Safety and effectiveness of termination services performed by doctors versus midlevel providers: a systematic review and analysis
Thoai D Ngo,1,2 Min Hae Park,1 Caroline Free2
1Research, Monitoring and Evaluation Team, Health System Department, Marie Stopes International, UK; 2Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
Objective: Training midlevel providers (MLPs) to conduct surgical abortions and manage medical abortions has been proposed as a way to increase women's access to safe abortion. This paper reviews the evidence that compares the effectiveness and safety of abortion procedures administered by MLPs versus doctors.
Methods: A systematic search was conducted of published trials and comparison studies assessing the effectiveness and/or safety of abortion provided by MLPs compared to doctors. The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, and Popline were searched. The primary outcomes of interest were: (1) incomplete or failed abortion; and (2) measures of safety (adverse events and complications) of abortion procedures administered by MLPs and doctors. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated for each study. Data were synthesized in a narrative fashion.
Findings: Five studies were included in this review (n = 8539 women), comprising two randomized controlled trials (RCTs) (n = 3821) and three prospective cohort studies (n = 4718). In total, 4198 women underwent a procedure administered by an MLP, and 4341 women underwent a physician-administered procedure. Studies took place in the US, Nepal, South Africa, Vietnam, and India. Four studies used surgical abortion with maximum gestational ages ranging from 10 to 16+ weeks, while a medical abortion study had gestational ages up to 9 weeks. In RCTs, the effect estimates for incomplete or failed abortion for procedures performed by MLPs compared with doctors were OR = 2.00 (95% CI 0.85–4.68) for surgical abortion, and OR = 0.69 (95% CI 0.34–1.37) for medical abortion. Complications were rare among both provider types (1.2%–3.1%; OR = 1.80, 95% CI 0.83–3.90 for surgical abortions), and no deaths were reported.
Conclusion: There were no statistical differences in incomplete abortion and complications for first trimester surgical and medical abortion up to 9 weeks performed by MLPs compared with physicians. Further studies are required to establish more precise effect estimates.
Keywords: abortion, misoprostol, manual vacuum aspiration, medical abortion
This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms.Download Article [PDF]