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Are abortion procedures by nondoctor providers effective and safe?

Training midlevel providers (midwives, nurses, and other nondoctor providers) to conduct surgical aspiration abortions and manage medical abortions has been proposed as a way of increasing women’s access to safe abortion in developing countries. It is important to know if abortion procedures administered by midlevel providers are more or less effective and safe than those administered by doctors. 

Key messages

  • Surgical aspiration abortion procedures administered by midlevel providers probably lead to little or no difference in incomplete and failed abortions, compared to doctors.

  • Surgical aspiration abortion procedures administered by midlevel providers probably lead to slightly more complications, compared to doctors.

  • Medical abortion procedures administered by midlevel providers probably lead to slightly less incomplete and failed abortions, compared to doctors.

  • Factors that need to be considered when assessing the transferability of the findings to a low income setting include the availability of doctors to perform abortion procedures, the availability and training of midlevel providers to perform surgical and medical abortions and the abortion rates and incidence of unsafe abortion procedures.

 

 

Background

Unsafe abortion remains a major public health concern in developing countries. Abortions are conventionally administered by trained doctors (gynecologists and obstetricians). In many low income countries, even in settings where abortion is legal, access to abortion remains limited due to a shortage of trained doctors. Irrespective of legal conditions, in settings where access to safe abortion care is lacking, women often obtain abortions from unqualified or unskilled providers. Therefore, training and authorising midlevel providers (midwives, nurses, and other nondoctor providers) to conduct aspiration abortions and manage medical abortions has been proposed as a way to increase women’s access to safe abortion services.

 

 



About the systematic review underlying this summary

Review objectives: To compare the effectiveness and safety of abortion procedures administered by midlevel providers versus procedures administered by doctors.
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, non randomised trials and comparison studies exploring effectiveness or safety of abortion procedures (surgical or medical) provided by midlevel providers and doctors

Five studies: Randomised trials (2) one exploring surgical aspiration procedures and the other medical abortion procedures;

Prospective cohort studies (3) all exploring surgical aspiration abortion procedures

 

Participants Women seeking termination of pregnancy
Total of 8539 women seeking termination of pregnancy; women aged from <20 to >40 years. In the four studies of surgical abortion procedures, maximum gestational ages ranged from 10 to 16+ weeks. In the trial of medical abortion, women with gestational ages of up to 9 weeks were included.
Settings Any setting South Africa and Vietnam (1); Nepal (1); US (2) and India (1). All studies took place in either a hospital or specialist health clinic, such as a women’s health centre or sexual and reproductive health clinic.
Outcomes

Effectiveness or efficacy of abortion procedures, provided by midlevel providers versus doctors, measured as incomplete or failed abortion.

Safety of abor¬tion procedures administered by midlevel providers versus doctors, measured as adverse events and complications.

 

Both randomised trials and two of the cohort studies examined effectiveness, measured as incomplete or failed abortion.

The trial of surgical abortion and the three cohort studies examined safety, measured as complications (immediate and delayed).

 

Date of most recent search: February 2012
Limitations: This is a well-conducted review with minor limitations.
Ngo TD, Park MH, Free C. Safety and effectiveness of termination services performed by doctors versus mid-level providers: a systematic review and analysis. Int J Women Health 2013: 5; 9–17.

Ngo TD, Park MH, Free C. Safety and effectiveness of termination services performed by doctors versus midlevel providers: a systematic review and analysis. Int J Women Health 2013: 5; 9–17.

Summary of findings

A total of five studies were included in this review. Four studies, one in Vietnam and South Africa, two in the US and one in India, examined surgical aspiration abortion by midlevel providers compared to doctors. These studies looked at effectiveness of abortion procedures, measured as incomplete or failed abortion, and at safety of abortion procedures, measured as complications related to the procedure. The other study was done in Nepal and examined medical abortion by midlevel providers compared to doctors. This study also looked at effectiveness of abortion procedures, measured as incomplete or failed abortion. 

1) Surgical aspiration abortion procedures administered by midlevel providers compared to doctors

  • Five studies examined this comparison but only the findings from two randomised trials are displayed in the table below. Two additional studies with low certainty of evidence also suggested more incomplete or failed abortions by midlevel providers. Three additional studies with low certainty of evidence suggested little or no difference in complications between midlevel providers and doctors.
  • Surgical aspiration abortion administered by midlevel providers probably leads to little or no difference in incomplete and failed abortions. The certainty of this evidence is moderate.
  • Surgical aspiration abortion administered by midlevel providers probably leads to slightly more complications. The certainty of this evidence is moderate.

Surgical aspiration abortion by midlevel providers versus doctors

People:  Women seeking termination of pregnancy
Settings
:  Specialist health clinics in South Africa and Vietnam and district hospitals in Nepal
Intervention
Surgical aspiration abortion by midlevel providers
Comparison
Surgical aspiration abortion by doctors
Outcomes Comparative risks*
By doctors                  By midlevel providers

Difference

(95% CI)

 


Number of

participants

(studies)

 


Certainty

of the

evidence

(GRADE)

 


Incomplete or failed abortion
6 per 1000                   11 per 1000

5 more per 1000 1

(9 fewer to 17 more)



2894

(1 study)


Moderate
Complications 
7 per 1000                   13 per 1000

6 more per 1000 2

(11 fewer to 167 more)



1104

(1 study)



Moderate 

CI: Confidence interval GRADE: GRADE Working Group grades of evidence (see above and last page)

*Illustrative comparative risks

1 Two additional cohort studies also suggested an increase in the risk of incomplete or failed abortion
2 Three additional cohort studies reported no difference in odds of complications

2) Medical abortion procedures administered by midlevel providers compared to doctors

This comparison was examined in only one study.

