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van den Brink GTWJ, Hooker RS, Van Vught AJ, Vermeulen H, Laurant MGH. The cost-effectiveness of physician assistants/associates: A systematic review of international evidence. PLoS One 2021; 16:e0259183. [PMID: 34723999 PMCID: PMC8559935 DOI: 10.1371/journal.pone.0259183] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 10/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The global utilization of the physician assistant/associate (PA) is growing. Their increasing presence is in response to the rising demands of demographic changes, new developments in healthcare, and physician shortages. While PAs are present on four continents, the evidence of whether their employment contributes to more efficient healthcare has not been assessed in the aggregate. We undertook a systematic review of the literature on PA cost-effectiveness as compared to physicians. Cost-effectiveness was operationalized as quality, accessibility, and the cost of care. METHODS AND FINDINGS Literature to June 2021 was searched across five biomedical databases and filtered for eligibility. Publications that met the inclusion criteria were categorized by date, country, design, and results by three researchers independently. All studies were screened with the Risk of Bias in Non-randomised Studies-of Interventions (ROBIN-I) tool. The literature search produced 4,855 titles, and after applying criteria, 39 studies met inclusion (34 North America, 4 Europe, 1 Africa). Ten studies had a prospective design, and 29 were retrospective. Four studies were assessed as biased in results reporting. While most studies included a small number of PAs, five studies were national in origin and assessed the employment of a few hundred PAs and their care of thousands of patients. In 34 studies, the PA was employed as a substitute for traditional physician services, and in five studies, the PA was employed in a complementary role. The quality of care delivered by a PA was comparable to a physician's care in 15 studies, and in 18 studies, the quality of care exceeded that of a physician. In total, 29 studies showed that both labor and resource costs were lower when the PA delivered the care than when the physician delivered the care. CONCLUSIONS Most of the studies were of good methodological quality, and the results point in the same direction; PAs delivered the same or better care outcomes as physicians with the same or less cost of care. Sometimes this efficiency was due to their reduced labor cost and sometimes because they were more effective as producers of care and activity.
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Affiliation(s)
- G. T. W. J. van den Brink
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
| | - R. S. Hooker
- Adjunct Professor, Health Policy, Northern Arizona University, United States of America
| | - A. J. Van Vught
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
| | - H. Vermeulen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
| | - M. G. H. Laurant
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
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American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists’ Abortion Access and Training Expert Work Group. Increasing Access to Abortion: ACOG Committee Opinion, Number 815. Obstet Gynecol 2020; 136:e107-15. [PMID: 33214531 DOI: 10.1097/AOG.0000000000004176] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Individuals require access to safe, legal abortion. Abortion, although legal, is increasingly out of reach because of numerous restrictions imposed by the government that target patients seeking abortion and their health care practitioners. Insurance coverage restrictions, which take many forms, constitute a substantial barrier to abortion access and increase reproductive health inequities. Adolescents, people of color, those living in rural areas, those with low incomes, and incarcerated people can face disproportionate effects of restrictions on abortion access. Stigma and fear of violence may be less tangible than legislative and financial restrictions, but are powerful barriers to abortion provision nonetheless. The American College of Obstetricians and Gynecologists, along with other medical organizations, opposes such interference with the patient-clinician relationship, affirming the importance of this relationship in the provision of high-quality medical care. This revision includes updates based on new restrictions and litigation related to abortion.
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Abstract
The changing political landscape has had a significant impact on abortion training in the United States. Access to training in medical and surgical abortion has been improving over the past several decades, though significant barriers exist in training providers adequately. We sought to evaluate access to abortion training to providers, including obstetrician-gynecologists, family practice physicians, and advanced practice providers. Training in contraception, miscarriage management, medication abortion and surgical abortion procedures is a requirement for Obstetrics and Gynecology residents. Limited information exists about the details of residency training, though larger percentages of graduating residents are reporting access to comprehensive family planning training. Initiatives by groups such as Medical Students for Choice and the Kenneth J. Ryan Program have greatly improved access to abortion training by increasing opportunities for resident involvement. Abortion training opportunities exist for Family Medicine residents and advanced practice clinicians, though this training is not mandated and as such, often not standardized. In light of increasingly restrictive legislation and decreasing numbers of abortion providers, concerns exist about the sustainability of abortion training access. Other noteworthy barriers to provider training include hospital policy, lack of expert faculty, and state laws. Ensuring integrated evidence-based and standardized abortion training is important in maintaining access to a full range of family planning services.
