SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
January, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Training midlevel providers (midwives, nurses, and other nondoctor providers) to conduct surgical aspiration abortions and manage medical abortions has been proposed as a way of increasing women’s access to safe abortion in developing countries. It is important to know if abortion procedures administered by midlevel providers are more or less effective and safe than those administered by doctors.
Key messages
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In-service neonatal emergency care training versus standard care for healthcare professionals |
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People: Nurses/midwives (Kenya); doctors, nurses and midwives (Sri Lanka) |
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| Outcomes |
Absolute effect |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
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Without training |
With training |
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Proportion of adequate initial resuscitation steps |
27 per 100 |
66 per 100 |
RR 2.45 |
Moderate |
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Difference: 39 more per 100 resuscitation practices
Difference: 39 more per 100 resuscitation practices (Margin of error: 20 to 65 more) |
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Inappropriate and potentially harmful practices per resuscitation |
Mean: 0.92 |
Mean: 0.53 |
- |
Moderate |
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Mean difference: 0.40 fewer per resuscitation (Margin of error: 0.13 to 0.66 fewer) |
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Mortality in all resuscitation episodes |
36 per 100 |
28 per 100 |
RR 0.77 (0.40 to 1.48) |
Low |
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Difference: 8 fewers deaths per 100 resuscitation episodes (Margin of error: 22 fewer to 17 more) |
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| Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) | ||||||
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Confidence interval GRADE: GRADE Working Group grades of evidence (see above and last page) *Illustrative comparative risks |
Ngo TD, Park MH, Free C. Safety and effectiveness of termination services performed by doctors versus midlevel providers: a systematic review and analysis. Int J Women Health 2013: 5; 9–17.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Unsafe abortion remains a major public health concern in developing countries. Abortions are conventionally administered by trained doctors (gynecologists and obstetricians). In many low income countries, even in settings where abortion is legal, access to abortion remains limited due to a shortage of trained doctors. Irrespective of legal conditions, in settings where access to safe abortion care is lacking, women often obtain abortions from unqualified or unskilled providers. Therefore, training and authorising midlevel providers (midwives, nurses, and other nondoctor providers) to conduct aspiration abortions and manage medical abortions has been proposed as a way to increase women’s access to safe abortion services.
| Review objectives: To compare the effectiveness and safety of abortion procedures administered by midlevel providers versus procedures administered by doctors. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials, non randomised trials and comparison studies exploring effectiveness or safety of abortion procedures (surgical or medical) provided by midlevel providers and doctors |
Five studies: Randomised trials (2) one exploring surgical aspiration procedures and the other medical abortion procedures; Prospective cohort studies (3) all exploring surgical aspiration abortion procedures
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| Participants | Women seeking termination of pregnancy |
Total of 8539 women seeking termination of pregnancy; women aged from <20 to >40 years. In the four studies of surgical abortion procedures, maximum gestational ages ranged from 10 to 16+ weeks. In the trial of medical abortion, women with gestational ages of up to 9 weeks were included. |
| Settings | Any setting | South Africa and Vietnam (1); Nepal (1); US (2) and India (1). All studies took place in either a hospital or specialist health clinic, such as a women’s health centre or sexual and reproductive health clinic. |
| Outcomes |
Effectiveness or efficacy of abortion procedures, provided by midlevel providers versus doctors, measured as incomplete or failed abortion. Safety of abor¬tion procedures administered by midlevel providers versus doctors, measured as adverse events and complications.
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Both randomised trials and two of the cohort studies examined effectiveness, measured as incomplete or failed abortion. The trial of surgical abortion and the three cohort studies examined safety, measured as complications (immediate and delayed).