 

  • Medical abortion administered by midlevel providers probably leads to fewer incomplete and failed abortions. The certainty of this evidence is moderate 

Medical abortion by midlevel providers compared to doctors

People:  Women seeking termination of pregnancy
Settings
:  District hospitals in Nepal
Intervention
:Medical abortion by midlevel providers
Comparison
Medical abortion by doctors
Outcomes Comparative risks*
By doctors                  By midlevel providers

Difference

(95% CI)

 


Number of

participants

(studies)

 


Certainty

of the

evidence

(GRADE)

 


Incomplete or failed abortion
39 per 1000                   27 per 1000

12 fewer

per 1000

(200 fewer to 77 more)

 



1104

(1 study)


Moderate

CI:  Confidence interval     GRADE:   GRADE Working Group grades of evidence (see above and last page)

*Illustrative comparative risks

 

 

Confidence interval     GRADE: GRADE Working Group grades of evidence (see above and last page)

*Illustrative comparative risks

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
The two randomised trials were carried out in lower and upper middle income countries and thus the measured effects may be transferable to low income countries.

When assessing the transferability of these findings to low-income settings, the following factors need to be considered:

- Local epidemiology of abortion rates and incidence of unsafe abortion procedures

- The availability of doctors in these settings to perform abortion procedures

- The availability and training of midlevel providers to perform surgical and medical abortions, with special attention to providers in public health facilities and rural areas

- Accessibility to the necessary pre to post abortion care, especially in public facilities and rural areas

- The differences in effectiveness and safety of surgical versus medical abortion procedures by midlevel providers

- Cost implications of other models of care compared to midlevel provider care

 


EQUITY
There was no information in the included studies regarding differential effects of the interventions in disadvantaged populations. The trial of surgical abortion procedures was done in private settings in South Africa and Vietnam and participants are likely not representative of disadvan-taged populations in these countries. Given the scarcity of obstetricians and gynaecol-ogists serving disadvantaged populations in low income settings, using midlevel providers has the potential to expand women’s access to safe abortion procedures in underserved areas, especially when incidence of unsafe abortion procedures is high, providing the midlevel providers are recruited, trained, supported and retained in underserved communities. Consideration should be given to health system factors and regulations that will encourage this.
ECONOMIC CONSIDERATIONS
None of the included studies presented cost data comparing midlevel and doctor providers.
It is likely that the provision and management of abortion procedures by midlevel providers may be cost effective in resource limited settings due to lower salary costs and scarcity of obstetricians and gynaecologists. However, formal economic evaluations are needed to assess whether midlevel providers of abortion procedures are affordable alternatives to doctor providers with comparable outcomes, specifically in relation to infrastructure and training.
MONITORING & EVALUATION
High certainty evidence on the effectiveness and safety of abortion procedures administered by midlevel providers versus procedures administered by doctors is lacking.

Operational research studies are needed to assess the feasibility and accept¬ability of rolling out midlevel provision, as well as impact evaluations. Evaluations should also consider the structure of the wider healthcare system and availability of personnel to identify which midlevel providers, if any, are best placed to provide abortion procedures, and also consider how the process from pre- to post-abortion care is managed.


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

 

Additional information

Related literature

Lassi ZS, Bhutta ZA. Mid‐level health workers for improving the delivery of health services. Cochrane Database Syst Rev 2012; 2: CD009649.

 

Kulier R, Kapp N, Gülmezoglu AM, Hofmeyr GJ, Cheng L, Campana A. Medical methods for first trimester abor-tion. Cochrane Database Syst Rev 2011; 11: CD002855.

 

Renner RM, Brahmi D, Kapp N. Who can provide effective and safe termination of pregnancy care? A systematic review. BJOG 2013 Jan;120(1):23-31.

 

This summary was prepared by

Celeste Naude, Centre for Evidence-based Health Care, Stellenbosch University, South Africa.

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by one external referee. We did not receive any comments from the review authors.

 

This review should be cited as

Ngo TD, Park MH, Free C. Safety and effectiveness of termination services per-formed by doctors versus midlevel providers: a systematic review and analysis. Int J Women Health 2013: 5; 9–17.

 

The summary should be cited as

Celeste Naude. Are abortion procedures by nondoctor providers effective and safe? A SUPPORT Summary of a systematic review. January 2017. www.supportsummaries.org

 

Keywords

evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care, abortion, midlevel providers, midwives, nurses, non-doctor, task shifting

 

This summary was prepared with additional support from:

 The Centre for Evidence-based Health Care is a coordinating and di-rective institution for research and training of the Faculty of Medicine and Health Sciences of Stellenbosch University in the field of evidence-based health care. The CEBHC aims to conduct and support relevant systematic reviews and primary research related to evidence-informed health care; enhance evidence-informed healthcare knowledge, skills and practices through teaching healthcare professionals and other stakeholders; and promote the use of best evidence in healthcare decision making and the uptake of current best evidence in healthcare policy and practice. Core activities of the CEBHC include research, teaching and knowledge transla-tion.

 

 

 

 



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