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Affiliation(s)
- Aleksandra Polic
- Department of Obstetrics/Gynecology, University of South Florida Morsani College of Medicine. United States.
| | - Rachel B Rapkin
- Division of Specialists in OB/Gyn, Department of Obstetrics and Gynecology, University of South Florida. United States
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Abstract
OBJECTIVE This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care. INTENDED USERS Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs. TARGET POPULATION Women with an unintended or abnormal first or second trimester pregnancy. EVIDENCE PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched. VALUES The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request. BENEFITS, HARMS, AND/OR COSTS IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.
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Levi A, Goodman S, Weitz T, AbiSamra R, Nobel K, Desai S, Battistelli M, Taylor D. Training in aspiration abortion care: An observational cohort study of achieving procedural competence. Int J Nurs Stud 2018; 88:53-59. [DOI: 10.1016/j.ijnurstu.2018.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 08/05/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022]
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Williams SG, Roberts S, Kerns JL. Effects of Legislation Regulating Abortion in Arizona. Womens Health Issues 2018; 28:297-300. [DOI: 10.1016/j.whi.2018.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 01/28/2018] [Accepted: 02/05/2018] [Indexed: 10/17/2022]
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Costescu D, Guilbert É. No 360 - Avortement provoqué : avortement chirurgical et méthodes médicales au deuxième trimestre. Journal of Obstetrics and Gynaecology Canada 2018; 40:784-821. [DOI: 10.1016/j.jogc.2018.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Taylor D, Upadhyay UD, Fjerstad M, Battistelli MF, Weitz TA, Paul ME. Standardizing the classification of abortion incidents: the Procedural Abortion Incident Reporting and Surveillance (PAIRS) Framework. Contraception 2017; 96:1-13. [PMID: 28578150 DOI: 10.1016/j.contraception.2017.05.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 04/30/2017] [Accepted: 05/14/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To develop and validate standardized criteria for assessing abortion-related incidents (adverse events, morbidities, near misses) for first-trimester aspiration abortion procedures and to demonstrate the utility of a standardized framework [the Procedural Abortion Incident Reporting & Surveillance (PAIRS) Framework] for estimating serious abortion-related adverse events. STUDY DESIGN As part of a California-based study of early aspiration abortion provision conducted between 2007 and 2013, we developed and validated a standardized framework for defining and monitoring first-trimester (≤14weeks) aspiration abortion morbidity and adverse events using multiple methods: a literature review, framework criteria testing with empirical data, repeated expert reviews and data-based revisions to the framework. RESULTS The final framework distinguishes incidents resulting from procedural abortion care (adverse events) from morbidity related to pregnancy, the abortion process and other nonabortion related conditions. It further classifies incidents by diagnosis (confirmatory data, etiology, risk factors), management (treatment type and location), timing (immediate or delayed), seriousness (minor or major) and outcome. Empirical validation of the framework using data from 19,673 women receiving aspiration abortions revealed almost an equal proportion of total adverse events (n=205, 1.04%) and total abortion- or pregnancy-related morbidity (n=194, 0.99%). The majority of adverse events were due to retained products of conception (0.37%), failed attempted abortion (0.15%) and postabortion infection (0.17%). Serious or major adverse events were rare (n=11, 0.06%). CONCLUSIONS Distinguishing morbidity diagnoses from adverse events using a standardized, empirically tested framework confirms the very low frequency of serious adverse events related to clinic-based abortion care. IMPLICATIONS The PAIRS Framework provides a useful set of tools to systematically classify and monitor abortion-related incidents for first-trimester aspiration abortion procedures. Standardization will assist healthcare providers, researchers and policymakers to anticipate morbidity and prevent abortion adverse events, improve care metrics and enhance abortion quality.
