- Email: [email protected]
I172 FIGO SAVING MOTHERS AND NEWBORNS PROJECT IN UGANDA
Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
I168 IJGO AUTHOR WORKSHOP: AN INSIDER’S GUIDE TO GETTING PUBLISHED T. Johnson1 , R. Adanu2 , V. Obama3 , V. Guinto4 , C. Sosa5 , C. Addington6 . 1 IJGO Editor-in-Chief ([email protected]); 2 Associate Editor: Contemporary Issues in Women’s Health ([email protected]); 3 Associate Editor: Contemporary Issues in Women’s Health ([email protected]); 4 Associate Editor: Contemporary Issues in Women’s Health ([email protected]); 5 Associate Editor: Contemporary Issues in Women’s Health ([email protected]); 6 IJGO Managing Editor (clare@figo.org) General overview of the session: An opportunity to learn more about how to maximize your chances of getting your research published from the IJGO Editorial team. From manuscript preparation, submission requirements, understanding the submission process and what’s happening at each stage, to top tips and insights from IJGO’s Editor and Associate Editors. I169 THE RESPECTFUL MATERNITY CARE CHARTER: A COLLABORATIVE WORK R.R. Jolivet Human rights are fundamental entitlements due to all people, recognized by societies and governments and enshrined in international declarations and conventions. A new charter, Respectful Maternity Care: the Universal Rights of Childbearing Women aims to address the problem of disrespect and abuse among women seeking maternity care and provide a platform for improvement by: • Raising awareness of childbearing women’s inclusion in guarantees of human rights recognized in internationally adopted standards and covenants; • Highlighting the connection between human rights language and key program issues in maternity care; • Increasing the capacity of maternal health advocates to participate in human rights processes; • Aligning childbearing women’s sense of entitlement to highquality maternity care with international human rights community standards; and • Providing a basis for holding maternal care systems and communities accountable to these rights. By drawing from established human rights instruments, the Charter demonstrates the legitimate place of maternal health rights within the broader context of human rights. Seven rights are included, corresponding to the seven categories of disrespect and abuse identified in the literature by Bowser and Hill (2010) in their review, “Exploring Evidence for Disrespect and Abuse in Facilitybased Childbirth: Report of a Landscape Analysis”. This charter was developed collaboratively by a multi-stakeholder group with expertise bridging research, educational, clinical, human rights, and advocacy perspectives. This presentation describes that process and methodology. I170 THE ROLE OF MIDWIVES & OBSTETRICIANS IN DELIVERING RESPECTFUL MATERNITY CARE R.R. Jolivet Evidence from 34 countries around the world documents physical assault, verbal insults, discrimination, abandonment, or detention without legal authority, perpetrated against childbearing women in maternal health facilities. Too often, women seeking maternity care receive treatment from their providers that ranges from disrespect to outright abuse, violating their basic human rights and the trust that is the foundation of the patient-provider relationship. Research suggests that fear of ill treatment can be a greater deterrent than cost or distance in the decision to seek facility-based maternity care. Furthermore, analysis of the available evidence suggests disrespect and abuse are associated with poor clinical
S203
quality of care, imposing undue risk on those women who seek skilled attendance in maternal health facilities. With support from USAID, the White Ribbon Alliance is working with partners from clinical, educational, research, human rights, and advocacy sectors. This collaboration resulted in the Respectful Maternity Care Charter: the Universal Rights of Childbearing Women and companion advocacy materials including a poster, brochure, and film. Grounded in human rights from internationally adopted declarations, these documents set the standard for Respectful Maternity Care and affirm it as every woman’s right. Promoting alignment among consumers and providers of health care about this framework of entitlement is a top priority. To eliminate disrespect and abuse during maternity care, the engagement of midwives and obstetricians is imperative. This presentation explores the conditions that may lead care providers to perpetrate abuses, and discusses their role as critical change agents through research, education, quality improvement, and community engagement. I171 PROMOTING WOMEN’S PARTICIPATION IN MATERNITY CARE: EXAMPLES FROM LEBANON T. Kabakian-Khasholian. Lebanon Women’s active involvement in maternity care and the responsiveness of different health care systems to women’s needs is a major deficiency encountered in different contexts around the world, both in developed and developing countries. The vast majority of systems providing maternity care around the world seek avoiding mortality