Select Committee on Science and Technology Written Evidence

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.


  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.


  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.



  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]


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]


  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]


    —    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

124   Essential Medicines: WHO Model List (revised March 2005) 14th edition. At: Back

125   World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva: WHO, 2003. Back

126   Freedman MA, Jillson D, Coffin RR, Novick LF. Comparison of complication rates in first trimester abortions performed by physician assistants and physicians. American Journal of Public Health 1986; 76: 550-54. Back

127   Iyengar S Introducing medical abortion within the primary health system: comparison with other health interventions and commodities. Reproductive Health Matters 2005; 13(26): 13-19. Back

128   Yap-Seng Chong, Citra Nurfarah Mattar. Mid-level providers: a safe solution for unsafe abortion. Lancet 2006; 368: 1-2. Back

129   Kowalczyk EA. Access to abortion services: abortions performed by mid-level practitioners. Trends in Health Care Law and Ethics 1993; 8(3): 37-45. Back

130   Jonsson IM, Za­tterstro­m C, Sundstrm K. Midwives' role in management of medical abortion: Swedish country report. Unpublished paper prepared for the conference "Expanding Access: Advancing the Role of Midlevel Providers in Menstrual Regulation and Elective Abortion Care," Pilanesberg National Park, South Africa, 2-6 December 2001. Back

131   Hassoun D, Delafontaine Hospital, Saint Denis, France, 2001. Referenced in: Jones RK, Henshaw SK. Mifepristone for early medical abortion: experiences in France, Great Britain and Sweden. Perspectives on Sexual and Reproductive Health 2002; 34(3). At: Back

132   Freedman MA, Jillson DA, Coffin RR. Comparison of complications in first trimester abortions performed by physician assistants and physicians. American Journal of Public Health 1986; 76: 550-54. Back

133   Goldman MB, Occhiuto JS, Peterson LE, et al. Physician assistants as providers of surgically induced abortion services. American Journal of Public Health 2004; 94(8): 1,352-57. Back

134   See McKee K, Adams E. Nurse midwives' attitudes toward abortion performance and related procedures. Journal of Nurse-Midwifery 1994; 39: 300-11; Lieberman D, Lalwani A Physician-only and physician assistant statutes: a case of perceived but unfounded conflict. Journal of American Medical Women's Association 1994; 49: 146-49; National Abortion Federation. The Role of Physician Assistants, Nurse Practitioners, and Nurse-Midwives in Providing Abortions. Symposium Report, Atlanta, 13-14 December 1996. Donovan P Vermont physician assistants perform abortions, train residents. Family Planning Perspectives 1992; 24: 225. Back

135   Joffe C, Yanow S. Advanced practice clinicians as abortion providers: current developments in the United States No 24. Reproductive Health Matters 2004; 12(24 Suppl): 198-206. Back

136   S Yanow, former Director, Abortion Access Project, Cambridge, MA. Personal communication, 31 August 2007. Back

137   Warriner IK, Meirik O, Hoffman M, et al. Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and mid-level providers in South Africa and Vietnam: a randomised controlled equivalence trial. Lancet 2006; 368: 1,965-72. Back

138   Dickson-Tetteh K, Billings DL. Abortion care services provided by registered midwives in South Africa. International Family Planning Perspectives 2002; 28(3): 144-50. Back

139   Long C, Neang R. Abortion in Cambodia: Country report, 2001. At: Back

140   Akhter HH. Expanding access: mid-level providers in menstrual regulation, Bangladesh experience, 2001. At: Back

141   18 Vaz F, Bergstrm S, Vaz ML, et al. Training medical assistants for surgery. Bulletin of World Health Organization 1999; 77(8). Back

142   Ipas, IHCAR. Deciding Women's Lives Are Worth Saving: Expanding the Role of Mid-Level Providers in Safe Abortion Care. Issues in Abortion Care 7. Chapel Hill: Ipas, 2002. Back

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