Safety and effectiveness of termination services performed by doctors versus midlevel providers: a systematic review and analysis

Figures & data

Figure 1 Summary of study selection process.

Table 1 Characteristics of included studies

Study name	Study design	Study setting and period of data collection	Intervention	Providers	Outcome(s)	N	Characteristics of women	Gestational age
RCTs
Warriner et al^Citation11	Multicentre randomized controlled equivalence trial	MSI clinics providing FP and abortion services. Four clinics in South Africa and four in Vietnam. September 2003–June 2004 in South Africa, May–December 2003 in Vietnam	MVA: All participants offered paracervical block with lidocaine and additional oral analgesia. Misoprostol 400 mg administered sublingually or orally in South Africa 2–3 hours before abortion (not used in Vietnam). Follow-up 10–14 days later	Midlevel providers with government-accredited training in abortion, or doctors	Immediate complications: excess bleeding > 500 mL, cervical injury, uterine perforation, adverse drug reaction Delayed complications: retained products of conception necessitating re-evacuation, hematometra, post-abortion pelvic infection, excessive post-abortion bleeding (>500 mL), abortion-related death	South Africa: 1160 Vietnam: 1734	Age 18 to >40 years	Up to 12 weeks (LMP, pelvic examination, and ultrasound)
Warriner et al^Citation12	Multicentre randomized controlled equivalence trial	Five rural/peri-urban district hospitals in Nepal April 2009–March 2010	Medical abortion: Day 1: 200 mg mifepristone orally Day 3: 800 μg misoprostol vaginally and monitored for 3 hours Follow-up 10–14 days later	Providers trained in MVA: staff nurses, auxiliary midwives, obstetricians/gynecologists, general practitioners, doctors	Complete abortion without MVA within 30 days of treatment Serious adverse events (hemorrhage necessitating transfusion, conditions necessitating hospitalization)	1104	Mean age: 28.0 ± 5.9 years	Mean: 6.9 ± 1.0 weeks (range 5–9) (LMP and bimanual pelvic examination; ultrasound used in 2.3% women)
Prospective cohort studies
Freedman et al^Citation13	Prospective cohort	Vermont Women’s Health Center, USA January 1981–December 1982	Early uterine evacuation or suction curettage up to 8 weeks LMP. Follow-up visit within 4 weeks, at clinic or by personal physician	Physician assistant or physician. Women seen by next available provider	Complications (immediate or delayed): excessive bleeding, uterine perforation, cervical laceration, incomplete abortion/retained products, infection, post-abortion syndrome, vagal reaction	2458	Age: 29% < 20 years, 42% 20–24 years	Up to 12 weeks (pelvic estimate)
Goldman et al^Citation14	Prospective cohort	Feminist Health Center of Portsmouth, New Hampshire, USA Vermont Women’s Health Center, USA July 1996–October 1997	Standard vacuum curettage performed by physicians through to 12 weeks gestation. MVA or standard vacuum curettage performed by physician assistants through to 14 weeks gestation. Follow-up within 2 weeks of discharge	Physician assistant or physician with ≥5 years experience in abortion procedures	Complications (immediate or delayed): incomplete abortion, failed abortion, ectopic/extrauterine pregnancy, perforation, cervical laceration, infection, hemorrhage, others	1363	Age: 23.7% < 20 years, 23.3% 20–24 years, 21.4% 25–29 years	Up to 13–15 weeks Up to 16+ weeks (LMP, pelvic examination and ultrasound)
Jejeebhoy et al^Citation15	Prospective cohort	Five clinics of non-government organization Janani in Bihar and Jharkhand states, India One provider type (nurse or physician) assigned to each facility at any given time July 2009–January 2010	MVA: Day 1 – intramuscular prostaglandin analog injection administered 1–2 hours before procedure; MVA performed with double-valve syringe; provider could call upon supervisor for assistance; antibiotics and pain relief prescribed Follow-up 7 days later	Nurse or physician with no previous experience of providing abortion or pelvic examination All providers underwent standard MVA training	Complete abortion by day 7 Complications: incomplete abortion or ongoing pregnancy, blood transfusion or hospitalization, injury to cervix, uterus or bowel, signs of infection Unscheduled contacts Accuracy of assessment of gestational age; failure to assess complete abortion Women’s satisfaction with experience and provider	897	Mean age: 27–28 years	Mean: 8.6 weeks (range 5–11+; inclusion criterion: gestational age ≤ 10 weeks) (pelvic examination)

Abbreviations: LMP, last menstrual period; MSI, Marie Stopes International; MVA, manual vacuum aspiration; RCT, randomized controlled trial.