by intervening excessively, thus leading to morbidity that could have been prevented. The alarming increase in cesarean births is one substantial example of these approaches. These maternity care models are characterized by their divergence from the scientific evidence indicating improved health outcomes of women-centered approaches, such as provision of information to women on different obstetrical procedures to facilitate women’s participation in the process of care by providing informed choices. Researchers of the Choices and Challenges in Changing Childbirth network in Lebanon have attempted influencing women’s perspectives and facilitating their inclusion in the maternal health care system through research and practice related activities. These were done by disseminating information on best practices to women and advocating for the adoption of evidence-based approaches in maternity care. These activities aimed at shaping women’s demand for a different model of maternity care that is based on scientific evidence and at encouraging a women-centered approach. This presentation will discuss these different activities as examples of promoting women’s participation in maternity care. I172 FIGO SAVING MOTHERS AND NEWBORNS PROJECT IN UGANDA F. Kaharuza, D. Zaake, S. Muwanguzi, O. Kakaire, J. Beyeza-Kashesya. Association of Obstetricians and Gynaecologists of Uganda (AOGU), Uganda Objectives: To contribute to reduction of maternal morality through increasing demand for and access to emergency obstetric and newborn care services in two rural districts in Uganda. Materials and Methods: Association of Obstetricians and Gynaecolgists of Uganda (AOGU) members developed partnerships with other professional associations to provide ALARM training and monthly onsite coaching and mentorship at six facilities; equipped the facilities, mobilized communities though training and support of 250 community health care workers Results: Facility births increased by 28% from baseline, facility based neonatal mortality reduced by 78%. Over 90 health care workers were trained in ALARM, and six health facilities were improved to provide at least five EmNOC signal functions. Eight management protocols were implemented by health workers while maternal death review committees were established at
S204
Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
the hospitals. Sexual and reproductive rights approaches were emphasized and health administrators were introduced to an abridged ALARM course. On the demand side, 40% of facility deliveries were referred by community health workers and 85 community groups were mobilized to save money for health emergencies. End of project evaluation, showed that over 300 pregnant women, over 9,000 men, women, and children had been supported to meet health care costs. Conclusion: This project demonstrates the pivotal role of professional organizations in the implementation of low-cost interventions to reduce maternal mortality and a model of supervision that has contributed towards “up-skilling” of clinicians in preventing and managing obstetric complications. Community based savings schemes can support funding for emergencies. I173 PRIMARY OVARIAN FAILURE S. Kalantaridou. Obstetrics and Gynecology, University of Ioannina Medical School, Ioannina, Greece Organized by: Hellenic Society of PAG Primary ovarian failure (POF) is a condition characterized by sexsteroid deficiency, amenorrhea, and infertility in women younger than 40 years. POF once was considered irreversible and was described as “premature menopause”. POF is not an early natural menopause and may present as primary or secondary amenorrhea. Normal menopause results from ovarian follicle depletion, whereas POF may occur as a result of either ovarian follicle dysfunction or ovarian follicle depletion. The term “primary ovarian insufficiency” may be a more accurate term to describe this condition. Women with POF produce estrogen intermittently and may ovulate despite the presence of high gonadotropin concentrations (intermittent ovarian function). Pregnancies may occur in 5–10% of women after the diagnosis of POF. There are no proven therapies to improve ovarian function and increase fertility rates in these young women. Women with POF sustain sex steroid deficiency for more years than do naturally menopausal women. This deficiency can result in a significantly higher risk for osteoporosis and cardiovascular disease. Postmenopausal women who take hormone therapy prolong their exposure to estrogen beyond the average age of completion of their reproductive phase. In contrast, women with POF need exogenous sex steroids to compensate for the decreased production by their ovaries. The goal of therapy in young women with POF is to provide a hormone replacement regimen that maintains sex steroid status as effectively as the normal, functioning ovary. Thus, premenopausal hormone therapy is required at least until these women reach the age of “natural menopause.” I174 FEMALE GENITAL MUTILATION/CUTTING IN THE GAMBIA: RESEARCH FOR KNOWLEDGE TRANSFER A. Kaplan1,2,3 , I. Bonhoure2 , S. Hechavarr´ıa4,5,6 , M. Mart´ın7 , M. Uzet7 , M.R. Pous2,8 . 