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, 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 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 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, nurse−midwives characteristics of the women and type (in 2007) where mid-level providers do with special training in Sweden have of abortion procedure used, rather than not yet have the legal authority to ad- also been the main providers of contra- the cadre of providers.9 minister the drugs, the mid-level clini- ceptive services, with the authority to In recent years, the role of advanced cian assesses the woman’s overall health, prescribe oral contraceptives and insert practice clinicians in the USA – in- dates the , and then reviews intrauterine devices. Many also serve cluding nurse practitioners, physician the choice of a medical versus a surgi- as educators on sexuality, assistants and nurse-midwives − has cal procedure. The physician briefly and abortion in the community, e.g. in been expanding in first-trimester abor- meets the patient and administers the schools and at youth clinics. Although tion provision. A large proportion of mifepristone. The mid-level provider by law only physicians are entitled to primary health care in the country then reviews with the woman how and perform abortion, nurse−midwives’ is currently being provided by these when to take the misoprostol at home responsibilities for counselling and care non-physicians and their involvement (almost all American women using early during medical abortions have steadily in abortion care is crucial, given the medical abortion take the misoprostol increased.5 serious shortage of physician providers at home). A large 2-year, multisite study In France and Great Britain, both in many states. Since January 2005, has recently started in California, where medical and surgical abortions must trained advanced practice clinicians nurse practitioners are being trained in be performed by a physician. However, have been providing medical and, in early aspiration abortion in seven clin- in France, as in Sweden, practice has some cases, early surgical abortion in ics, but no data have yet been generated developed in such a way as to minimize 15 states. This has led to the establish- (personal communication, S Yanow, physicians’ involvement in medical ment of appropriate clinical training in former director, Abortion Access Project, abortion, thereby reducing staff costs. those states, but it has required political Cambridge, MA, 2007). Regulations in Great Britain are already advocacy to achieve the necessary legal interpreted to allow nurses to administer and regulatory changes. Recent surveys South Africa and Viet Nam medical abortion drugs − as long as a in three states showed a substantial South Africa and Viet Nam were, until physician prescribes them. As a result, interest among mid-level providers in fairly recently, the only two developing medical abortion services are largely obtaining abortion training, leading to countries where it is legal for mid-level supervised by nurses, with physicians cautious optimism about the possibil- providers to do aspiration abortions. available if needed. In France, physi- ity of increasing access to abortion care Nurse practitioners and physician as-

