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Policy & Practice Policy & practice Provision of abortion by mid-level providers: international policy, practice and perspectives Marge Berer a Abstract Based on articles found on the PubMed and Popline databases on the provision of first-trimester abortion by mid-level providers, this article describes policies on type of abortion provider, comparative studies of different types of abortion provider, provider perspectives, and programmatic experience in Bangladesh, Cambodia, France, Mozambique, South Africa, Sweden, the United States of America and Viet Nam. It shows that it is safe and beneficial for suitably trained mid-level health-care providers, including nurses, midwives and other non-physician clinicians, to provide first-trimester vacuum aspiration and medical abortions. Moreover, it finds that projects in Kenya, Myanmar and Uganda have successfully trained nurse-midwives to provide post-abortion care for incomplete abortion with manual vacuum aspiration, and that studies in Ethiopia and India have recommended that providers such as auxiliary nurse-midwives should be trained in abortion service delivery to ensure that they provide safe abortions for low-income women. The paper recommends the authorization of all qualified mid-level health-care providers to carry out first-trimester abortions, and it also recommends the integration of training in providing first-trimester abortion care into basic education and clinical training for all mid-level providers and medical students interested in obstetrics and gynaecology. Finally, it calls for documentation of the role of mid-level providers in managing second-trimester medical abortions to further inform policy and practice. الرتجمة العربية لهذه الخالصة يف نهاية النص الكامل لهذه املقالة. .Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español Introduction weeks of pregnancy and medical abortion up to 9 completed weeks of pregnancy, and that mid-level health workers can be Since the 1960s, when laws legalizing abortion began to be trained to provide safe, early abortion without compromis- passed in industrialized countries and in a growing number ing safety. It includes as mid-level providers: midwives, nurse of developing countries, abortion has become one of the saf- practitioners, clinical officers, physician assistants and others. est and most frequent clinical procedures used by women. In Training includes bimanual pelvic examination to determine skilled hands, surgical methods of abortion using aspiration pregnancy and positioning of the uterus, uterine sounding, techniques at up to 15 weeks of pregnancy, and dilation and transcervical procedures, provision of abortion and skills for evacuation in the second trimester, are very safe, as is medical recognition and management of complications. abortion. Medical abortion using a combination of the drugs This paper brings together published information from mifepristone and misoprostol, which have been on WHO’s both developed and developing countries to gain an interna- 1 complementary List of Essential Medicines since 2005, has tional perspective on the question of whether suitably trained transformed both how abortion is provided and how it is mid-level health-care providers, including nurses, midwives experienced by women. Yet, laws and policies on abortion and other non-physician clinicians, can safely provide first- have lagged behind in recognizing and responding to these trimester vacuum aspiration and medical abortions and treat changes. incomplete first-trimester abortions. It covers policies on For many years now, since first-trimester abortion tech- type of abortion provider, comparative studies of the safety of niques have become so straightforward, it has been techni- abortion with different types of abortion provider, provider cally feasible for health professionals other than physicians perspectives and programmatic experience. It is based on ar- to carry out first-trimester aspiration abortions, to provide ticles found on PubMed and Popline, the two main databases medication to women for medical abortion and, in both likely to cover this subject, using the keywords “abortion” types of procedure, to monitor and follow-up the process to and “nurse-midwives.” Other keywords, such as mid-level a safe conclusion. Yet, in most countries, doctors are the only providers and others used in this article, yielded no additional health professionals permitted to provide abortions, with the references specific to abortion provision. All relevant articles support of nurses. This paper argues that this policy has not found, covering the years 1986 to 2007, are referenced here. kept up with technical innovation and is not only out-of-date Unless otherwise indicated, the role of mid-level providers is but makes it more difficult for countries to provide highly described in relation to first-trimester abortion only. accessible, quality abortion services at low cost. The idea of mid-level providers carrying out first-trimester In 2003, WHO’s safe abortion guidance 2 recommended abortions is far from new. For example, physician assistants, that abortion services be provided at the lowest appropriate certified by the Board of Medical Practice in the United States level of the health-care system. It states that vacuum aspira- of America (USA), have been permitted to carry out early tion can be provided at primary-care level up to 12 completed abortions in the states of Montana and Vermont since 1975.3 a Reproductive Health Matters Journal, 53–79 Highgate Road, London NW5 1TL, England. Correspondence to Marge Berer (e-mail: [email protected]). (Submitted: 4 December 2007 – Revised version received: 3 June 2008 – Accepted: 4 June 2008 – Published online: 4 November 2008 ) 58 Bull World Health Organ 2009;87:58–63 | doi:10.2471/BLT.07.050138 Policy & practice Marge Berer Provision of abortion by mid-level providers The role of mid-level health workers is cians confirm the pregnancy and con- without requiring patients to travel long growing in many aspects of health care, duct the follow-up visit but nurses are distances.11,12 For example, a survey of both in developing countries because of often responsible for all the other proce- 1176 licensed advanced practice clini- the crisis in human resources in health dures involved in medical abortion.6 cians in the state of California deter- systems, and in developed countries mined that 25% of those interviewed to reduce the cost of health care when USA desired training in medical abortion. procedures allow for a lower cadre of During the 1990s, inspired by the Their most frequently cited reason for provider than physicians. As Iyengar potential of early medical abortion to not providing or assisting with abor- described in 2005: tion procedures was the lack of training improve access to abortion services in 13 the USA, a range of journal articles opportunities available to them. The “Measures for de-medicalising primary discussed the possibility of mid-level perceived lack of available training was health services include: adoption of providers taking on this role.7,8 Since proven by a study in the year 2000 of simpler technology and service protocols, 1986, several studies have been carried the 486 programmes available nation- ally for nurse practitioners, physician authorisation and training of less qualified out to compare the rate and type of assistants and certified nurse-midwives. providers, simplification or elimination complications in first-trimester vacuum It found that, of the 202 programmes of facility requirements, establishment of aspiration abortions performed by that replied to a postal survey, only just robust referral links to hospitals, increasing physician assistants versus physicians 4 over half (53%) reported didactic in- user control and self-medication.” in states that allow physician assistants struction on surgical abortion, manual to provide abortions.3,7–11 Outcomes vacuum aspiration or medical abortion International experience of 2458 first-trimester abortions in and only 21% reported including at a free-standing clinic in Vermont in Europe least one of these three procedures in 1986 found no differences in compli- their routine clinical curriculum.14 This According to the Swedish Abortion Act cation rates according to the provider.3 of 1974, abortions must be performed reflects a failure to include abortion Similarly, in 2004, a 2-year prospective in the medical school curricula across at a public hospital by a qualified medi- cohort study of 1363 women undergo- the USA. cal doctor. Today, however, much has ing surgically-induced abortion in two There are no comparison data on changed. By 2001, physicians’ main role clinics found that services provided by safety of medical abortion by type of in Sweden in the provision of medical experienced physician assistants were provider from the USA because, in most abortion was to estimate the duration of comparable in safety and efficacy to clinics providing medical abortion, pregnancy by ultrasound and to serve as those provided by physicians. The oc- mid-level providers already do gesta- consultants and supervisors. Midwives currence of complications at both clin- tional dating, counselling and blood are responsible for counselling women ics was very low. Moreover, the types work, and review the consent forms and administering the medical abortion of complications observed reflected required with women. In the 35 states drugs. For many years,
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