Applying the WHO Strategic Approach to Strengthening First and Second Trimester Abortion Services in Mongolia

Abstract

Abortion was made legal on request in Mongolia in 1989, following the collapse of the socialist regime, and later bound by a range of regulations. Concerned about the high number of abortions and inadequate quality of care in abortion services, the Ministry of Health applied the World Health Organization's Strategic Approach to issues related to abortion and contraception in 2003. The aim was to develop policies and programmes to reduce unintended pregnancies, mitigate complications from unsafe abortion, and improve the quality of abortion and contraception services for all socio-economic groups, including adolescents. This paper describes the changes that arose from a strategic assessment, highlighting the introduction of mifepristone–misoprostol for second trimester abortion. The aim was to replace mini-caesarean section and intra-uterine injection of Rivanol (ethacridine lactate), so that second trimester abortions could take place earlier than at 20 weeks gestation. National standards and guidelines for comprehensive abortion care were developed, the national pre-service training curriculum was harmonised with the new guidelines, at least one-third of the country's obstetrician–gynaecologists were trained in manual vacuum aspiration and medical abortion, and three model comprehensive abortion care units were established to provide high quality services to women, high quality training for providers and serve as nodes for further scaling up.

Résumé

L'avortement a été légalisé sur demande en Mongolie en 1989, après l'effondrement du régime socialiste et il a été par la suite réglementé par une série de textes. Préoccupé par le grand nombre d'avortements et la qualité médiocre des soins, en 2003, le Ministère de la Santé a appliqué l'approche stratégique de l'OMS aux questions liées à l'avortement et la contraception. Il s'agissait de définir des politiques et des programmes pour réduire les grossesses non désirées, diminuer les complications des avortements non médicalisés et relever la qualité des services d'avortement et de contraception pour tous les groupes socio-économiques, notamment les adolescents. Cet article décrit les changements déclenchés par une évaluation stratégique, mettant l'accent sur l'introduction de la mifépristone et du misoprostol pour les avortements du deuxième trimestre. L'objectif était de remplacer la mini-césarienne et l'injection intra-utérine de Rivanol (lactate d'éthacridine), afin que les avortements du deuxième trimestre puissent être pratiqués avant la vingtième semaine de gestation. Les normes et directives nationales sur des soins complets d'avortement ont été définies, le curriculum national de formation préalable a été harmonisé avec les nouvelles directives, au moins un tiers des obstétriciens-gynécologues du pays ont été formés à l'aspiration manuelle et à l'avortement médicamenteux, et trois unités modèles de soins complets d'avortement ont été créées pour assurer des services de qualité aux femmes et une formation de haut niveau pour les soignants, et servir de tremplin pour un futur élargissement.

Resumen

En Mongolia, el aborto a petición fue legalizado en 1989, tras la caída del régimen socialista, y después restringido por una serie de reglamentos. En 2003, preocupado por el alto índice de abortos y la deficiente calidad de la atención en los servicios de aborto, el Ministerio de Salud aplicó el Enfoque estratégico de la Organización Mundial de la Salud a los aspectos relacionados con el aborto y la anticoncepción. El objetivo era formular políticas y programas para disminuir el número de embarazos imprevistos, mitigar las complicaciones del aborto inseguro y mejorar la calidad de los servicios de aborto y anticoncepción para todos los grupos socioeconómicos, incluidos los adolescentes. En este artículo se describen los cambios que surgieron de una evaluación estratégica y se destaca el lanzamiento de mifepristona–misoprostol para el aborto en el segundo trimestre, cuya finalidad fue sustituir los procedimientos de mini-cesárea e inyección intrauterina de Rivanol (lactato de etacridina), de manera que los abortos en el segundo trimestre pudieran efectuarse antes de las 20 semanas de gestación. Se elaboraron normas y directrices nacionales para la atención integral del aborto, las cuales fueron utilizadas para armonizar el currículo nacional de capacitación de pregrado; por lo menos una tercera parte de los gineco-obstetras del país fueron capacitados en la aspiración manual endouterina y el aborto con medicamentos; y se establecieron tres unidades modelo de atención integral del aborto para proporcionar servicios de alta calidad a las mujeres y capacitación de alta calidad a los prestadores de servicios, así como para servir como centros para continuar ampliando los programas.

