Doctors or mid-level providers for abortion: Cochrane systematic review
Assessed as up to date: 2014/08/15
The World Health Organization recommends that abortion can be provided at the lowest level of the healthcare system. Training mid-level providers, such as midwives, nurses and other non-physician providers, to conduct first trimester aspiration abortions and manage medical abortions has been proposed as a way to increase women's access to safe abortion procedures.Objectives
To assess the safety and effectiveness of abortion procedures administered by mid-level providers compared to doctors.Search methods
We searched the CENTRAL Issue 7, MEDLINE and POPLINE databases for comparative studies of doctor and mid-level providers of abortion services. We searched for studies published in any language from January 1980 until 15 August 2014.Selection criteria
Randomised controlled trials (RCTs) (clustered or not clustered), prospective cohort studies or observational studies that compared the safety or effectiveness (or both) of any type of first trimester abortion procedure, administered by any type of mid-level provider or doctors, were eligible for inclusion in the review.Data collection and analysis
Two independent review authors screened abstracts for eligibility and double-extracted data from the included studies using a pre-tested form. We meta-analysed primary outcome data using both fixed-effect and random-effects models to obtain pooled risk ratios (RR) with 95% confidence intervals (CIs). We carried out separate analyses by study design (RCT or cohort) and type of abortion procedure (medical versus surgical).Main results
Eight studies involving 22,018 participants met our eligibility criteria. Five studies (n = 18,962) assessed the safety and effectiveness of surgical abortion procedures administered by mid-level providers compared to doctors. Three studies (n = 3056) assessed the safety and effectiveness of medical abortion procedures. The surgical abortion studies (one RCT and four cohort studies) were carried out in the United States, India, South Africa and Vietnam. The medical abortion studies (two RCTs and one cohort study) were carried out in India, Sweden and Nepal. The studies included women with gestational ages up to 14 weeks for surgical abortion and nine weeks for medical abortion.
Risk of selection bias was considered to be low in the three RCTs, unclear in four observational studies and high in one observational study. Concealment bias was considered to be low in the three RCTs and high in all five observational studies. Although none of the eight studies performed blinding of the participants to the provider type, we considered the performance bias to be low as this is part of the intervention. Detection bias was considered to be high in all eight studies as none of the eight studies preformed blinding of the outcome assessment. Attrition bias was low in seven studies and high in one, with over 20% attrition. We considered six studies to have unclear risk of selective reporting bias as their protocols had not been published. The remaining two studies had published their protocols. Few other sources of bias were found.
Based on an analysis of three cohort studies, the risk of surgical abortion failure was significantly higher when provided by mid-level providers than when procedures were administered by doctors (RR 2.25, 95% CI 1.38 to 3.68), however the quality of evidence for this outcome was deemed to be very low. For surgical abortion procedures, we found no significant differences in the risk of complications between mid-level providers and doctors (RR 0.99, 95% CI 0.17 to 5.70 from RCTs; RR 1.38, 95% CI 0.70 to 2.72 from observational studies). When we combined the data for failure and complications for surgical abortion we found no significant differences between mid-level providers and doctors in both the observational study analysis (RR 1.36, 95% CI 0.86 to 2.14) and the RCT analysis (RR 3.07, 95% CI 0.16 to 59.08). The quality of evidence of the outcome for RCT studies was considered to be low and for observational studies very low. For medical abortion procedures the risk of failure was not different for mid-level providers or doctors (RR 0.81, 95% CI 0.48 to 1.36 from RCTs; RR 1.09, 95% CI 0.63 to 1.88 from observational studies). The quality of evidence of this outcome for the RCT analysis was considered to be high, although the quality of evidence of the observational studies was considered to be very low. There were no complications reported in the three medical abortion studies.Authors' conclusions
There was no statistically significant difference in the risk of failure for medical abortions performed by mid-level providers compared with doctors. Observational data indicate that there may be a higher risk of abortion failure for surgical abortion procedures administered by mid-level providers, but the number of studies is small and more robust data from controlled trials are needed. There were no statistically significant differences in the risk of complications for first trimester surgical abortions performed by mid-level providers compared with doctors.
Barnard Sharmani, Kim Caron, Park Min Hae, Ngo Thoai D
Can health care providers who are not doctors perform abortions as well as doctors?
Unsafe abortion causes death and disability and remains a major public health concern in developing countries. Most of these deaths and disabilities could be prevented if safe and legal abortion were provided by trained people. This review looked at whether using mid-level providers (health care providers who are not doctors) to perform abortions is safe. It also looked at whether the abortions provided by mid-level providers worked as well as those provided by doctors.
We carried out searches for studies that compared medical abortion (using pills) or surgical abortion provided by either mid-level providers or doctors. We also wrote to researchers to find more studies. The studies could compare how safe the abortions were or how effective they were (whether they actually worked). The evidence we found is up to date as of the 15th of August 2014.
We found eight studies with a total of 22,018 participants. Five studies compared surgical abortion provided by doctors or mid-level providers and three studies compared medical abortion provided by doctors or mid-level providers. Of the five surgical abortion studies only one had a high-quality study design. Of the three medical abortion studies, two had a high-quality study design. Three of these studies were carried out in America, two in India, one in was carried out in both South Africa and Vietnam the remaining two were from Sweden and Nepal.
The results from the analyses of the medical abortion studies showed that there does not seem to be an advantage when these are provided by doctors. The results from most of the analyses of the surgical abortion studies showed that we cannot be sure that there is a difference in how safe and how effective mid-level providers are compared to doctors. One analysis of three low-quality studies of surgical abortion showed that there was more chance of the abortion being ineffective if it was provided by mid-level providers.
Most of the studies did not show a difference between mid-level providers and doctors in how safe the abortions were and how well they worked. Training mid-level providers to give medical or surgical abortions could reduce the number of deaths and the disability caused by unsafe abortion. Studies in the future should focus on what types of mid-level providers can provide safe and effective abortions. They should also look at whether mid-level providers are as safe and effective as doctors for providing abortions in rural developing country settings.
Implications for practice
Our findings suggest that mid-level providers can provide medical abortion safely and effectively. Based on a small number of studies, there may be some difference in the effectiveness of surgical abortion procedures performed by mid-level providers compared with physicians, however we cannot be sure. Observational data indicate that there may be a higher risk of abortion failure for surgical abortion procedures administered by mid-level providers, but the number of studies is small and more robust data from controlled trials are needed. There is no significant difference in the risk of complications when surgical abortions are provided by mid-level providers. If these findings are confirmed in further studies, in settings with a shortage of trained providers coupled with a high incidence of unsafe abortion, mid-level provision of terminations could potentially reduce complications and death related to unsafe abortion.
Implications for research
Further studies are required to establish the minimum level of provider training and experience required for safe and effective abortion procedures in both low and high-resource settings.Get full text at The Cochrane Library
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