1 C´ atedra de Transferencia del Conocimiento/Parc de Recerca UAB-Santander, Departamento de Antropolog´ıa Social y Cultural, Universitat Aut` onoma de Barcelona, Barcelona, Spain; 2 Grupo Interdisciplinar para la Prevenci´ on y el Estudio de las Pr´ acticas Tradicionales Perjudiciales (GIPE/PTP), Departamento de Antropolog´ıa Social y Cultural, Facultad de Letras y Psicolog´ıa, Universitat Aut` onoma de Barcelona, Barcelona, Spain; 3 NGO Wassu Gambia Kafo, Fajara F Section, Banjul, The Gambia; 4 Cuban Medical Mission in The Gambia, Banjul, The Gambia; 5 Community Based Medical Program, Ministry of Health and Social Welfare, Banjul, The Gambia; 6 Facultad de Ciencias M´edicas Manuel Fajardo. Universidad M´edica ´ frica de la Habana, La Habana, Cuba; 7 Grups de Recerca d’Am`erica i A Llatines (GRAAL), Unitat de Bioestadist´ıca. Facultat de Medicina, Universitat Aut` onoma de Barcelona, Barcelona, Spain; 8 Gynaecologist, Institut Catal` a de la Salut, Barcelona, Spain Objectives: In The Gambia, the prevalence of “Female Genital Mutilation/Cutting” (FGM/C) is 78.3% (MICS 2006). The study consists
of two clinical surveys done in The Gambia in order to identify the types practiced, the related health consequences of each type and the problems associated during delivery with FGM/C. Materials and Methods: For the first survey, nationwide, data was collected from 871 female patients who consulted for any problem requiring a medical gynaecologic examination and who had undergone FGM/C. For the second clinical survey, data was collected on 588 women who consulted for antenatal care or delivery and that had undergone or not, FGM/C. Results: The results show that FGM/C is still practiced in the six regions of The Gambia, the most common form being type I (66.2%), followed by type II (26.3%). All forms, including type I, produce significantly high percentages of complications, especially infections. The analysis of the consequences of FGM/C during delivery and foetal suffering revealed a strong correlation between these factors and that women with FGM/C are four times more likely to suffer complications during delivery. Conclusions: These results allowed the implementation of a national training work plan for the health professionals and students regarding the issue of FGM/C, directly based on knowledge transfer as the training contents include the observed health consequences in The Gambia. The results of the studies became a powerful tool in order to do advocacy at other decision-making levels, such as religious and political. I175 ETHICS AND TRENDS IN PRENATAL DIAGNOSIS S. Karchmer The financial setting of most of Latin American countries is not the most propitious; poverty and extreme poverty continue raising as the purchasing power of the income goes down, not only as absolute figures, but as it comes to the inflation. Therefore, the repercussions for health and education are bigger every time. On the other hand, the coverage of the reproductive event in Latin American countries is generally difficult to determine, especially about the evaluation of prenatal care quality. In most of Latin American counties the gynecological and obstetric services lack the appropriate resources to follow the guidelines and proceedings, and there is an inexistent educational background for the patient’s health. There are three reasons, which warrant the need of an ethical consensus for prenatal diagnosis in the clinical practice. First, the former guidelines need to be applied to the current issues of moral decision-making. Most of the current problems of prenatal diagnosis demand the ability to advise, and ethical sensitivity, which outstand the demands of the daily clinical practice. Second, even when the physicians of several counties agree about some basic principles and practical approaches to moral issues, their point of view becomes an “oral tradition,” instead of regulation principles. Nevertheless, not establishing a consensus through written guidelines reduces the relevance of a more important need. Third, the future of the prenatal diagnosis and medical genetics is going to be more ethically complex then ever. Physicians must a wait for a trouble storm that will demand the participation of the society and the establishment of public policies. The ethical evolution of prenatal diagnosis then would go through an early stage of oral tradition towards a more definitive in which there will emerge guidelines with the greatest professional and social support. It is not ethical for anyone to exert pressure in order to influence on the couple to accept a determined choice. I176 LESSONS LEARNED FROM NEPAL’S EXPERIENCE IN ESTABLISHING SECOND-TRIMESTER ABORTION SERVICES C. Karki. Institutional Development Committee, Nepal Society of Obstetrics and Gynecology (NESOG), Nepal This presentation will discuss Nepal’s expansion of comprehensive abortion services to include abortions in the second trimester.