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Affiliation(s)
- Diana Taylor
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, and School of Nursing, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612.
| | - Ushma D Upadhyay
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612
| | - Mary Fjerstad
- National Abortion Federation, 1090 Vermont Avenue NW #1000, Washington, DC 20005
| | - Molly F Battistelli
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612
| | - Tracy A Weitz
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway, Suite 1100, Oakland, CA 94612
| | - Maureen E Paul
- Beth Israel Deaconess Medical Center, Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215
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Patil E, Darney B, Orme-Evans K, Beckley EH, Bergander L, Nichols M, Bednarek PH. Aspiration Abortion With Immediate Intrauterine Device Insertion: Comparing Outcomes of Advanced Practice Clinicians and Physicians. J Midwifery Womens Health 2016; 61:325-30. [DOI: 10.1111/jmwh.12412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Johnston HB, Ganatra B, Nguyen MH, Habib N, Afework MF, Harries J, Iyengar K, Moodley J, Lema HY, Constant D, Sen S. Accuracy of Assessment of Eligibility for Early Medical Abortion by Community Health Workers in Ethiopia, India and South Africa. PLoS One 2016; 11:e0146305. [PMID: 26731176 PMCID: PMC4701452 DOI: 10.1371/journal.pone.0146305] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 12/15/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To assess the accuracy of assessment of eligibility for early medical abortion by community health workers using a simple checklist toolkit. DESIGN Diagnostic accuracy study. SETTING Ethiopia, India and South Africa. METHODS Two hundred seventeen women in Ethiopia, 258 in India and 236 in South Africa were enrolled into the study. A checklist toolkit to determine eligibility for early medical abortion was validated by comparing results of clinician and community health worker assessment of eligibility using the checklist toolkit with the reference standard exam. RESULTS Accuracy was over 90% and the negative likelihood ratio <0.1 at all three sites when used by clinician assessors. Positive likelihood ratios were 4.3 in Ethiopia, 5.8 in India and 6.3 in South Africa. When used by community health workers the overall accuracy of the toolkit was 92% in Ethiopia, 80% in India and 77% in South Africa negative likelihood ratios were 0.08 in Ethiopia, 0.25 in India and 0.22 in South Africa and positive likelihood ratios were 5.9 in Ethiopia and 2.0 in India and South Africa. CONCLUSION The checklist toolkit, as used by clinicians, was excellent at ruling out participants who were not eligible, and moderately effective at ruling in participants who were eligible for medical abortion. Results were promising when used by community health workers particularly in Ethiopia where they had more prior experience with use of diagnostic aids and longer professional training. The checklist toolkit assessments resulted in some participants being wrongly assessed as eligible for medical abortion which is an area of concern. Further research is needed to streamline the components of the tool, explore optimal duration and content of training for community health workers, and test feasibility and acceptability.
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Affiliation(s)
- Heidi Bart Johnston
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Bela Ganatra
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - My Huong Nguyen
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Ndema Habib
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Jane Harries
- Women’s Health Research Unit, School of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town, Cape Town, South Africa
| | - Kirti Iyengar
- Action Research & Training for Health, Udaipur, Rajasthan, India
| | - Jennifer Moodley
- Women’s Health Research Unit, School of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town, Cape Town, South Africa
| | | | - Deborah Constant
- Women’s Health Research Unit, School of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town, Cape Town, South Africa
| | - Swapnaleen Sen
- Action Research & Training for Health, Udaipur, Rajasthan, India
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White K, Carroll E, Grossman D. Complications from first-trimester aspiration abortion: a systematic review of the literature. Contraception 2015; 92:422-38. [DOI: 10.1016/j.contraception.2015.07.013] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 06/03/2015] [Accepted: 07/26/2015] [Indexed: 01/09/2023]
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Foster AM, Jackson CB, LaRoche KJ, Simmonds K, Taylor D. From qualified physician to licensed health care professional: the time has come to change mifepristone's label. Contraception 2015; 92:200-2. [PMID: 26134281 DOI: 10.1016/j.contraception.2015.06.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 06/25/2015] [Accepted: 06/26/2015] [Indexed: 11/19/2022]
Affiliation(s)
| | | | | | | | - Diana Taylor
- Advancing New Standards in Reproductive Health, University of California, San Francisco
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Abstract
Access to safe abortion hinges upon the availability of trained abortion providers. The American College of Obstetricians and Gynecologists supports education for students in health care fields as well as clinical training for residents and advanced practice clinicians in abortion care in order to increase the availability of trained abortion providers. The American College of Obstetricians and Gynecologists supports the expansion of abortion education and an increase in the number and types of trained abortion providers in order to ensure women's access to safe abortions. Integrated medical education and universal opt-out training policies help to lessen the stigma of abortion provision and improve access by increasing the number of abortion providers. This Committee Opinion reviews the current status of abortion education, describes initiatives to ensure the availability of appropriate and up-to-date abortion training, and recommends efforts for integrating and improving abortion education in medical schools, residency programs, and advanced practice clinician training programs.
