Memorandum 24
Submission from Reproductive Health Matters
This submission presents international evidence
from Sweden, France, United States, South Africa, Vietnam and
several other developing country settings that it is safe and
beneficial for suitably trained mid-level health care providers,
including nurses and midwives, to carry out first trimester aspiration
and medical abortions, and calls for documentation of the role
of mid-level providers in managing second trimester medical abortions
in Britain and other European countries.
EXECUTIVE SUMMARY
This submission presents international evidence
from Sweden, France, United States, South Africa, Vietnam and
several other developing country settings that it is safe and
beneficial for suitably trained mid-level health care providers,
including nurses and midwives, to carry out first trimester aspiration
and medical abortions. It recommends increasing the number of
health service sites offering abortion; authorisation of all qualified
health care personnel, including nurses and midwives, to provide
appropriate elements of abortion care; integration of training
in providing abortion care into basic training for midwives and
for all nurses and medical students interested in obstetrics and
gynaecology; and calls for documentation of the role of mid-level
providers in managing second trimester medical abortions in Britain
and other European countries to inform regulations.
INTRODUCTION
Since the 1967 Abortion Act was passed, abortion
has become one of the safest medical procedures available from
health services and one of the most frequently provided to women.
Surgical methods of abortion using aspiration techniques (up to
15 weeks of pregnancy in skilled hands) are extremely safe, as
is medical abortion. Medical abortion, using a combination of
the drugs mifepristone and misoprostol, which have been on the
WHO complementary List of Essential Medicines since 2005, [124]has
transformed both how abortion is provided and how it is experienced
by women. Yet, law and policy on abortion have lagged behind in
recognising and responding to these changes.
The fact is, however, that for many years now,
it has been technically feasible for other health professionals
as well as physicians to carry out first trimester aspiration
abortions, to provide medication to women for medical abortion,
and in both types of procedure, to monitor and follow-up the process
to a safe conclusion.
In Britain, two doctors are still required in
law to serve as the gatekeepers to obtaining an abortion, and
they are also the only health professionals still permitted to
provide abortions, with the support of nurses. These policies
are increasingly becoming out of date in comparison to other countries,
and making it unnecessarily expensive and bureaucratic for the
National Health Service to provide a first-class abortion service
at low cost.
The World Health Organization recommends that
abortion services be provided at the lowest appropriate level
of the health care system. Its 2003 guidance states that vacuum
aspiration can be provided at primary care level up to 12 completed
weeks of pregnancy and medical abortion up to nine completed weeks
of pregnancy, and that mid-level health workers can be trained
to provide safe, early abortion without compromising safety. They
include as mid-level providers: midwives, nurse practitioners,
clinical officers, physician assistants and others. Training includes
bimanual pelvic examination to determine pregnancy and positioning
of the uterus, uterine sounding, transcervical procedures, provision
of abortion and skills for recognition and management of complications
of abortion. [125]
The idea of mid-level providers carrying out
abortions is also far from new. For example, physician assistants,
certified by the Board of Medical Practice in the USA, have been
permitted to carry out early abortions in the states of Vermont
and Montana since 1975. [126]The
role of mid-level health workers is growing in many aspects of
health care, both in developing countries because of the crisis
in human resources in health systems, and in developed countries
to reduce the cost of health care when procedures allow for a
lower cadre of provider than physicians.
"Measures for de-medicalising primary health
services include: adoption of simpler technology and service protocols,
authorisation and training of less qualified providers, simplification
or elimination of facility requirements, establishment of robust
referral links to hospitals, increasing user control and self-medication."
[127]
Why would Gynaecologists be Opposed to Abortions
being Carried out by Mid-level Providers?
Provision of most contraceptives is an example
of a sexual health service at primary care level that long ago
safely passed from physicians to family planning nurses in many
countries, including the UK, sometimes not without controversy.
"Any proposal to use non-physicians for
surgical procedures or any medical role is unlikely to be widely
accepted without substantial scepticism and some level of professional
turf protection." [128]
In the past, obstetrician/gynaecologists in
the United States opposed allowing nurse practitioners to provide
a number of routine gynaecological services. [129]
In Britain, when the Abortion Act was passed,
physicians supported it in large numbers because they had had
to deal with the complications of unsafe, illegal abortions, especially
in young and poor women. Medical students and physicians today
have never had to deal with the kinds of complications that were
common in those days, nor are they required to gain the skills
needed to provide abortions. Today, there are fewer physicians
willing to provide abortions, but those who do provide abortions
want to protect their skills, caseloads and income. However, in
the current circumstances in Britain, training and allowing nurses
and midwives to provide abortions may be the best—if not
the only—way of avoiding a crisis caused by the falling
number of physician abortion providers, including for the management
of second trimester medical abortions.
