Can midlevel providers administer medical abortion as safely as physicians?

Monday, August 11, 2014

women talking

Yes, there is strong evidence that trained midlevel providers such as nurses, midwives and clinical officers can provide first-trimester medical abortion as safely and effectively as physicians. Backed by this evidence, health-care system managers and policymakers increasingly support expanding the provider base to include non-physician providers as a way to increase women’s access to safe medical abortion care.

“Midwives, nurses and clinical officers have terrific experience in delivering women’s health care, whether through assisting women with labor and delivery, helping women use contraception, or giving women access to gynecologic care,” says Dr. Alice Mark, Ipas senior advisor for clinical affairs. “By increasing their training and skills to include safe abortion care, they can provide abortion as safely and sensitively as doctors and are often more available to women who need care.”

According to the World Health Organization (WHO) 2012 publication Safe abortion: Technical and policy guidance for health systems, “Abortion care can be safely provided by any properly trained health-care provider, including midlevel (i.e. non-physician) providers. Abortion care provided at the primary-care level and through outpatient services in higher-level settings is safe, and minimizes costs while maximizing the convenience and timeliness of care for the woman.” Task-shifting to other cadres of providers is a WHO-recommended strategy to improve access to contraception and other vital maternal and newborn health services and should be broadly considered for abortion care as well.

Ipas’s January 2014 edition of Clinical Updates in Reproductive Health summarizes the evidence on midlevel providers safely providing medical abortion:

  • A randomized control trial of 1,104 women seeking abortion at less than nine weeks gestation in Nepal compared the efficacy and safety of medical abortion when performed by either physicians or nurses and auxiliary nurse midwives. The women in both groups had equivalent rates of successful abortion (96.7 percent overall), which is defined as not requiring manual vacuum aspiration (MVA) within 30 days of treatment. The study, published in 2011 in The Lancet, also found no serious complications reported in either group of women.
  • A prospective cohort study of 1,414 Indian women seeking abortion up to eight weeks gestation compared the safety and efficacy of medical abortion when it was performed by three groups of providers: allopathic physicians, ayurvedic (traditional) physicians, and nurses. The providers in this study, published in 2012 in International Perspectives on Sexual and Reproductive Health, were newly trained in medical abortion and had not been doing pelvic examination or vacuum aspiration previously. The women in all provider groups had equivalent rates of successful abortions (95 percent overall). The accuracy of the providers’ gestational age assessment and determination of abortion success was similar across all groups, and no women in the study had serious complications.

Because many women can’t seek care from doctors because of cost, geography, or a shortage of providers, training and supporting midwives, nurses and clinical officers can increase women’s ability to access safe services in their own communities. 

Looking forward: Ipas is committed to expanding the evidence base around who can safely administer medical abortion, including pharmacists and women themselves.


Midwives’ support for abortion care grows

The International Confederation of Midwives (ICM) has long supported midwives providing abortion care—and that support is growing.

ICM made clear its support for abortion care in a 2008 position statement: “The education of midwives should include training … in providing abortion-related services that ensure safety and well-being for the woman.”

In June 2014 at ICM’s 30th International Triennial Congress, abortion care featured prominently in midwives’ discussion of their efforts to reduce maternal mortality. And the 2014 edition of The State of the World’s Midwifery report articulates a vision of abortion and postabortion care integrated into the full continuum of care—from sexual and reproductive health through pregnancy, birth and postnatal care.

As young Jamaican midwife Victoria Melhado says in her poem “We are midwives,” which won her an award in the Ipas Young Midwife Contest: “We give competent and nonjudgmental care… we empathize with and empower our women.”