Clinical Updates in Reproductive Health

Midlevel providers: Safety and effectiveness

Key Information:

  • Many cadres of trained health workers can provide vacuum aspiration and medical abortion before 13 weeks gestation as safely and effectively as physicians.

Quality of evidence: High

Who is a midlevel provider?

“Midlevel provider” is a general term used to describe multiple cadres of trained health-care providers such as nurses, nurse midwives, clinical officers, advanced practice clinicians, and physician assistants. Expanding the abortion provider base to include midlevel providers increases access to safe abortion and postabortion care.

Vacuum aspiration

A 2015 systematic review compiled data from five studies, one randomized controlled trial and four cohort studies, that compared provision of aspiration abortion by midlevel providers to that by doctors (Barnard, Kim, Park, & Ngo, 2015). Included studies were from India, South Africa, the United States and Vietnam. Combined data found no difference in the overall risk of complications between physicians and non-physician providers (relative risk [RR] 1.36, 95% CI 0.86, 2.14). When examining risk of incomplete abortion separately, observational data (three studies including 13,715 women) indicated an increased risk of incomplete abortion when performed by midlevel providers (RR 2.25, 95% CI 1.38, 3.68) (Goldman, Occhuito, Peterson, Zapka, & Palmer, 2004; Jejeebhoy et al., 2011; Weitz et al., 2013); this increased risk was not observed in randomized controlled trial data (one study, 2789 women, RR 2.97, 95% CI 0.21, 41.82) (Warriner et al., 2006). One study showed that vacuum aspiration performed by midlevel providers was as acceptable to women as services provided by physicians (Jejeebhoy et al., 2011).

The World Health Organization (WHO) states that non-specialist doctors, associate and advanced associate clinicians, midwives and nurses can be trained to perform vacuum aspiration for induced abortion (WHO, 2015). In settings where there are established mechanisms to include auxiliary nurses and auxiliary nurse midwives in basic emergency obstetric care or postabortion care, these cadres can also perform vacuum aspiration. Where doctors of complementary medicine participate in other tasks related to maternal and reproductive health, they can also perform vacuum aspiration. WHO recommends against provision of vacuum aspiration by pharmacists, pharmacy workers or lay health providers.

Medical abortion

A 2017 systematic review and meta-analysis comparing medical abortion provision by midlevel providers and doctors (Sjostrom, Dragoman, Fonhus, Ganatra, & Gemzell-Danielsson, 2017) included three randomized controlled trials, reporting outcomes for 3,670 women from Mexico, Nepal and Sweden. Midlevel providers in the included studies were nurses, auxiliary nurse midwives, ayurvedic (traditional) physicians and midwives. The review found that effectiveness, measured as rate of complete pregnancy termination, was equivalent between the physician and non-physician groups (RR 1.0, 95% CI 0.99, 1.02). Across all included studies, only one serious adverse event—heavy bleeding requiring uterine aspiration—was recorded. Authors concluded that although the rarity of such events limits the ability to statistically analyze their likelihood based on provider type, the overall low rate was reassuring. Women consistently rate medical abortion provided by midlevel providers as highly acceptable (Kopp Kallner et al., 2014; Olavarrieta et al., 2015; Tamang et al., 2017).

WHO states that, in addition to specialist and non-specialist doctors, associate and advanced associate clinicians, midwives, nurses, auxiliary nurses and auxiliary nurse midwives can be trained to provide medical abortion. Where doctors of complementary medicine participate in other tasks related to maternal and reproductive health, they can also provide medical abortion. For pharmacists or lay health workers, WHO recommends that the provision of medical abortion subtasks, specifically assessing women’s eligibility for medical abortion, administering the medications and managing the process and common side-effects, and assessing abortion success and the need for clinic-based follow-up occur only within the context of rigorous research. WHO recommends against the provision of medical abortion by pharmacy workers (2015).


Barnard, S., Kim, C., Park, M. H., & Ngo T. D. (2015). Doctors or mid-level providers for abortion? Cochrane Database of Systematic Reviews, 7, CD011242.

Goldman, M. B., Occhuito, J. S., Peterson, L. E., Zapka, J. G., & Palmer, R. H. (2004). Physician assistants as providers of surgically induced abortion services. Research and Practice, 94(8), 1352-1357.

Jejeebhoy, S., Kalyanwala, S., Zavier, A., Kumar, R., Mundle, S., Tank, J., & Jha, N. (2011). Can nurses perform manual vacuum aspiration (MVA) as safely and effectively as physicians? Evidence from India. Contraception, 84(6), 615-621.

Kopp Kallner, H., Gomperts, R., Salomonsson, E., Johansson, M., Marions, L., & Gemzell-Daniellsson, K. (2014). The efficacy, safety and acceptability of medical termination of pregnancy provided by standard care by doctors of by nurse-midwives: A randomized controlled equivalence trial.  BJOG: An International Journal of Obstetrics & Gynaecology, 122(4), 510-7.

Olavarrieta, C. D., Ganatra, B., Sorhaindo, A., Karver, T. S., Seuc, A., Villalobos, A., … & Sanhueza, P. (2015). Nurse versus physician-provision of early medical abortion in Mexico: a randomized controlled non-inferiority trial. Bulletin of the World Health Organization, 93(4), 249-58.

Sjostrom, S., Dragoman, M., Fonhus, M. S., Ganatra, B., & Gemzell-Danielsson, K. (2017). Effectiveness, safety, and acceptability of first-trimester medical termination of pregnancy performed by non-doctor providers: A systematic review. BJOG: An International Journal of Obstetrics & Gynaecology, 124, 1928-1940.

Tamang, A., Shah, I. H., Shrestha, P., Warriner, I. K., Wang, D., Thapa, K., . . . Meirik, O. (2017). Comparative satisfaction of receiving medical abortion service from nurses and auxiliary nurse-midwives or doctors in Nepal: results of a randomized trial. Reproductive Health, 14(1), 176.

Warriner, I., Meirik, O., Hoffman, M., Morroni, C., Harries, J., My Huong, N., & Seuc, A. (2006). Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and midlevel providers in South Africa and Vietnam: A randomised controlled equivalence trial. The Lancet, 368(9551), 1965-1972.

Weitz, T. A., Taylor, D., Desai, S., Upadhyay, U. D., Waldman, J., Battistelli, M. R., & Drey, E. A. (2013). Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver. American Journal of Public Health, 103(3), 454-461.

World Health Organization. (2015). Health worker roles in providing safe abortion care and post-abortion contraception. Geneva: World Health Organization Press.