INTERNATIONAL EVIDENCE
OF THE
SAFETY OF
ABORTION PROVISION
BY MID-LEVEL
PROVIDERS
Europe
According to the Swedish Abortion Act of 1974,
abortions must be performed at a public hospital by a qualified
medical doctor. Today, however, much has changed. By 2001, physicians'
main role in Sweden in provision of medical abortion was to estimate
the duration of pregnancy by ultrasound and to serve as consultants
and supervisors. Midwives are responsible for counselling women
and administering both drugs. For many years, nurse-midwives with
special training in Sweden have been the main providers of contraceptive
services, with the authority to prescribe oral contraceptives
and insert intra-uterine devices. Many also serve as educators
on sexuality, birth control and abortion in the community, in
schools and at youth clinics. Although by law only physicians
are entitled to perform abortion, nurse-midwives' responsibilities
for counselling and care during medical abortions have steadily
increased. [130]
In France, as in Britain, both medical and surgical
abortions must be performed by a physician. However, in France,
as in Sweden, practices have been developed to minimise physicians'
involvement in medical abortion, thereby reducing staff costs.
Regulations in Great Britain are already interpreted to allow
nurses to administer medical abortion drugs as long as a physician
prescribes them. As a result, medical abortion services are largely
supervised by nurses with physicians available if needed. In France,
physicians confirm the pregnancy and conduct the follow-up visit,
but nurses are often responsible for the other procedures involved
in medical abortion. [131]
United States
Since 1986, a number of studies have compared
the rate and type of complications in first trimester aspiration
abortions performed by physician assistants vs physicians
in US states that allow physician assistants to provide abortions,
[132],[133]
and related issues. [134]Outcomes
of 2,458 first trimester abortions in a free-standing clinic in
Vermont in 1986 found no differences in complications rates according
to provider. 132 Similarly, in 2004 a two-year prospective cohort
study of 1,363 women undergoing surgically-induced abortion in
two clinics found that services provided by experienced physician
assistants were comparable in safety and efficacy to those provided
by physicians. The occurrence of complications at both clinics
was very low. Moreover, the types of complications observed reflected
characteristics of the women and type of abortion procedure used,
rather than cadre of provider. 133
In recent years, the role of advanced practice
clinicians in the US—nurse practitioners, physician assistants
and nurse-midwives—has been expanding in first trimester
abortion provision. A large percentage of primary health care
in the US is currently provided by these non-physicians, and their
involvement in abortion care is crucial, given serious shortages
of physician providers in many US states. As of January 2005,
trained advanced practice clinicians were providing medical, and
in some cases, early surgical abortion in 15 states. This has
led to the setting up of appropriate clinical training but has
also required political advocacy to achieve the necessary legal
and regulatory changes. Recent surveys in three states showed
a substantial interest among mid-level providers in obtaining
abortion training, leading to cautious optimism about the possibility
of increasing access to abortion care without long-distance travel.
[135]
There are no comparison data on safety of medical
abortion by type of provider from the United States because in
most clinics providing medical abortion, mid-level providers already
do gestational dating, counselling and blood work, and review
the consent forms required with women. In the 35 states in 2007
where mid-level providers do not yet have legal authority to administer
the drugs, the physician usually meets briefly with the patient,
administers the mifepristone and leaves. The mid-level provider
then reviews with the woman how and when to take the misoprostol
at home (almost all US women having early medical abortion take
the misoprostol at home). A large two-year, multi-site study has
just started in California, where nurse practitioners are being
trained in early aspiration abortion in seven clinics, but no
data have yet been generated. [136]
DEVELOPING COUNTRIES
South Africa and Viet Nam
South Africa and Vietnam were, until fairly
recently, the only two developing countries where it is permitted
in law for mid-level providers to do aspiration abortions. Nurse
practitioners and physician assistants have been permitted to
provide first trimester abortion services in Viet Nam since 1945
and in South Africa since 1997. [137]South
Africa has recently updated its abortion regulations to allow
trained mid-level providers to manage the whole medical abortion
procedure as well. A growing number of other countries are also
now reviewing their guidelines to allow trained nurse-midwives
to do abortions.
