-
The Cochrane Database of Systematic... Jul 2015The World Health Organization recommends that abortion can be provided at the lowest level of the healthcare system. Training mid-level providers, such as midwives,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
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.
Topics: Abortifacient Agents; Abortion, Legal; Abortion, Therapeutic; Allied Health Personnel; Clinical Competence; Cohort Studies; Female; Humans; Midwifery; Mifepristone; Misoprostol; Nurses; Nursing Assistants; Observational Studies as Topic; Physician Assistants; Physicians; Pregnancy; Pregnancy Trimester, First; Randomized Controlled Trials as Topic; Vacuum Curettage
PubMed: 26214844
DOI: 10.1002/14651858.CD011242.pub2 -
British Medical Journal Nov 1972
Topics: Abortion, Therapeutic; Contraceptive Agents; Diarrhea; Fatty Acids, Essential; Female; Headache; Humans; Labor, Induced; Male; Nausea; Phlebitis; Pregnancy; Prostaglandins; Vomiting
PubMed: 4637516
DOI: No ID Found -
Canadian Medical Association Journal Oct 1974Surveys conducted after therapeutic abortion were used to evaluate contraceptive use, to assess early physical and emotional effects and to provide feedback to the...
Surveys conducted after therapeutic abortion were used to evaluate contraceptive use, to assess early physical and emotional effects and to provide feedback to the hospital nurses on their counselling role. The follow-up rate was only 53%. Of those who cooperated 82.9% were using effective contraception three months after abortion. Subjective morbidity was greater than anticipated. The main emotional response was relief coupled with some guilt and depression in a significant minority. The occurrence and significance of the after effects of abortion should be explained in advance. Training workshops for abortion counsellors would be useful. The surgical termination of pregnancy is only a small part of a comprehensive abortion service.
Topics: Abortion, Therapeutic; Adolescent; Adult; Canada; Contraception; Contraceptive Devices; Contraceptives, Oral; Counseling; Demography; Depression; Emotions; Feedback; Female; Follow-Up Studies; Humans; Nursing Staff, Hospital; Pregnancy; Surveys and Questionnaires; Uterine Hemorrhage
PubMed: 4412172
DOI: No ID Found -
CMAJ : Canadian Medical Association... Mar 1991
Topics: Abortion, Therapeutic; Female; Humans; Pregnancy; Religion and Medicine
PubMed: 1998917
DOI: No ID Found -
Canadian Medical Association Journal Mar 1971
Topics: Abortion, Therapeutic; Ethics, Medical; Female; Humans; Pregnancy
PubMed: 5557921
DOI: No ID Found -
BMJ (Clinical Research Ed.) Nov 1990
Topics: Abortion, Eugenic; Abortion, Induced; Abortion, Therapeutic; Conscience; Embryonic and Fetal Development; Fetal Viability; Government Regulation; Health Personnel; Humans; Jurisprudence; Legislation as Topic; Mifepristone; Pharmaceutical Preparations; Social Control, Formal; United Kingdom
PubMed: 11642801
DOI: No ID Found -
Canadian Medical Association Journal Aug 1983Responses to the question as to whether abortions should be performed at the woman's request during the first trimester of pregnancy were evenly divided. There was...
Responses to the question as to whether abortions should be performed at the woman's request during the first trimester of pregnancy were evenly divided. There was support for abortion on socioeconomic grounds, during the first trimester, from 61.5% of the respondents. Termination of pregnancy beyond the first trimester was supported by a majority of the respondents only in cases in which the woman's life is in danger (73.9%) or in which there is evidence of a severe physical abnormality in the fetus (70.6%) or in cases in which the woman's physical health is in danger (55.5%). Those who said they would not support abortion under any circumstances constitute, at most, 5.1% of the respondents. Support for the maintenance or the elimination of therapeutic abortion committees was addressed in two questions and in both cases the respondents were evenly divided. The responses to these two questions were compared and found to be logically consistent. Only physicians should perform abortions, and they should be performed in hospitals with the woman either as an inpatient or, during the first trimester, as an outpatient. The performance of first-trimester abortions in provincially approved abortion clinics was supported by 47.3% of the respondents. Of the 885 respondents who wished to see some amendment to the Criminal Code, 409 stated that the term "health" as used in the Criminal Code relative to the legal grounds for therapeutic abortion should be defined.
Topics: Abortion, Therapeutic; Canada; Criminal Law; Decision Making; Female; Government Regulation; Humans; Patient Advocacy; Physicians; Pregnancy; Pregnancy Trimester, First; Surveys and Questionnaires
PubMed: 6861064
DOI: No ID Found -
The British Journal of Venereal Diseases Jun 1982Chlamydia trachomatis was isolated from the cervix of 30 of 218 (13.8%) women admitted for legal termination of pregnancy. During the first two weeks after the abortion...
Chlamydia trachomatis was isolated from the cervix of 30 of 218 (13.8%) women admitted for legal termination of pregnancy. During the first two weeks after the abortion seven of the 30 (23.3%) patients developed pelvic inflammatory disease. Four of these had serological evidence of recent active chlamydial infection. Thus, routine examination of patients for genital chlamydial infection before termination of pregnancy is recommended.
Topics: Abortion, Therapeutic; Adult; Cervix Uteri; Chlamydia Infections; Chlamydia trachomatis; Female; Humans; Immunoglobulin G; Neisseria gonorrhoeae; Pelvic Inflammatory Disease; Postoperative Complications; Pregnancy
PubMed: 6805851
DOI: 10.1136/sti.58.3.182 -
British Medical Journal Jun 1968
Topics: Abortion, Therapeutic; England; Ethics, Medical; Female; Humans; Pregnancy; Scotland
PubMed: 5658905
DOI: 10.1136/bmj.2.5605.622-a -
Fertility and Sterility Nov 2012Nowadays ectopic pregnancy often can be diagnosed before the woman's condition has deteriorated, which has altered the former clinical picture of a life-threatening... (Review)
Review
Nowadays ectopic pregnancy often can be diagnosed before the woman's condition has deteriorated, which has altered the former clinical picture of a life-threatening disease into a more benign condition. This review describes the historical developments in the diagnostic and therapeutic management of ectopic pregnancy leading up to current clinical practice. The first attempts to diagnose ectopic pregnancy originate from the beginning of the 20th century.
Topics: Abortifacient Agents, Nonsteroidal; Abortion, Therapeutic; Algorithms; Biomarkers; Chorionic Gonadotropin; Diagnostic Errors; Early Diagnosis; Fallopian Tubes; Female; Gynecologic Surgical Procedures; History, 20th Century; History, 21st Century; Humans; Laparoscopy; Methotrexate; Predictive Value of Tests; Pregnancy; Pregnancy Outcome; Pregnancy, Ectopic; Prenatal Diagnosis; Progesterone; Risk Assessment; Risk Factors; Treatment Outcome; Ultrasonography, Prenatal; Unnecessary Procedures
PubMed: 23084008
DOI: 10.1016/j.fertnstert.2012.09.040