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| Date of most recent search: February 2012 | ||
| Limitations: This is a well-conducted review with minor limitations. | ||
Ngo TD, Park MH, Free C. Safety and effectiveness of termination services performed by doctors versus midlevel providers: a systematic review and analysis. Int J Women Health 2013: 5; 9–17.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
A total of five studies were included in this review. Four studies, one in Vietnam and South Africa, two in the US and one in India, examined surgical aspiration abortion by midlevel providers compared to doctors. These studies looked at effectiveness of abortion procedures, measured as incomplete or failed abortion, and at safety of abortion procedures, measured as complications related to the procedure. The other study was done in Nepal and examined medical abortion by midlevel providers compared to doctors. This study also looked at effectiveness of abortion procedures, measured as incomplete or failed abortion
Five studies examined this comparison but only the findings from two randomised trials are displayed in the table below. Two additional studies with low certainty of evidence also suggested more incomplete or failed abortions by midlevel providers. Three additional studies with low certainty of evidence suggested little or no difference in complications between midlevel providers and doctors.
Surgical aspiration abortion by midlevel providers versus doctors |
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| Patient or population: Women seeking termination of pregnancy Settings: Specialist health clinics in South Africa and Vietnam and district hospitals in Nepal Intervention: Surgical aspiration abortion by midlevel providers Comparison: Surgical aspiration abortion by doctors |
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| Outcomes | Illustrative comparative risks |
Difference (95% CI) |
Numbers of participants (studies) |
Certainty of the evidence (GRADE) |
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| By doctors | By midlevel providers | |||||
| Incomplete or failed abortion | 6 per 1000 |
11 per 1000 |
5 more per 1000 1 (9 fewer to 17 more) |
2894 (1 study) |
Moderate |
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| Complications | 7 per 1000 | 13 per 1000 |
6 more per 1000 2 (11 fewer to 167 more) |
1104 (1 study) |
Moderate |
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CI: Confidence interval GRADE: GRADE Working Group grades of evidence (see above and last page) *Illustrative comparative risks |
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1 Two additional cohort studies also suggested an increase in the risk of incomplete or failed abortion 2 Three additional cohort studies reported no difference in odds of complications |
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This comparison was examined in only one study.
| Medical abortion by midlevel providers compared to doctors | ||||||
| Patient or population: Women seeking termination of pregnancy Settings: District hospitals in Nepal Intervention: Medical abortion by midlevel providers Comparison: Medical abortion by doctors |
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| Outcomes | Illustrative comparative risks |
Difference (95% CI) |
Numbers of participants (studies) |
Certainty of the evidence (GRADE) |
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| By doctors | By midlevel providers | |||||
| Incomplete or failed abortion | 39 per 1000 |
27 per 1000 |
12 fewer per 1000 (200 fewer to 77 more) |
1104 (1 study) |
Moderate |
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CI: Confidence interval GRADE: GRADE Working Group grades of evidence (see above and last page) *Illustrative comparative risks |
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1 Two additional cohort studies also suggested an increase in the risk of incomplete or failed abortion 2 Three additional cohort studies reported no difference in odds of complications |
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|
In-service neonatal emergency care training versus standard care for healthcare professionals |
||||||
|
People: Nurses/midwives (Kenya); doctors, nurses and midwives (Sri Lanka) |
||||||
| Outcomes |
Absolute effect |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
|||
|
Without training |
With training |
|||||
|
Proportion of adequate initial resuscitation steps |
27 per 100 |
66 per 100 |
RR 2.45 |
Moderate |
||
|
Difference: 39 more per 100 resuscitation practices
Difference: 39 more per 100 resuscitation practices (Margin of error: 20 to 65 more) |
||||||
|
Inappropriate and potentially harmful practices per resuscitation |
Mean: 0.92 |
Mean: 0.53 |
- |
Moderate |
||
|
Mean difference: 0.40 fewer per resuscitation (Margin of error: 0.13 to 0.66 fewer) |
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|
Mortality in all resuscitation episodes |
36 per 100 |
28 per 100 |
RR 0.77 (0.40 to 1.48) |
Low |
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|
Difference: 8 fewers deaths per 100 resuscitation episodes (Margin of error: 22 fewer to 17 more) |
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| Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) | ||||||