In South Africa, a programme was initiated to
train registered midwives throughout the country to provide abortion
services at primary care facilities. As required by the South
African Nursing Council, midwives are considered for certification
in abortion care after completing 160 hours of training: 80 hours
of theoretical training and 80 hours of clinical training under
the supervision of experienced, practising physicians in accredited
hospitals. The clinical training must be completed within three
months of the theoretical training. From October 1999 through
January 2000, an evaluation was conducted at 27 public health
care facilities in South Africa's nine provinces to assess the
quality of care provided by midwives who had been trained and
certified to provide abortion services. Data were collected by
observing abortion procedures and counselling sessions, reviewing
facility records and patients' charts, and interviewing patients
and certified midwives. The physicians who assessed the midwives
concluded that the midwives showed good clinical skills in 75%
of the procedures. The only area identified as needing significant
improvement was regarding the need to administer antibiotics.
The authors concluded that midwives can provide high-quality abortion
services in the absence of physicians. [138]
Randomised, controlled trials were conducted
in both South Africa and Viet Nam, published in 2006, to compare
safety and rates of complications of first trimester manual vacuum
aspiration abortion by mid-level providers and doctors in clinics
run by Marie Stopes International. All participating mid-level
providers had received government-certified training under supervision
and had experience of doing abortions at the primary care level.
In both countries, the abortions were done equally safely by the
doctors and mid-level providers, and women reported equal satisfaction
with services from both types of providers. 137
Cambodia, Bangladesh and Mozambique
In 2001, Ipas and the Division of International
Health, Department of Public Health Sciences, Karolinska Institutet,
Stockholm, Sweden (IHCAR) organised an international conference
on expanding the role of mid-level providers in safe abortion
care. Reports revealed that the abortion law in Cambodia establishes
women's right to first trimester abortion on any grounds, performed
by a qualified doctor, medical assistant or midwife at public
or private health facilities licensed by the Ministry of Health.
[139]In
Bangladesh, the government collaborates with non-governmental
organisations to train female paramedics called "family welfare
visitors" to perform menstrual regulation with manual vacuum
aspiration up to 10 weeks of pregnancy. In 2001, nearly 7,000
trained paramedics were providing menstrual regulation in government
clinics, with many more in private practice. [140]
Evaluation of the surgical performance of mid-level
providers (surgical technicians) in Mozambique documented successful
surgery in 90% of 7,080 emergency surgeries undertaken by these
providers at rural hospitals. Emergency uterine evacuation following
unsafe abortions accounted for 26% of the procedures. In fact,
these surgical technicians successfully performed many gynaecological
procedures that were much more complicated than vacuum aspiration
abortion, including caesarean sections and hysterectomies. [141]
CONCLUSION
If mid-level providers in other countries can
successfully provide first trimester abortions, there is no reason
whatsoever why providers in Britain cannot and should not do so
as well.
"The principal obstacle preventing nurses,
midwives... and other mid-level providers from helping meet women's
needs for safe abortion-related care is that... training and authori-zation
to perform abortions... are restricted to physicians. Even where
policies or regulations do not explicitly include such restrictions,
opportunities for non-physician health care providers to learn
clinical and other skills needed for abortion care are scarce."
[142]
RECOMMENDATIONS
— Increase the number of health
service sites offering abortions, including first trimester aspiration
and medical abortion at primary level, and second trimester abortions.
— Authorise all qualified health
care personnel, including nurses and midwives, to provide appropriate
elements of abortion care. Remove existing policy restrictions
that allow only doctors to perform first trimester abortion-related
procedures.
— Integrate training in providing
abortion care into basic training for all midwives and all nurses
and medical students interested in obstetrics-gynaecology, and
in in-service training and refresher courses.
— Seek documentation of the role
of nurses and other mid-level providers as compared to physicians
in second trimester medical abortions, especially in Britain,
Sweden, Norway and France, and use the findings as the basis for
recommendations of changes to British law, regulations and training
that would support their capacity to play a greater role safely.
September 2007
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