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Upadhyay UD, Desai S, Zlidar V, Weitz TA, Grossman D, Anderson P, Taylor D. Incidence of Emergency Department Visits and Complications After Abortion. Obstet Gynecol 2015; 125:175-83. [DOI: 10.1097/aog.0000000000000603] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Begum F, Zaidi S, Fatima P, Shamsuddin L, Anowar-ul-Azim A, Begum RA. Improving manual vacuum aspiration service delivery, introducing misoprostol for cases of incomplete abortion, and strengthening postabortion contraception in Bangladesh. Int J Gynaecol Obstet 2014; 126 Suppl 1:S31-5. [DOI: 10.1016/j.ijgo.2014.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Weitz TA, Taylor D, Desai S, Upadhyay UD, Waldman J, Battistelli MF, Drey EA. Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver. Am J Public Health 2013; 103:454-61. [PMID: 23327244 DOI: 10.2105/ajph.2012.301159] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the impact on patient safety if nurse practitioners (NPs), certified nurse midwives (CNMs), and physician assistants (PAs) were permitted to provide aspiration abortions in California. METHODS In a prospective, observational study, we evaluated the outcomes of 11 487 early aspiration abortions completed by physicians (n = 5812) and newly trained NPs, CNMs, and PAs (n = 5675) from 4 Planned Parenthood affiliates and Kaiser Permanente of Northern California, by using a noninferiority design with a predetermined acceptable risk difference of 2%. All complications up to 4 weeks after the abortion were included. RESULTS Of the 11 487 aspiration abortions analyzed, 1.3% (n = 152) resulted in a complication: 1.8% for NP-, CNM-, and PA-performed aspirations and 0.9% for physician-performed aspirations. The unadjusted risk difference for total complications between NP-CNM-PA and physician groups was 0.87 (95% confidence interval [CI] = 0.45, 1.29) and 0.83 (95% CI = 0.33, 1.33) in a propensity score-matched sample. CONCLUSIONS Abortion complications were clinically equivalent between newly trained NPs, CNMs, and PAs and physicians, supporting the adoption of policies to allow these providers to perform early aspirations to expand access to abortion care.
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Affiliation(s)
- Tracy A Weitz
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, University of California, San Francisco, CA 94612, USA.
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Abstract
The Roe v Wade decision made safe abortion available but did not change the reality that more than 1 million women face an unwanted pregnancy every year. Forty years after Roe v Wade, the procedure is not accessible to many US women. The politics of abortion have led to a plethora of laws that create enormous barriers to abortion access, particularly for young, rural, and low-income women. Family medicine physicians and advanced practice clinicians are qualified to provide abortion care. To realize the promise of Roe v Wade, first-trimester abortion must be integrated into primary care and public health professionals and advocates must work to remove barriers to the provision of abortion within primary care settings.
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Affiliation(s)
- Susan Yanow
- Advancing New Standards in Reproductive Health, University of California, San Francisco, CA, USA.
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Abstract
Throughout history, the care of women's reproductive health needs has included termination of unwanted pregnancy. Unfortunately, access to safe first-trimester abortion is restricted by a lack of skilled providers. In an effort to provide data-based evidence and increase access to first-trimester abortion care in California, the University of California, San Francisco, under the auspices of the Health Workforce Pilot Program, developed a competency-based training model to increase the number of certified nurse-midwives, nurse practitioners, and physician assistants who can provide uterine aspiration. This article describes the training program, which uses a curriculum comprising both self-directed didactic material and supervised clinical experience with a minimum of 40 procedures. Successful completion of the program requires passing a written examination and satisfactory achievement of a competency-based clinical assessment. Thirty-eight trainees have completed the training to date, achieving competency following an average of 6 training days. Competency development in the clinical area is monitored by both the trainer and the trainee, using daily and final competency assessments in 4 domains: patient comfort, procedural completeness, speed, and ability to identify problems. Analysis of complications is used to identify concerns about clinician safety. The availability of a competency-based training curriculum for uterine aspiration has the potential to increase the number of first-trimester abortion providers by making training available to experienced clinicians, including nurse-midwives, who would like to provide this care.