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Confidence interval GRADE: GRADE Working Group grades of evidence (see above and last page) *Illustrative comparative risks |
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| The two randomised trials were carried out in lower and upper middle income countries and thus the measured effects may be transferable to low income countries. |
When assessing the transferability of these findings to low-income settings, the following factors need to be considered: - Local epidemiology of abortion rates and incidence of unsafe abortion procedures - The availability of doctors in these settings to perform abortion procedures - The availability and training of midlevel providers to perform surgical and medical abortions, with special attention to providers in public health facilities and rural areas - Accessibility to the necessary pre to post abortion care, especially in public facilities and rural areas - The differences in effectiveness and safety of surgical versus medical abortion procedures by midlevel providers - Cost implications of other models of care compared to midlevel provider care
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| EQUITY | |
| There was no information in the included studies regarding differential effects of the interventions in disadvantaged populations. The trial of surgical abortion procedures was done in private settings in South Africa and Vietnam and participants are likely not representative of disadvan-taged populations in these countries. | Given the scarcity of obstetricians and gynaecol-ogists serving disadvantaged populations in low income settings, using midlevel providers has the potential to expand women’s access to safe abortion procedures in underserved areas, especially when incidence of unsafe abortion procedures is high, providing the midlevel providers are recruited, trained, supported and retained in underserved communities. Consideration should be given to health system factors and regulations that will encourage this. |
| ECONOMIC CONSIDERATIONS | |
| None of the included studies presented cost data comparing midlevel and doctor providers. |
It is likely that the provision and management of abortion procedures by midlevel providers may be cost effective in resource limited settings due to lower salary costs and scarcity of obstetricians and gynaecologists. However, formal economic evaluations are needed to assess whether midlevel providers of abortion procedures are affordable alternatives to doctor providers with comparable outcomes, specifically in relation to infrastructure and training. |
| MONITORING & EVALUATION | |
| High certainty evidence on the effectiveness and safety of abortion procedures administered by midlevel providers versus procedures administered by doctors is lacking. |
Operational research studies are needed to assess the feasibility and accept¬ability of rolling out midlevel provision, as well as impact evaluations. Evaluations should also consider the structure of the wider healthcare system and availability of personnel to identify which midlevel providers, if any, are best placed to provide abortion procedures, and also consider how the process from pre- to post-abortion care is managed. |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
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Lassi ZS, Bhutta ZA. Mid‐level health workers for improving the delivery of health services. Cochrane Database Syst Rev 2012; 2: CD009649.
Kulier R, Kapp N, Gülmezoglu AM, Hofmeyr GJ, Cheng L, Campana A. Medical methods for first trimester abor-tion. Cochrane Database Syst Rev 2011; 11: CD002855.
Renner RM, Brahmi D, Kapp N. Who can provide effective and safe termination of pregnancy care? A systematic review. BJOG 2013 Jan;120(1):23-31.
Celeste Naude, Centre for Evidence-based Health Care, Stellenbosch University, South Africa.
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by one external referee. We did not receive any comments from the review authors.
Ngo TD, Park MH, Free C. Safety and effectiveness of termination services per-formed by doctors versus midlevel providers: a systematic review and analysis. Int J Women Health 2013: 5; 9–17.
Celeste Naude. Are abortion procedures by nondoctor providers effective and safe? A SUPPORT Summary of a systematic review. January 2017. www.supportsummaries.org
evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care, abortion, midlevel providers, midwives, nurses, non-doctor, task shifting
The Centre for Evidence-based Health Care is a coordinating and di-rective institution for research and training of the Faculty of Medicine and Health Sciences of Stellenbosch University in the field of evidence-based health care. The CEBHC aims to conduct and support relevant systematic reviews and primary research related to evidence-informed health care; enhance evidence-informed healthcare knowledge, skills and practices through teaching healthcare professionals and other stakeholders; and promote the use of best evidence in healthcare decision making and the uptake of current best evidence in healthcare policy and practice. Core activities of the CEBHC include research, teaching and knowledge transla-tion.