Key Words:

• abortion law and policy
• WHO Strategic Approach
• second trimester abortion
• manual vacuum aspiration
• medical abortion
• Rivanol
• mini-caesarean section
• Mongolia

In the late 1990s Ministry of Health officials in Mongolia were growing increasingly concerned about both the high number of abortions and the inadequate quality of care in abortion services. Following participation in a World Health Organization (WHO) sub-regional workshop on the Strategic Approach to strengthening sexual and reproductive health policies and programmes, held in Kunming, China in 2002, they requested support to apply the process to issues related to abortion in Mongolia and implement the first stage – a strategic assessment. This paper presents findings from the strategic assessment and follow-up actions addressing second trimester abortion in the context of a broad-based, participatory effort to strengthen abortion services in general. These included: development of new national standards and guidelines, introduction of new technologies and procedures; and initiation of the process of scaling up services for both first and second trimester abortion. The assessment and follow-up was led by the Ministry of Health's Public Health Institute and collaborating partners, including the Mongolian Foundation for Open Society (Soros Foundation), WHO, GTZ, Population Council and Ipas.

The WHO Strategic Approach is a three-stage process that includes: 1) a national-level strategic assessment to identify and prioritise needs; 2) policy and programme changes to address the most urgent needs and action–research to test pilot interventions; and 3) scaling up proven innovations so the benefits can reach more people.¹² To date, the Strategic Approach has been applied to issues related to abortion and contraception in nine countries – Bangladesh, Ghana, Macedonia, Moldova, Mongolia, Romania, Ukraine, Viet Nam and Zambia.

Background and legal context of abortion

In Mongolia, abortion has been legal since 1943 if a medical doctor certified that the pregnancy constituted a threat to the woman's life.³ In 1985, the grounds for legal abortion were expanded to include some non-medical factors including married women over 35 with more than five children, single women with more than three children, and women who became pregnant within one year of a prior pregnancy.⁴ In 1989, the Health Protection Law of the Mongolian People's Republic included an amendment that: “A woman has the right to decide whether and when to become a mother”, thus legalising abortion at a woman's request.⁵ At the same time, all restrictions on use, distribution and importation of contraceptives were removed. The current law defines first trimester procedures as “early” abortion and second trimester procedures as “late” abortion. The upper time limit is 22 weeks of pregnancy.

A number of other Ministerial orders and amendments have decreed that abortions can only be provided by licensed obstetrician–gynaecologists in licensed facilities that have the equipment necessary for management of complications and beds for recuperation. All women presenting for abortion should also have a referral from their family doctor,⁶ be registered in the district where services are provided, and have undergone an HIV test⁷ and a swab test for other sexually transmitted infections (STIs).⁸ Private facilities can be licensed to provide abortions if all the required criteria are met. However, private sector health facilities are expanding rapidly in a relatively unmonitored environment in Mongolia, and many provide abortion without a licence to do so.

Second trimester abortion can only be performed at the Maternal and Child Health Research Centre (Ulaanbaatar), and Ulaanbaatar city maternity homes, delivery departments of aimag (provincial) hospitals and licensed private clinics,⁷ if one or more of the following criteria are met: the pregnancy constitutes a threat to the life of the woman or fetus; at the request of the woman if she is aged under 16 or over 45 years; where the woman has a psychological disorder; or where the pregnancy is the result of rape or incest.⁹

However, many second trimester abortions continue to be performed for non-medical reasons. For example, in 2000, 49 of 58 cases of second trimester abortion registered at an Ulaanbaatar maternity hospital were for non-medical reasons.¹⁰

Moving from unsafe to safe abortion 1989–2003

Prior to 1989, the number of admissions to hospital for abortion complications suggests there were a significant number of unsafe abortions. Following the change in the law in 1989, an increasing number of private clinics began providing abortion, which although probably safer than those provided before legalisation, were also mostly unreported. Between 1989 and 1999, the abortion ratio, based on national statistics, rose dramatically, from 241 per 1,000 live births in 1989 to 442 in 1992, and then began to fall again, reaching a stable ratio of 200–248 after 1999. In 2004, 2005 and 2006 the ratio was 200.¹⁰¹¹ The government's goal for 2011 is 160.¹²