Table 2 Percentage and OR of incomplete abortion and complications in included studies, by provider type

	Number of women		Incomplete or failed abortiona, % (n)		Incomplete or failed abortion, OR (95% CI)b	Overall complications % (n)		Overall complications, OR (95% CI)c	Immediate complications, % (n)		Immediate complications, OR (95% CI)	Delayed complications % (n)		Delayed complications, OR (95% CI)
	MLP	Physician	MLP	Physician		MLP	Physician		MLP	Physician		MLP	Physician
RCTs
Warriner et al^Citation11 (surgical abortion)	1400	1389	1.1 (16)	0.6 (8)	2.00 (0.85–4.68)	1.3 (18)	0.7 (10)	1.80 (0.83–3.90)	0	0.1 (1)	0.33 (0.01–8.12)	1.3 (18)	0.6 (9)	2.00 (0.89–4.46)
Warriner et al^Citation12 (medical abortion)	518	514	2.7 (14)	3.9 (20)	0.69 (0.34–1.37)	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a	n/a
Total	1918	1903
Cohort studies
Freedman et al^Citation13	1285	1173	n/a	n/a	n/a	2.7 (35)	3.1 (36)	0.88 (0.55–1.42)	0.5 (6)	0.8 (9)	0.61 (0.22–1.71)	2.3 (29)	2.4 (27)	0.98 (0.58–1.67)
Goldman et al^Citation14	546	817	1.5 (8)	0.4 (3)	4.03 (1.07–15.28)	2.2 (12)	2.3 (19)	1.28 (0.66–2.47)	0.5 (2)	0.1 (1)	4.51 (0.47–43.45)	1.8 (10)	2.2 (17)	1.11 (0.55–2.22)
Jejeebhoy et al^Citation15	449	448	1.2 (5)	0.9 (4)	1.25 (0.33–4.69)	1.4 (6)	0.9 (4)	1.50 (0.42–5.36)	n/a	n/a	n/a	n/a	n/a	n/a
Total	2280	2438

Notes:

a Incomplete abortion (retained products) and failed abortion (continuing pregnancy);

b OR of incomplete or failed abortion for MLP group compared with physician group;

c OR of overall complications for MLP group compared with physician group;

n/a indicates that information on this outcome was not available.

Abbreviations: CI, confidence interval; MLP, midlevel provider; OR, odds ratio; RCT, randomized controlled trial.

WarrinerIKMeirikOHoffmanMRates 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 trialLancet200636895511965197217141703

 PubMed Web of Science ®Google Scholar

WarrinerIKWangDHuongNTCan midlevel health-care providers administer early medical abortion as safely and effectively as doctors? A randomised controlled equivalence trial in NepalLancet201137797721155116121458058

 PubMed Web of Science ®Google Scholar

FreedmanMAJillsonDACoffinRRNovickLFComparison of complication rates in first trimester abortions performed by physician assistants and physiciansAm J Public Health19867655505542870654

 PubMed Web of Science ®Google Scholar

GoldmanMBOcchiutoJSPetersonLEZapkaJGPalmerRHPhysician assistants as providers of surgically induced abortion servicesAm J Public Health20049481352135715284043

 PubMed Web of Science ®Google Scholar

JejeebhoySJKalyanwalaSZavierAJCan nurses perform manual vacuum aspiration (MVA) as safely and effectively as physicians? Evidence from IndiaContraception201184661562122078191

 PubMed Web of Science ®Google Scholar