Bull World Health Organ 2009;87:58–63 | doi:10.2471/BLT.07.050138 59 Policy & practice Provision of abortion by mid-level providers Marge Berer sistants have been permitted to provide In both countries, the abortions were organization sector nurse-midwives in first-trimester abortion services in Viet done equally safely by the doctors and post-abortion care at 44 private sector Nam since 1945 and in South Africa mid-level providers and women re- facilities in six districts, serving both since 1997.15 South Africa has recently ported equal satisfaction with services urban and rural populations, starting updated its abortion regulations to from both types of providers.15 with a pilot programme in 1999, which allow trained mid-level providers to was scaled up in 2004.21 In Uganda, manage the whole medical abortion Bangladesh, Cambodia and as part of the same PRIME-assisted procedure as well. A growing number Mozambique project, 24 midwives from 13 public of other countries are also now review- In 2001, Ipas and the Division of Inter- sector facilities in nine districts received ing their guidelines to allow trained national Health, Department of Public training, followed by supervisory visits nurse-midwives to perform abortions. Health Sciences, Karolinska Institutet, for quality assurance and for monitor- In South Africa, a programme was 22 Stockholm, Sweden (IHCAR) organized ing post-training performance. initiated to train registered midwives an international conference on expand- In India, both a nationwide study throughout the country to provide 23 ing the role of mid-level providers in published in 2004 and a study in Ra- abortion services at primary-care fa- 24 safe abortion care. Reports revealed that jasthan in 2004 found that providers cilities. For example, Sibuyi found that the abortion law in Cambodia estab- such as auxiliary nurse-midwives were involving mid-level providers had an lishes women’s rights to first-trimester providing abortions to low-income important impact on expanding the abortion on any grounds, performed women, mostly without the benefit of availability and accessibility of safe, legal by a qualified doctor, medical assistant training, often leading to complica- abortion.16 As required by the South or at public or private health tions. The authors of the Rajasthan African Nursing Council, midwives are facilities licensed by the Ministry of study recommended that, given the considered for certification in abortion Health.18 In Bangladesh, the govern- prevalence of such providers, the feasi- care after completing 160 hours of bility of training some of them to offer training: 80 hours of theoretical train- ment collaborates with nongovern- mental organizations to train female safe abortion services, particularly for ing and 80 hours of clinical training terminations in early pregnancy, should under the supervision of experienced, paramedics called “family welfare visi- tors” to perform “menstrual regulation” be explored at policy, programme and practising physicians in accredited research levels. Similar recommenda- hospitals. The clinical training must with manual vacuum aspiration up to tions were made in a study in Ethiopia, be completed within 3 months of 10 weeks of pregnancy. In 2001, nearly before abortion was legalized there, the theoretical training. From Octo- 7000 trained paramedics were provid- which also found high complication ber 1999 through January 2000, an ing menstrual regulation in government rates as a result of a lack of training. It evaluation was conducted at 27 public clinics, with many more in private 19 recognized that making abortion safe health-care facilities in South Africa’s practice. would only be possible if mid-level nine provinces to assess the quality of In Mozambique, evaluation of the providers were trained, as physicians care provided by midwives who had performance of surgical technicians (mid-level providers with 3 years’ in- were lacking, particularly in low socio- been trained and certified to provide 25 abortion services. Data were collected tensive training in surgical procedures) economic and rural areas. by observing abortion procedures and documented successful surgery in 90% In Myanmar, following a study counselling sessions, reviewing facil- of 7080 emergency surgeries under- in 2000 showing high mortality rates ity records and patients’ charts, and taken by these providers at rural hos- from unsafe abortions, post-abortion interviewing patients and certified mid- pitals. Emergency uterine evacuation care and contraceptive services were wives. The physicians who assessed the following unsafe abortions accounted integrated into the township health midwives concluded that the midwives for 26% of the procedures. In fact, system, led by township medical of- showed good clinical skills in 75% of these surgical technicians success- ficers in the initial towns participating the procedures. The only area identified fully performed many gynaecological in the project, with the intention of as needing significant improvement was procedures that were much more com- scaling up services if the outcomes regarding administration of antibiotics. plicated than vacuum aspiration abor- were good. Hospital-based doctors The authors concluded that midwives tion, including Caesarean sections and and nurses, clinic midwives, village can provide high-quality abortion ser- hysterectomies.20 midwives and other volunteer health vices in the absence of physicians.17 providers, including traditional birth Randomized, controlled trials con- Post-abortion care attendants, were all trained but the ducted in both South Africa and Viet key providers were the medical officers Nam, published in 2006, compared Nurse-midwives have also been success- and midwives. The role of the local safety and rates of complications of fully trained to carry out post-abortion clinic midwife was extended to make first-trimester manual vacuum aspira- care for complications of incomplete follow-up home visits to the women tion abortion by mid-level providers abortion using manual vacuum as- with post-abortion complications and and doctors in clinics run by Marie piration. For example, in Kenya, the provide them with contraception when Stopes International. All participat- PRIME II Project collaborated with the requested.26 Indeed, one of the reasons ing mid-level providers had received Kenya Ministry of Health, the Nursing why it has been considered important government-certified training under Council of Kenya, National Nursing to involve midwives has been to link supervision and had experience of do- Association of Kenya and others to post-abortion contraceptive provision ing abortions at the primary-care level. train private and nongovernmental with abortion care.

