These methods will not merely help in time of epidemic and humanitarian crisis by minimizing the need for health facility visit and health providers' time but also enhances women’s autonomy and control over their health.
(Public Health Professional Working in Health Sector in Nepal)