Information based on survey data suggests that unsafe abortion remained a problem in the mid-1990s. Approximately one-quarter of women in the 1998 Reproductive Health Survey who underwent an abortion reported health problems afterwards. Furthermore, 61% of the women reporting complications (7% of all women having abortions) required subsequent hospitalisation.¹³ This contrasts with an average of 4.6% post-abortion complications reported in national health statistics between 1996 and 2000.¹⁰ In 2000, haemorrhage was the most frequently reported complication (44.2%), followed by uterine infection (38.5%), other reasons (8.3%), sepsis (5.7%), and perforation (3.2%).¹⁴ In 2000, 9.9% of all abortions were in the second trimester of pregnancy, with nearly 70% of all late abortions being performed in Ulaanbaatar.¹⁴ Published data for 1996–2000 suggest that the reported number of deaths resulting from post-abortion complications was small.¹⁰ However, there is some reason to believe that maternal mortality from post-abortion complications is also under-reported. The number of maternal deaths in 2002 was 57, or 124 per 100,000 live births; 15 of these deaths were a result of complications of abortion.¹⁵

The 1998 Reproductive Health Survey showed that 44% of all Mongolian women used a contraceptive method. The most common methods were IUDs (23%) and periodic abstinence (10%).¹³ Less commonly used methods included pills (3%), condoms (2.8%) and injectable contraceptives (2.3%).¹³ Contraceptives were supposed to be available through family doctors and aimag reproductive health cabinets. However, recourse to abortion remained high in the late 1990s. In an effort to address the high number of abortions, free provision of contraceptives at public health facilities was mandated under the National Reproductive Health Programme, starting in 2001. Also, a team from the Ministry of Health and partner institutions decided abortion should be addressed using the WHO Strategic Approach.

The following describes, in brief, the 2003 strategic assessment,^{16 *} what emerged about second trimester abortion during the analysis of the findings, and the policy and service delivery changes that arose, particularly with regard to the provision of second trimester abortion.

The 2003 strategic assessment

The process began in early 2003 with the writing and dissemination of a background paper summarising available research and information on abortion policy and law in Mongolia. In April 2003 a national stakeholders' workshop, which included high-level Ministry of Health policymakers, was convened to discuss the findings of the background paper and identify strategic questions that would guide the strategic assessment. These included the following:

• What strategies could be used to reduce the demand for abortion and mitigate complications arising from abortion?

• How can the quality of abortion services be improved in different types of service delivery settings?

• What options are available for improving the delivery of family planning in order to meet the needs of women from all socio-economic and demographic groups, including adolescents?

Fieldwork took place over a three-week period from mid-May to early June 2003 in six of Mongolia's 21 aimags as well as in Ulaanbaatar. Ten soums (districts) and 22 baghs (smaller administrative units) from these six aimags and six districts of the capital city were included. The sites for visits were purposively selected so as to reflect variations in access to services, geographic diversity and socio-economic differentials.

The 19-member assessment team included staff from the Public Health Institute, Maternal and Child Health Research Centre, two youth organisations, abortion service providers from the public, private and NGO sectors, and international NGOs with offices in the region. The team conducted over 600 discussions with community members, abortion patients, state and private service providers, decision-makers, programme managers, and in-school and out-of-school adolescents. 62 abortion procedures at all levels of service provision, including the private sector, were observed.

Key findings and recommendations

The assessment team members took a comprehensive, systems approach to issues related to fertility regulation, investigating interactions among service users and providers, policy and institutional capacities, and contraception and abortion services and methods being provided. Team members' field notes were analysed and discussed on a nightly basis and the interview strategy was revised accordingly to capture the widest possible range of variation in knowledge and attitudes related to strengthening abortion policies and service delivery.

Availability of contraception and abortion services

At the time of the assessment, nearly all contraceptives in the country were provided free of charge by UNFPA; however, stockouts were common in some parts of the country, especially at the soum level. Eastern and northern aimags visited reported they had not received new contraceptive supplies in the previous two months, while the western aimags visited reported no new supplies in the previous six months. The local system for procurement and distribution of contraception appeared to be complicated and not working well. Assessment team members found that contraceptives were often not available in private pharmacies or from family doctors, and were rarely available in or near the abortion unit in the hospitals.