60 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

Opposition from physicians developing countries where abortion is wives, to provide appropriate ele- decreasing not legally restricted, given the dearth ments of abortion care; of physicians available to provide abor- • remove existing policy restrictions Provision of most contraceptives is an tions in most cases, particularly in rural that allow only doctors to perform example of a sexual health service at areas, opposition to the training of mid- abortions; primary-care level that long ago safely level providers in abortion provision • establish regulations and training passed from physicians to family-plan- would be even less defensible. However, that support the capacity of mid- ning nurses in many countries, though it would appear that change will come level providers to play a greater role not always without controversy. As a only slowly. in providing abortions; and Lancet commentary in 2006 pointed • integrate training in providing abor- out: “Any proposal to use non-phy- Conclusion tion care into basic training for all sicians for surgical procedures or any mid-level providers interested in ob- medical role is unlikely to be widely The evidence described in this paper stetrics and gynaecology, including confirms the similar experience of the accepted without substantial scepti- midwives, nurses and other cadres, individual countries where surveys and cism and some level of professional turf as well as all medical students, and 27 studies have been carried out. They all protection.” also in in-service training and re- conclude that it is safe and beneficial For example, the number of phy- fresher courses. sicians trained and willing to provide for suitably trained mid-level health- care providers to provide first-trimester abortions in the USA has been falling By training mid-level providers to vacuum aspiration and medical abor- since the 1990s,28 a problem com- tions and to treat incomplete abortions. provide first-trimester aspiration abor- pounded by anti-abortion violence. As Ipas has noted, however: tions and manage medical abortions, Naturally, those who do provide abor- countries will be able to increase the tions want to protect their skills, their “The principal obstacle preventing nurses, number of health service sites offering caseloads and their income. In the midwives … and other mid-level providers first-trimester abortions at primary-care current circumstances, however, al- from helping meet women’s needs for safe level, thereby improving and increasing lowing nurses, midwives and other abortion-related care is that … training women’s access to abortion services trained mid-level providers to manage and authorization to perform abortions without compromising safety or qual- abortions may be the best, if not the … are restricted to physicians. Even where ity of care. In addition, documenta- only, way of avoiding a crisis due to policies or regulations do not explicitly tion is needed on the role of nurses, lack of accessibility. In 1993, obstetri- include such restrictions, opportunities midwives and other mid-level providers cians and gynaecologists in the USA for non-physician health-care providers to in second-trimester medical abortions, opposed allowing nurse practitioners learn clinical and other skills needed for especially in France, Great Britain, Nor- 33 to provide several routine gynaecologi- abortion care are scarce.” way and Sweden, where they already cal services.29 The trend appears to be play an important role in managing This, then, is where change needs towards increasing acceptance of these these abortions. ■ to begin, with different cadres of health role changes, however. A 1998 survey professional working side-by-side to Acknowledgements of obstetricians and gynaecologists and ensure accessibility and availability of family practice physicians in the USA abortion. Existing programmes from An earlier version of this paper that found that one-third believed that ad- South Africa and the USA could serve focused on the situation in the United vanced practice clinicians should be al- as models for other countries to adapt Kingdom was submitted to the Inquiry 30 lowed to offer medical abortion, while for purposes of education and practi- on Scientific Developments Relating a 2002 study of experienced abortion cal training.13,17 If mid-level provid- to the Abortion Act 1967 of the Select providers found that 80−85% of those ers in a range of both developed and Committee on Science and Technol- interviewed believed that advanced developing countries are successfully ogy, House of Commons, the United practice clinicians were qualified to providing first-trimester aspiration and Kingdom Parliament in September provide medical abortions.31 More- medical abortions, there is no reason 2007 and was published in their final over, since 1999, the American Public why providers in other countries where report: Scientific developments relating to Health Association has endorsed the abortion is legal cannot and should not the Abortion Act 1967: twelfth report of role of advanced practice clinicians to do so as well, with appropriate train- session 2006–07. Permission was granted be permitted to provide first-trimester ing. To make this feasible, countries to submit a revised text for journal surgical and medical abortions.32 will need to: publication. Trends in other developed coun- • authorize all qualified health-care tries remain to be documented. In personnel, including nurses and mid- Competing interests: None declared.

Bull World Health Organ 2009;87:58–63 | doi:10.2471/BLT.07.050138 61 Policy & practice Provision of abortion by mid-level providers Marge Berer

Résumé Pratique de l’avortement par des prestateurs de soins de niveau intermédiaire : politiques, pratiques et perspectives dans plusieurs pays D’après des articles trouvés dans les bases de données PubMed et incomplet par aspiration manuelle et que des études réalisées en Popline sur la pratique de l’avortement pendant le premier trimestre Ethiopie et en Inde recommandent la formation de prestateurs de grossesse par des prestateurs de niveau intermédiaire, le présent tels que des infirmières obstétriciennes auxiliaires aux services article présente les politiques relatives au type de prestateur de d’avortement pour s’assurer qu’elles pratiquent des avortements services d’avortement, des études comparatives sur les différents sans risque chez les femmes à faible revenu. L’article recommande types de prestateurs, les perspectives pour ces prestateurs et d’autoriser tous les prestateurs de niveau intermédiaire disposant l’expérience programmatique acquise en Afrique du Sud, au des qualifications nécessaires à pratiquer des avortements pendant Bangladesh, au Cambodge, aux Etats-Unis d’Amérique, en France, le premier trimestre de grossesse et d’intégrer la formation aux soins au Mozambique, en Suède et au Viet Nam. Il montre que des liés à ces avortements dans l’enseignement de base et la formation prestateurs de soins de niveau intermédiaire correctement formés, clinique destinés à tous les prestateurs de niveau intermédiaire notamment des infirmières, des sages-femmes et d’autres cliniciens et étudiants du domaine médical, intéressés par l’obstétrique et non médecins, peuvent pratiquer des aspirations pendant le premier la gynécologie. Enfin, il lance un appel à documents sur le rôle trimestre et des avortements médicaux de manière sûre et bénéfique. des prestateurs de niveau intermédiaire dans la prise en charge En outre, il constate que des projets menés au Kenya, au Myanmar et des avortements médicaux du second trimestre, en vue d’étayer en Ouganda ont formé avec succès des infirmières obstétriciennes davantage les politiques et les pratiques. à la dispensation de soins post-avortement en cas d’avortement