I168 IJGO AUTHOR WORKSHOP: AN INSIDER’S GUIDE TO GETTING PUBLISHED T. Johnson1 , R. Adanu2 , V. Obama3 , V. Guinto4 , C. Sosa5 , C. Addington6 . 1 IJGO Editor-in-Chief ([email protected]); 2 Associate Editor: Contemporary Issues in Women’s Health ([email protected]); 3 Associate Editor: Contemporary Issues in Women’s Health ([email protected]); 4 Associate Editor: Contemporary Issues in Women’s Health ([email protected]); 5 Associate Editor: Contemporary Issues in Women’s Health ([email protected]); 6 IJGO Managing Editor (clare@figo.org) General overview of the session: An opportunity to learn more about how to maximize your chances of getting your research published from the IJGO Editorial team. From manuscript preparation, submission requirements, understanding the submission process and what’s happening at each stage, to top tips and insights from IJGO’s Editor and Associate Editors. I169 THE RESPECTFUL MATERNITY CARE CHARTER: A COLLABORATIVE WORK R.R. Jolivet Human rights are fundamental entitlements due to all people, recognized by societies and governments and enshrined in international declarations and conventions. A new charter, Respectful Maternity Care: the Universal Rights of Childbearing Women aims to address the problem of disrespect and abuse among women seeking maternity care and provide a platform for improvement by: • Raising awareness of childbearing women’s inclusion in guarantees of human rights recognized in internationally adopted standards and covenants; • Highlighting the connection between human rights language and key program issues in maternity care; • Increasing the capacity of maternal health advocates to participate in human rights processes; • Aligning childbearing women’s sense of entitlement to highquality maternity care with international human rights community standards; and • Providing a basis for holding maternal care systems and communities accountable to these rights. By drawing from established human rights instruments, the Charter demonstrates the legitimate place of maternal health rights within the broader context of human rights. Seven rights are included, corresponding to the seven categories of disrespect and abuse identified in the literature by Bowser and Hill (2010) in their review, “Exploring Evidence for Disrespect and Abuse in Facilitybased Childbirth: Report of a Landscape Analysis”. This charter was developed collaboratively by a multi-stakeholder group with expertise bridging research, educational, clinical, human rights, and advocacy perspectives. This presentation describes that process and methodology. I170 THE ROLE OF MIDWIVES & OBSTETRICIANS IN DELIVERING RESPECTFUL MATERNITY CARE R.R. Jolivet Evidence from 34 countries around the world documents physical assault, verbal insults, discrimination, abandonment, or detention without legal authority, perpetrated against childbearing women in maternal health facilities. Too often, women seeking maternity care receive treatment from their providers that ranges from disrespect to outright abuse, violating their basic human rights and the trust that is the foundation of the patient-provider relationship. Research suggests that fear of ill treatment can be a greater deterrent than cost or distance in the decision to seek facility-based maternity care. Furthermore, analysis of the available evidence suggests disrespect and abuse are associated with poor clinical
S203
quality of care, imposing undue risk on those women who seek skilled attendance in maternal health facilities. With support from USAID, the White Ribbon Alliance is working with partners from clinical, educational, research, human rights, and advocacy sectors. This collaboration resulted in the Respectful Maternity Care Charter: the Universal Rights of Childbearing Women and companion advocacy materials including a poster, brochure, and film. Grounded in human rights from internationally adopted declarations, these documents set the standard for Respectful Maternity Care and affirm it as every woman’s right. Promoting alignment among consumers and providers of health care about this framework of entitlement is a top priority. To eliminate disrespect and abuse during maternity care, the engagement of midwives and obstetricians is imperative. This presentation explores the conditions that may lead care providers to perpetrate abuses, and discusses their role as critical change agents through research, education, quality improvement, and community engagement. I171 PROMOTING WOMEN’S PARTICIPATION IN MATERNITY CARE: EXAMPLES FROM LEBANON T. Kabakian-Khasholian. Lebanon Women’s active involvement in maternity care and the responsiveness of different health care systems to women’s needs is a major deficiency encountered in different contexts around the world, both in developed and developing countries. The vast majority of systems providing maternity care around the world seek avoiding mortality by intervening excessively, thus leading to morbidity that could have been prevented. The alarming increase in cesarean