Although abortion services were readily accessible to women seeking both first and second trimester procedures, availability of services was often limited to the main hospital in the aimag hospitals and private clinics that were not officially licensed to provide abortion. This meant that women from rural areas often had to travel long distances at considerable cost to obtain services, especially for second trimester abortion, which was only available in the aimag hospitals. Also, mifepristone and misoprostol illegally imported from China were available in some pharmacies in Ulaanbaatar. However, based on visits to several pharmacies, team members discovered that pharmacists were not uniformly knowledgeable about how to use the drugs. In at least one pharmacy, the team found misoprostol for sale that was well past its expiry date. Many providers interviewed reported that they often saw cases of incomplete abortion caused by the so-called “Chinese drug”. We could not ascertain whether this was from incorrect home use, poor drug quality or other causes.

The actual number of abortions was difficult to ascertain at the facility level due to under-reporting. This was related in part to administrative and bureaucratic delays in the financial reimbursement by the State to providers who, depending on the facility, received 25%–60% of the abortion fee. Rather than wait several months to receive their reimbursement, some providers chose not to register the procedure and kept the entire fee. Another reason for under-reporting was the desire of some providers to avoid taxation on earnings. Private clinics that did not have official approval to provide services were also unlikely to report abortions.

Poor quality of care and other barriers to utilisation of public sector services

Inconvenient hours of operation (often only three hours in the morning on weekdays) were especially inconvenient for working women. Poor quality of care, the requirement of HIV and other STI screening tests, and the lack of privacy and confidentiality all served to discourage many women from utilising public sector abortion facilities as well.

In general, the layout of abortion units was not conducive to provision of information and counselling or patient privacy. Procedure rooms were usually some distance from the waiting and recuperation area, and the latter were often just one room. In some units there was no visual privacy between two procedure tables. Manual vacuum aspiration (MVA) instruments observed in public hospitals tended to be old, worn, and in short supply. Infection prevention procedures varied widely and pain management interventions were often not available, or if available, not utilised unless specifically requested by the patient. Counselling of any sort and informational materials were rarely if ever available. No providers interviewed had received training in pre- or post-abortion counselling.

Public hospitals were more likely than private clinics to require an HIV test and vaginal swab test to screen for STIs. Public hospitals also required women to produce legal identification, a referral letter from their family doctor, and their permanent health record. Women expressed concerns about the abortion being entered on their permanent health record. According to key informants, many women continue to consider these requirements invasions of privacy and confidentiality.

Furthermore, women could only receive public sector services in locations where they were officially registered. For example, students who lived in Ulaanbaatar for university education could only receive services in their home aimags where they were registered, unless they were willing to pay the fee to change their registration from one district to another.

Second trimester abortion

Prior to 2005, there were no methods available to induce abortion between 12 weeks and 19 weeks gestation, so women presenting during this time were instructed to return after their pregnancy had reached 20 weeks. At 20+ weeks gestation one of two methods was used: either Rivanol (ethacridine lactate) was injected through the abdominal wall into the uterus to induce abortion or a “mini-caesarean section” (hysterotomy) was performed. A mini-caesarean was usually performed if the woman had completed her fertility goals and desired a tubal ligation in conjunction with the abortion. The mini-caesarean section/tubal ligation was also reported to be used for mentally disabled women,⁹ with consent usually obtained from the woman's mother.

All second trimester abortions observed during the assessment were for non-medical reasons (although sometimes recorded as medical reasons), such as low socio-economic status, the last child being too young, marital discord or divorce, or gender-based violence in the home. Second trimester abortion for medical indications was free of charge. However, the cost of late abortion for non-medical reasons was considerably higher than for first trimester procedures and varied among different providers. Women who could not obtain late abortion in a public sector facility were forced to seek services in the private sector, the majority of which were not licensed and therefore provided the procedure clandestinely.

As previously mentioned, transport was a major problem in rural areas both in terms of availability and cost. In some areas the cost of transport and accommodation could double the cost of obtaining an abortion. This was especially problematic for women wanting second trimester abortion, who often made a wasted journey if they were early in the second trimester and had to come back some weeks later. It also added significant risk for complications and mortality.

