MTP Training
As per GoI guidelines MTP training was being conducted for a period of 12 working days. However in view of the feedback received from various sources, the hand on training experience obtained in 12 days was not found adequate. It has been decided to fix the duration of MTP training to 18 days for MBBS doctors and 4 days for ObGyns. Manual Vaccum Aspiration (MVA), Medical Abortion has been included in the syllabus of this training.

IPAS, is partnering Government of Maharashtra in providing MTP training (Safe Abortion) under RCH II.

Training Site: 20 (Medical Colleges/District Hospital/Women’s Hospital)
Details of training site:

MVA (Manual Vaccum Aspiration)

Increasing Access to Safe Abortion Services in Maharashtra
Ipas is an international non-governmental organization which has partnered with the Department of Health and Family Welfare, Government of Maharashtra and has been providing technical and programmatic support to the NRHM/ RCH II program in the state. As part of this program, the Government of Maharashtra envisages expanding access to safe and comprehensive abortion care (CAC) services.

In partnership with the Department of Health and Family Welfare, Ipas initiated a pilot project in the district of Pune to develop models for increasing access to comprehensive abortion care. The pilot involved strengthening training capacities and establishing a model for providing comprehensive abortion care services in three rural hospitals and six primary health centres.

Based on the experience gained and lessons learnt during the pilot project, it was decided to scale-up this component across the state under the NRHM/RCH II project. Ipas continues to provide technical assistance to operationalize this component based on the action plan. The key objective of the plan is to make available CAC services on a regular basis in public sector sites focusing on the rural hospitals and primary health centers in a phased manner.

Ipas along with Government of Maharashtra has been able to establish training and service delivery interventions in the following districts of the state:

Map of Maharashtra

Key accomplishments of the project till dat
20 functional CAC training sites have been established. (3 Sites for Only Private Doctors training)

	323 doctors and 153 support staff have been trained as the master trainers in TOTs till June 2008.
	Till Dec 2007, 667 doctors and 404 support staff have been trained at the CAC training sites in the state. These include 632 doctors and 404 support staff from the public sector, and 35 doctors from the private sector). Following is the facility level breakup of the trained providers:
Facility Level Breakup
	To increase access to safe abortion services in the private sector:
	four sites from the private sector have been approved as CAC training sites.
	operationalization of District Level Committees was facilitated to enable smooth approval of the private sector sites as MTP clinics.
	Training materials and curriculum for ToT workshops and second generation CAC trainings have been revised both for providers and support staff.
	A 'trainee tracking survey’ to assess the post training performance has been recently been completed by Ipas. A total of 447 doctors were tracked to see the initiation of CAC services following the training. Qualitative aspects of the service delivery (pain management, appropriate technology, contraceptive acceptance etc.) were also a part of the tracking. Following are the key findings of the survey:
Post Training Performance
		No.	%
Ever Provided MTP		404	90.4
Never Provided MTP		43	9.6
Currently Providng MTP		332	74.3
Provided earlier and dropped out		72	16.1
Never initiated provding MTP		43	9.6
Total		447	100

Information on Medication Abortion
Medication abortion offers doctors and women choice and helps increase access to safe abortions. Medication abortion is a non-surgical method to terminate early pregnancies and is based on a proven regimen combining two drugs – Mifepristone and Misoprostol.

Medication Abortion became an option for early abortion in India when in April 2002, the Drugs Controller General approved the use of Mifepristone to terminate early pregnancies. In December 2006, the Drugs Controller General of India granted the permission for Misoprostol use in gynecological conditions like cervical ripening, prevention of post partum hemorrhage and first trimester abortion with Mifepristone.

In India, a combination of Mifepristone and Misoprostol is recommended for termination of early pregnancy up to 49 days/seven weeks from the last menstrual period (LMP).

Mechanism of Action of the drugs
Mifepristone is an anti-progestin, which stops the pregnancy from growing, detaches it from the lining of the uterus and softens the cervix.

Misoprostol is a prostaglandin E1 analogue that dilates the cervix, causes the uterus to contract and expel the pregnancy. Misoprostol is well absorbed through gastrointestinal as well as vaginal mucosa.

Medication Abortion is a process and therefore, it completes over a period of time. The beginning and duration of bleeding and cramping is different for every woman. Most (75%) women abort within four-six hours of taking Misoprostol, 30% of the remaining abort later at home on the same day. Remaining women mostly abort within the next five days. The heaviest bleeding lasts up to 4 hours, generally occurs during the actual abortion process and is almost always accompanied by cramps, bleeding might continue for about 8-13 days.

Effectiveness
The combination of Mifepristone and Misoprostol has been proven to be very effective. In combination, their efficacy rate is 95-99% for early abortions up to seven weeks. 1-2% may require aspiration methods due to heavy bleeding, 1-2% may fail to abort, 2-3% may have incomplete abortion for which aspiration methods are to be used, 0.1-0.2% may have profuse bleeding requiring blood transfusion.

Key Steps for Medication Abortion

• Counseling and obtaining informed consent.
• Medical history and examination.
• Drug protocol including follow up visit for confirmation of completeness of abortion.
• Contraceptive services.
• Referral for other reproductive health services (if required).

Important Points to be Emphasized during Counseling

• Minimum three visits to the facility will be required to follow the drug protocol.
• She may have vaginal bleeding for 8-13 days.
• Expected side effects of the drugs. Misoprostol causes teratogenic effects leading to fetal malformation if pregnancy continues, hence willingness for vacuum aspiration if failure or excessive bleeding occurs.
• Recognition of warning signs.
• Steps to be taken in emergency-Access to providers during the process.

Medication Abortion & the MTP Act
It is a termination of pregnancy and therefore falls under the purview of the MTP Act 1971. A recent amendment in the MTP rules (made in 2003) allows certified practitioners to provide Medication Abortion from his/her clinic, even if it may not be an approved site) provided he/she has access to a site approved under MTP Act. The law requires that for the purpose of access, the provider should display a Certificate to this effect from the owner of the approved site. The providers should comply with the requirements of MTP Act.