births is one substantial example of these approaches. These maternity care models are characterized by their divergence from the scientific evidence indicating improved health outcomes of women-centered approaches, such as provision of information to women on different obstetrical procedures to facilitate women’s participation in the process of care by providing informed choices. Researchers of the Choices and Challenges in Changing Childbirth network in Lebanon have attempted influencing women’s perspectives and facilitating their inclusion in the maternal health care system through research and practice related activities. These were done by disseminating information on best practices to women and advocating for the adoption of evidence-based approaches in maternity care. These activities aimed at shaping women’s demand for a different model of maternity care that is based on scientific evidence and at encouraging a women-centered approach. This presentation will discuss these different activities as examples of promoting women’s participation in maternity care. I172 FIGO SAVING MOTHERS AND NEWBORNS PROJECT IN UGANDA F. Kaharuza, D. Zaake, S. Muwanguzi, O. Kakaire, J. Beyeza-Kashesya. Association of Obstetricians and Gynaecologists of Uganda (AOGU), Uganda Objectives: To contribute to reduction of maternal morality through increasing demand for and access to emergency obstetric and newborn care services in two rural districts in Uganda. Materials and Methods: Association of Obstetricians and Gynaecolgists of Uganda (AOGU) members developed partnerships with other professional associations to provide ALARM training and monthly onsite coaching and mentorship at six facilities; equipped the facilities, mobilized communities though training and support of 250 community health care workers Results: Facility births increased by 28% from baseline, facility based neonatal mortality reduced by 78%. Over 90 health care workers were trained in ALARM, and six health facilities were improved to provide at least five EmNOC signal functions. Eight management protocols were implemented by health workers while maternal death review committees were established at
S204
Invited presentations and presentations by organisations and societies / International Journal of Gynecology & Obstetrics 119S3 (2012) S161–S260
the hospitals. Sexual and reproductive rights approaches were emphasized and health administrators were introduced to an abridged ALARM course. On the demand side, 40% of facility deliveries were referred by community health workers and 85 community groups were mobilized to save money for health emergencies. End of project evaluation, showed that over 300 pregnant women, over 9,000 men, women, and children had been supported to meet health care costs. Conclusion: This project demonstrates the pivotal role of professional organizations in the implementation of low-cost interventions to reduce maternal mortality and a model of supervision that has contributed towards “up-skilling” of clinicians in preventing and managing obstetric complications. Community based savings schemes can support funding for emergencies. I173 PRIMARY OVARIAN FAILURE S. Kalantaridou. Obstetrics and Gynecology, University of Ioannina Medical School, Ioannina, Greece Organized by: Hellenic Society of PAG Primary ovarian failure (POF) is a condition characterized by sexsteroid deficiency, amenorrhea, and infertility in women younger than 40 years. POF once was considered irreversible and was described as “premature menopause”. POF is not an early natural menopause and may present as primary or secondary amenorrhea. Normal menopause results from ovarian follicle depletion, whereas POF may occur as a result of either ovarian follicle dysfunction or ovarian follicle depletion. The term “primary ovarian insufficiency” may be a more accurate term to describe this condition. Women with POF produce estrogen intermittently and may ovulate despite the presence of high gonadotropin concentrations (intermittent ovarian function). Pregnancies may occur in 5–10% of women after the diagnosis of POF. There are no proven therapies to improve ovarian function and increase fertility rates in these young women. Women with POF sustain sex steroid deficiency for more years than do naturally menopausal women. This deficiency can result in a significantly higher risk for osteoporosis and cardiovascular disease. Postmenopausal women who take hormone therapy prolong their exposure to estrogen beyond the average age of completion of their reproductive phase. In contrast, women with POF need exogenous sex steroids to compensate for the decreased production by their ovaries. The goal of therapy in young women with POF is to provide a hormone replacement regimen that maintains sex steroid status as effectively as the normal, functioning ovary. Thus, premenopausal hormone therapy is required at least until these women reach the age of “natural menopause.” I174 FEMALE GENITAL MUTILATION/CUTTING IN THE GAMBIA: RESEARCH FOR KNOWLEDGE TRANSFER A. Kaplan1,2,3 , I. Bonhoure2 , S. Hechavarr´ıa4,5,6 , M. Mart´ın7 , M. Uzet7 , M.R. Pous2,8 . 