New research: Expanding abortion access after 12 weeks with mid-level providers


Can mid-level providers manage medical abortion after 12 weeks’ gestation as safely and effectively as physicians? A non-inferiority, randomized controlled trial in Addis Ababa, Ethiopia

Published in International Journal of Gynecology and Obstetrics

This randomized controlled non-inferiority trial was conducted by Ipas and St. Paul Hospital Millennium Medical College.

Main takeaway

Training mid-level providers to offer medical abortion services after 12 weeks of pregnancy independently of physicians is feasible—and results in comparable clinical outcomes.

“About 1 in 10 abortions globally take place after 12 weeks of pregnancy, but restrictions that limit provision of this care to physicians, a group whose numbers are in great deficit globally, means that many people have difficulty accessing the services they need. This research proves that training other providers like nurses and midwives has the potential to vastly expand access to high quality abortion services at later gestational ages, services often needed by the most vulnerable and socially disadvantaged groups.”

— Sally Dijkerman, Ipas senior research scientist

Why it matters

Abortion by mid-level providers is known to increase access for people seeking abortion in the first 12 weeks of pregnancy. This is largely because randomized controlled trials have found that mid-level providers can perform abortions in the first 12 weeks as safely and effectively as physicians, with no differences in incomplete abortion or complication following either surgical or medical abortion.

This study is designed like those earlier studies and seeks to expand the potential for mid-level provision of abortion services to after 12 weeks, thereby increasing access to abortion at later gestations. The results have the potential to impact health-care policy on which cadres of provider can offer abortion care, which could in turn expand abortion access for people in vulnerable groups, such as those living in rural communities. Policy change could also help health systems with cost-savings for health providers and technologies such as ultrasound and equipment for abortion procedures.

Later abortions are a persistent need; about 10% of all abortions take place beyond 12 weeks’ gestation globally. People seeking later abortion services are often among the most vulnerable and socially disadvantaged populations. This study contributes to WHO’s call for research on this topic by investigating whether outcomes differ among women who receive this care from mid-level providers and those who are cared for by physicians.

In Ethiopia, abortions after 12 weeks gestation are conducted at facilities by physicians, but there are insufficient providers to meet the current need—as is true in many settings globally. Expanding services to mid-level providers has the potential to increase accessibility, particularly in rural areas, and prevent maternal deaths and injuries.

Key findings

  • Training mid-level clinicians to provide abortion services from 13 to 20 weeks gestation, independent of physicians, is feasible and, in this trial, resulted in comparable clinical outcomes.
  • Medical abortion care (abortion with pills) by mid-level providers was comparable to care by physicians in terms of how long it took patients to complete the abortion process.
  • Secondary clinical outcomes—abortion quality of care and patient experience—were comparable between the two provider groups. Patient experience was largely positive and did not differ by provider group.