Follow-up to the strategic assessment

Priority recommendations from the strategic assessment focused on the need for national standards and guidelines for comprehensive abortion care, ensuring increased availability of MVA and the need for in-service training in MVA for all abortion providers, as well as pre-service training for all medical students. One of the most urgent recommendations was for introduction of mifepristone–misoprostol to replace Rivanol for induction of second trimester abortion. Team members felt that widespread availability of mifepristone–misoprostol would help to make many second trimester procedures earlier and safer, thus having an immediate impact on the high rates of abortion-related morbidity and mortality.

The follow-up activities were intended to strengthen the quality of abortion care in general. The first steps included developing national standards¹⁷ and guidelines and revising pre-service training curricula. At the same time, the Ministry of Health persuaded a private company to register mifepristone and misoprostol for first and second trimester abortion. The drugs were also included in the National Drugs Registry in 2006. A workshop organised for obstetricians and gynaecologists in Ulaanbaatar provided the opportunity to disseminate information on issues related to use of the two drugs for first and second trimester abortion. An official private pharmacy was opened to assure quality drug distribution and the drugs are sold only by prescription from doctors. The prices of the drugs for the recommended first trimester abortion regimen were set at what was considered an affordable level of MNT 8,400 (US$7.16) for 200 mg of mifepristone and MNT 6,000 (US$5.11) for 800 mcg of misoprostol. However, at US$17–26, first trimester medical abortion in Mongolia remains considerably more expensive than abortion using MVA, which ranges from US$7–15. A study of second trimester abortion in the Maternal and Child Health Research Centre also indicated higher costs for mifepristone–misoprostol compared to Rivanol.¹⁸

WHO recommendations for second trimester medical abortion are included in the national guidelines as follows: 200 mg mifepristone orally, then after 36–48 hours 800 mcg misoprostol vaginally followed (as and if required) by 400 mcg misoprostol orally every three hours up to four doses.¹⁵ All women undergoing medical abortion are required to stay in the hospital under doctors' observation until completion of the abortion.¹⁵

In-service training of trainers in comprehensive abortion care utilising MVA for first trimester abortion and mifepristone–misoprostol for first and second trimester abortion was conducted by international experts. Between 2004–2007 nearly a third of obstetrician–gynaecologists in Mongolia had received training in comprehensive abortion care and post-abortion family planning.

To support the ambitious training programme, there was a need to upgrade the training centres to improve quality of care and increase capacity. The outpatient abortion unit in the Maternal and Child Health Research Centre in Ulaanbaatar was renovated with funding from GTZ and transformed into a model national training facility in 2005. GTZ and WHO also provided funding for similar renovations to the abortion units at the Central Regional Diagnostic and Treatment Centre in Arvaikheer (Uvurhangai aimag) and the First Maternity Hospital in Ulaanbaatar, which is a major training centre for general medical students from the Health Sciences University. Renovations included expansion of the abortion units to include linked rooms that facilitate a one-way patient flow system for waiting, counselling, abortion procedures, and recuperation. Toilet facilities were also installed in the renovated units. Further expansion of training and facility improvement is planned in 2008 and beyond, with funding and technical support from WHO and other partners.

Discussion

Today, throughout Mongolia, according to the Ministry of Health, manual vacuum aspiration has almost completely replaced dilatation and curettage for first trimester abortion. Indeed MVA was used almost exclusively in the three pilot sites and a new WHO baseline study¹⁹ shows that MVA is also used exclusively for first trimester abortion in the Western and Eastern Regional Diagnostic and Treatment Centres (in Khovd and Dornod respectively). However, use of mifepristone–misoprostol for early abortion has been slow to be adopted, primarily because of the higher cost and providers' concerns about women aborting at home.

There is much less certainty about the extent to which mifepristone–misoprostol is available and being used for second trimester abortion. The baseline study conducted in the Western and Eastern Regional Diagnostic and Treatment Centres found that mifepristone–misoprostol was not in use in Khovd but accounted for 52% of reported second trimester abortions in Dornod. Other procedures used still included mini-caesarean section and intra-amniotic injections of Rivanol, as described earlier. The difficulty in obtaining service delivery data on methods used by gestational age underlines the need for strengthening the monitoring, evaluation and reporting system.