Resumen Realización de abortos por personal de nivel medio: políticas, prácticas y perspectivas internacionales A partir de artículos hallados en las bases de datos PubMed y atención postaborto en los casos de aborto incompleto con Popline en relación con la práctica de abortos durante el primer aspiración por vacío manual, así como de estudios realizados trimestre de embarazo por personal de nivel medio, se describen en Etiopía y la India en los que se recomienda que se capacite aquí las políticas existentes sobre el tipo de personal encargado a personal como enfermeras auxiliares y parteras en la práctica de realizarlos, diversos estudios comparativos sobre los diferentes de abortos para garantizar que ofrezcan abortos seguros a las tipos de proveedores de esa intervención, las perspectivas de mujeres de ingresos bajos. En el artículo se recomienda que se los proveedores y la experiencia de programas emprendidos en autorice a todo el personal sanitario de nivel medio cualificado a Bangladesh, Camboya, Francia, los Estados Unidos de América, practicar abortos durante el primer trimestre, y que la capacitación Mozambique, Sudáfrica, Suecia y Viet Nam. Se muestra que para la realización de abortos en ese intervalo se integre en la la práctica de abortos mediante aspiración por vacío y abortos formación básica y clínica destinada a todos los proveedores de farmacológicos en el primer trimestre es una opción segura nivel medio y estudiantes de medicina interesados en la obstetricia y provechosa para el personal de nivel medio debidamente y la ginecología. Por último, se pide que se aporte documentación capacitado, incluidas enfermeras, parteras y demás personal sobre la función del personal de nivel medio en el manejo de los clínico no médico. Se informa además de proyectos emprendidos abortos farmacológicos en el segundo trimestre para fundamentar en Kenya, Myanmar y Uganda en los que se ha adiestrado así mejor las políticas y las prácticas. satisfactoriamente a enfermeras-parteras para que proporcionen

ملخص تقديم القامئني عىل إيتاء املستوى املتوسط من الرعاية الصحية للخدمات املتعلقة باإلجهاض السياسات، املامرسات، ووجهات النظر عىل الصعيد الدويل إىل استناداًاملقاالت املوجودة يف قواعد البيانات الخاصة بالشؤون الطبية تقديم الرعاية التالية لإلجهاض يف حالة اإلجهاض الناقص باستخدام الشفط “بامبيد”، والشؤون السكانية “بوب الين” حول تقديم القامئني من املستوى اليدوي بالتخلية، وأن الدراسات املجراة يف الهند وأثيوبيا أوصت برضورة املتوسط للخدمات املتعلقة باإلجهاض خالل األثلوث األول من الحمل ، توضح تدريب ِّمي مقدالخدمات من قبيل القابالت املمرضات املعاونات عىل تقديم هذه املقالة السياسات الخاصة بنمط ِّمقدمي خدمات اإلجهاض، والدراسات خدمات اإلجهاض لضامن تقدميهن خدمات إجهاض مأمونة للنساء ذات املقارنة ملختلف أمناط ِّمقدمي خدمات اإلجهاض، ووجهات نظرهم، وتجاربهم الدخل املنخفض. ومن ثـَ َّ متويص الورقة بتفويض جميع ِّمقدمي الرعاية الربمجية يف الواليات املتحدة األمريكية، وبنغالديش، وجنوب أفريقيا، الصحية املؤهلني بتقديم خدمات اإلجهاض خالل األثلوث األول من الحمل، والسويد، وفرنسا، وفييت نام، وكمبوديا، وموزمبيق. وتب ِّين هذه املقالة كام تويص بإدماج التدريب عىل تقديم رعاية حاالت اإلجهاض يف األثلوث سالمة وجدوى قيام ِّمقدمي الرعاية الصحية من املستوى املتوسط املدربني األول من الحمل ضمن التعليم األسايس والتدريب الرسيري لجميع ِّمقدمي تدريباً جيدا،مبا ًفيهم املمرضات والقابالت وغريهن من املامرسني ِّالرسيريـني الرعاية من املستوى املتوسط وطالب الطب املهتمني بالتوليد وأمراض النساء. منغري األطباء بالشفط بالتخلية، واإلجهاض تحت اإلرشاف الطبي يف األثلوث وأخريا ًتطالب بتوثيق دور مقدمي الخدمات من املستوى املتوسط يف معالجة األول من الحمل. باإلضافة إىل ذلك، فقد وجد الباحثون أن املرشوعات التي حاالت اإلجهاض الطبية يف األثلوث الثاين من الحمل لتوفر املزيد من التوجيه ِّنفذت يف أوغندا، وميامنار، وكينيا قد دربت بنجاح املمرضات – القابالت عىل للمامرسة والسياسات.

62 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

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