1 C´ atedra de Transferencia del Conocimiento/Parc de Recerca UAB-Santander, Departamento de Antropolog´ıa Social y Cultural, Universitat Aut` onoma de Barcelona, Barcelona, Spain; 2 Grupo Interdisciplinar para la Prevenci´ on y el Estudio de las Pr´ acticas Tradicionales Perjudiciales (GIPE/PTP), Departamento de Antropolog´ıa Social y Cultural, Facultad de Letras y Psicolog´ıa, Universitat Aut` onoma de Barcelona, Barcelona, Spain; 3 NGO Wassu Gambia Kafo, Fajara F Section, Banjul, The Gambia; 4 Cuban Medical Mission in The Gambia, Banjul, The Gambia; 5 Community Based Medical Program, Ministry of Health and Social Welfare, Banjul, The Gambia; 6 Facultad de Ciencias M´edicas Manuel Fajardo. Universidad M´edica ´ frica de la Habana, La Habana, Cuba; 7 Grups de Recerca d’Am`erica i A Llatines (GRAAL), Unitat de Bioestadist´ıca. Facultat de Medicina, Universitat Aut` onoma de Barcelona, Barcelona, Spain; 8 Gynaecologist, Institut Catal` a de la Salut, Barcelona, Spain Objectives: In The Gambia, the prevalence of “Female Genital Mutilation/Cutting” (FGM/C) is 78.3% (MICS 2006). The study consists
of two clinical surveys done in The Gambia in order to identify the types practiced, the related health consequences of each type and the problems associated during delivery with FGM/C. Materials and Methods: For the first survey, nationwide, data was collected from 871 female patients who consulted for any problem requiring a medical gynaecologic examination and who had undergone FGM/C. For the second clinical survey, data was collected on 588 women who consulted for antenatal care or delivery and that had undergone or not, FGM/C. Results: The results show that FGM/C is still practiced in the six regions of The Gambia, the most common form being type I (66.2%), followed by type II (26.3%). All forms, including type I, produce significantly high percentages of complications, especially infections. The analysis of the consequences of FGM/C during delivery and foetal suffering revealed a strong correlation between these factors and that women with FGM/C are four times more likely to suffer complications during delivery. Conclusions: These results allowed the implementation of a national training work plan for the health professionals and students regarding the issue of FGM/C, directly based on knowledge transfer as the training contents include the observed health consequences in The Gambia. The results of the studies became a powerful tool in order to do advocacy at other decision-making levels, such as religious and political. I175 ETHICS AND TRENDS IN PRENATAL DIAGNOSIS S. Karchmer The financial setting of most of Latin American countries is not the most propitious; poverty and extreme poverty continue raising as the purchasing power of the income goes down, not only as absolute figures, but as it comes to the inflation. Therefore, the repercussions for health and education are bigger every time. On the other hand, the coverage of the reproductive event in Latin American countries is generally difficult to determine, especially about the evaluation of prenatal care quality. In most of Latin American counties the gynecological and obstetric services lack the appropriate resources to follow the guidelines and proceedings, and there is an inexistent educational background for the patient’s health. There are three reasons, which warrant the need of an ethical consensus for prenatal diagnosis in the clinical practice. First, the former guidelines need to be applied to the current issues of moral decision-making. Most of the current problems of prenatal diagnosis demand the ability to advise, and ethical sensitivity, which outstand the demands of the daily clinical practice. Second, even when the physicians of several counties agree about some basic principles and practical approaches to moral issues, their point of view becomes an “oral tradition,” instead of regulation principles. Nevertheless, not establishing a consensus through written guidelines reduces the relevance of a more important need. Third, the future of the prenatal diagnosis and medical genetics is going to be more ethically complex then ever. Physicians must a wait for a trouble storm that will demand the participation of the society and the establishment of public policies. The ethical evolution of prenatal diagnosis then would go through an early stage of oral tradition towards a more definitive in which there will emerge guidelines with the greatest professional and social support. It is not ethical for anyone to exert pressure in order to influence on the couple to accept a determined choice. I176 LESSONS LEARNED FROM NEPAL’S EXPERIENCE IN ESTABLISHING SECOND-TRIMESTER ABORTION SERVICES C. Karki. Institutional Development Committee, Nepal Society of Obstetrics and Gynecology (NESOG), Nepal This presentation will discuss Nepal’s expansion of comprehensive abortion services to include abortions in the second trimester.