Mifepristone–misoprostol was successfully introduced for second trimester abortion in the Maternal and Child Health Research Centre and Central Regional Diagnostic and Treatment Centre, following the strategic assessment. These were the only two hospitals included in the assessment that reported data on second trimester abortion method in 2006 and 2007. In the former, there were 173 abortions between 13–22 weeks in both years, of which 75% were with mifepristone–misoprostol and the rest mini-caesareans. In the latter, there were 34 and 32 abortions at 13–22 weeks in the two years, respectively, all of which were with mifepristone–misoprostol. Questions remain about management of second trimester abortion in the third pilot site (which was reported to be using misoprostol and laminaria) and in other hospitals throughout the country.

A national survey on facility infrastructure and provider practices would provide valuable information about the number and types of procedures being used by gestational age, as well as about the infrastructure needs of clinics for providing high quality care. Such a survey would also help guide policymakers' decisions about future directions for scaling up services.

Other important unanswered questions related to second trimester abortion in Mongolia include:

• How has the introduction of mifepristone–misoprostol affected provider income generation and their willingness to report procedures?

• What proportion of second trimester procedures are now performed between 13–19 weeks gestation, rather than later for method-related reasons? Has mortality and morbidity from the later, higher risk methods fallen concomitantly?

• What is the level of quality of care in the provision of second trimester abortion, both in regard to technical issues, as well as with regard to provision of information, counselling, privacy, post-abortion contraception and related issues.

• What happens to poor women who need second trimester abortion for non-medical reasons, but cannot afford to pay the high fee?

• Do current regulations on second trimester abortion need to be revised to officially include provision of services for non-medical reasons?

Conclusions

The 2003 strategic assessment of abortion and contraception was a milestone in the improvement of induced abortion services in Mongolia. The WHO Strategic Approach continues to facilitate a participatory and collaborative process, which ensures that the Ministry of Health and its partners are primed to continue scaling up safe comprehensive abortion care, including second trimester abortion, and to address new challenges as private sector services expand nationwide.

Plans are being developed for expanding comprehensive abortion care, including post-abortion contraception, in 2008–09. Planned activities under discussion at this writing include: conducting a national facility infrastructure and provider skills survey to inform the scaling-up of training and infrastructure improvements; upgrading the Western (Khovd) and Eastern (Dornod) Regional Diagnostic and Treatment Centres; providing technical support for additional in-service training of providers; and possibly the re-introduction of mifepristone–misoprostol for early abortion through an operations research study at the Maternal and Child Health Research Centre.

There is an urgent need to scale up the use of mifepristone–misoprostol in order to make second trimester abortions earlier and to further reduce complications. The Ministry of Health and its partners deserve praise for their considerable achievements in implementing many of the priority recommendations from the strategic assessment within such a brief period, though much work remains to be done. Of special significance in these efforts have been the accomplishments in strengthening access to and quality of care of second trimester services in the context of a comprehensive programme for abortion care.

Note

The views expressed are the authors' and do not necessarily represent the decisions or policies of the World Health Organization.

Acknowledgements

The strategic assessment in Mongolia was funded primarily by the Open Society Institute of Mongolia (SOROS Foundation), with additional financial support from the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Mongolian-German Reproductive Health Project (GTZ), and Ipas. International technical support was provided by HRP, Population Council (Bangkok) and Ipas. GTZ and WHO provided primary funding for priority follow-up activities and WHO continues to fund activities related to scaling up interventions. The authors thank Dr I Davaadorj, Dr Peter Fajans, Dr Philip Guest and Dr Ts Sodnompil for the instrumental roles they played in bringing the strategic assessment to life. Dr Salik Govind and Mr Robert Hagan in the WHO Country Office provided critical technical and financial support for scaling up quality services. The authors also thank Dr Peter Fajans for review and helpful comments on early drafts of the manuscript.

Notes

* The full report of the strategic assessment, entitled “A strategic assessment of policy, program and research issues related to reducing the recourse to abortion and improving the quality of care of abortion and family planning services in Mongolia”, was written by the assessment team. Much of the background information on abortion in Mongolia reported here came from the background paper of the assessment. The authors of this paper all participated in the strategic assessment team.