Physicians' and non-physicians' views about provision of medical abortion by nurses and AYUSH physicians in Maharashtra and Bihar, India

Mid-level health providers for primary healthcare: a rapid evidence synthesis

Background: Healthcare services, in many countries, are increasingly being provided by cadres not trained as physicians, and these substitute health workers are referred to as mid-level health providers (MLHPs). The objective of this study was to rapidly synthesise evidence on the effectiveness of MLHPs involved in the delivery of healthcare, with a perspective on low- and middle-income countries.

Methods: The review team performed an overview of systematic reviews assessing various outcomes for participants receiving care from MLHPs. The team evaluated systematic reviews for methodological quality and certainty of the evidence. Also, the review team consulted relevant stakeholders in India.

Results: The final report included seven systematic reviews, with six assessed as moderate to high methodological quality. Mortality outcomes concerning pregnancy and childbirth care services showed no significant differences in care provided by MLHPs when compared with doctors. Pregnancy care provided by midwives was found to improve the quality of care slightly. The risk of failure or incomplete abortion for surgical abortion procedures provided by MLHPs was twice when compared to the procedures provided by doctors. Moderate to high certainty evidence showed that initiation and maintenance of antiretroviral therapy for HIV-infected patients by a nurse or clinical officer slightly reduced mortality. High certainty evidence showed that chronic disease management by non-medical prescribers reduced some important physiological measures compared to medical prescribing by doctors.

Conclusions: To date, this is the first rapid overview of the evidence on MLHPs. Low-quality evidence suggests that MLHPs might be suitable to deliver quality pregnancy care. Moderate and high-quality evidence from trials suggests that MLHPs are helpful for chronic disease management and initiation and maintenance of antiretroviral therapy in people with HIV/AIDS. However, the roles and subsequent training and regulation of MLHPs might be different for different care domains.

Medical Abortion Provided by Nurse-Midwives or Physicians in a High Resource Setting: A Cost-Effectiveness Analysis

Objective

The objective of the present study is to calculate the cost-effectiveness of early medical abortion performed by nurse-midwifes in comparison to physicians in a high resource setting where ultrasound dating is part of the protocol. Non-physician health care professionals have previously been shown to provide medical abortion as effectively and safely as physicians, but the cost-effectiveness of such task shifting remains to be established.

Study design

A cost effectiveness analysis was conducted based on data from a previously published randomized-controlled equivalence study including 1180 healthy women randomized to the standard procedure, early medical abortion provided by physicians, or the intervention, provision by nurse-midwifes. A 1.6% risk difference for efficacy defined as complete abortion without surgical interventions in favor of midwife provision was established which means that for every 100 procedures, the intervention treatment resulted in 1.6 fewer incomplete abortions needing surgical intervention than the standard treatment. The average direct and indirect costs and the incremental cost-effectiveness ratio (ICER) were calculated. The study was conducted at a university hospital in Stockholm, Sweden.

Results

The average direct costs per procedure were EUR 45 for the intervention compared to EUR 58.3 for the standard procedure. Both the cost and the efficacy of the intervention were superior to the standard treatment resulting in a negative ICER at EUR -831 based on direct costs and EUR -1769 considering total costs per surgical intervention avoided.

Conclusion

Early medical abortion provided by nurse-midwives is more cost-effective than provision by physicians. This evidence provides clinicians and decision makers with an important tool that may influence policy and clinical practice and eventually increase numbers of abortion providers and reduce one barrier to women’s access to safe abortion.

Medical students are afraid to include abortion in their future practices: in-depth interviews in Maharastra, India

BACKGROUND

Unsafe abortions are estimated to cause eight per-cent of maternal mortality in India. Lack of providers, especially in rural areas, is one reason unsafe abortions take place despite decades of legal abortion. Education and training in reproductive health services has been shown to influence attitudes and increase chances that medical students will provide abortion care services in their future practice. To further explore previous findings about poor attitudes toward abortion among medical students in Maharastra, India, we conducted in-depth interviews with medical students in their final year of education.

METHOD

We used a qualitative design conducting in-depth interviews with twenty-three medical students in Maharastra applying a topic guide. Data was organized using thematic analysis with an inductive approach.

RESULTS

The participants described a fear to provide abortion in their future practice. They lacked understanding of the law and confused the legal regulation of abortion with the law governing gender biased sex selection, and concluded that abortion is illegal in Maharastra. The interviewed medical students' attitudes were supported by their experiences and perceptions from the clinical setting as well as traditions and norms in society. Medical abortion using mifepristone and misoprostol was believed to be unsafe and prohibited in Maharastra. The students perceived that nurse-midwives were knowledgeable in Sexual and Reproductive Health and many found that they could be trained to perform abortions in the future.

CONCLUSIONS

To increase chances that medical students in Maharastra will perform abortion care services in their future practice, it is important to strengthen their confidence and knowledge through improved medical education including value clarification and clinical training.