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Affiliation(s)
- Amy Levi
- University of California, San Francisco, Obstetrics, Gynecology, and Reproductive Science, 1001 Potrero, 6D-29, San Francisco, CA 94920, USA.
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Jackson CB. Expanding the pool of abortion providers: nurse-midwives, nurse practitioners, and physician assistants. Womens Health Issues 2011; 21:S42-3. [PMID: 21530838 DOI: 10.1016/j.whi.2011.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 01/27/2011] [Accepted: 01/27/2011] [Indexed: 11/17/2022]
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Jennings L, Yebadokpo AS, Affo J, Agbogbe M, Tankoano A. Task shifting in maternal and newborn care: a non-inferiority study examining delegation of antenatal counseling to lay nurse aides supported by job aids in Benin. Implement Sci 2011; 6:2. [PMID: 21211045 PMCID: PMC3024964 DOI: 10.1186/1748-5908-6-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Accepted: 01/06/2011] [Indexed: 11/21/2022] Open
Abstract
Background Shifting the role of counseling to less skilled workers may improve efficiency and coverage of health services, but evidence is needed on the impact of substitution on quality of care. This research explored the influence of delegating maternal and newborn counseling responsibilities to clinic-based lay nurse aides on the quality of counseling provided as part of a task shifting initiative to expand their role. Methods Nurse-midwives and lay nurse aides in seven public maternities were trained to use job aids to improve counseling in maternal and newborn care. Quality of counseling and maternal knowledge were assessed using direct observation of antenatal consultations and patient exit interviews. Both provider types were interviewed to examine perceptions regarding the task shift. To compare provider performance levels, non-inferiority analyses were conducted where non-inferiority was demonstrated if the lower confidence limit of the performance difference did not exceed a margin of 10 percentage points. Results Mean percent of recommended messages provided by lay nurse aides was non-inferior to counseling by nurse-midwives in adjusted analyses for birth preparedness (β = -0.0, 95% CI: -9.0, 9.1), danger sign recognition (β = 4.7, 95% CI: -5.1, 14.6), and clean delivery (β = 1.4, 95% CI: -9.4, 12.3). Lay nurse aides demonstrated superior performance for communication on general prenatal care (β = 15.7, 95% CI: 7.0, 24.4), although non-inferiority was not achieved for newborn care counseling (β = -7.3, 95% CI: -23.1, 8.4). The proportion of women with correct knowledge was significantly higher among those counseled by lay nurse aides as compared to nurse-midwives in general prenatal care (β = 23.8, 95% CI: 15.7, 32.0), birth preparedness (β = 12.7, 95% CI: 5.2, 20.1), and danger sign recognition (β = 8.6, 95% CI: 3.3, 13.9). Both cadres had positive opinions regarding task shifting, although several preferred 'task sharing' over full delegation. Conclusions Lay nurse aides can provide effective antenatal counseling in maternal and newborn care in facility-based settings, provided they receive adequate training and support. Efforts are needed to improve management of human resources to ensure that effective mechanisms for regulating and financing task shifting are sustained.
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Affiliation(s)
- Larissa Jennings
- USAID Health Care Improvement Project, University Research Co,, LLC, Wisconsin Boulevard, Bethesda, MD, USA.
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Weitz TA, Cockrill K. Abortion clinic patients' opinions about obtaining abortions from general women's health care providers. Patient Educ Couns 2010; 81:409-414. [PMID: 20888725 DOI: 10.1016/j.pec.2010.09.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 08/28/2010] [Accepted: 09/01/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Most U.S. women obtain abortions at specialty clinics. This qualitative study explores abortion clinic patients' opinions about receiving abortions from general women's health care providers. METHODS We conducted 20 h-long, semi-structured interviews with diverse women who had abortions in the U.S. Heartland. Each described her usual health care provider and how she accessed abortion care. We used qualitative analytic methods to organize and interpret the data. RESULTS Despite having a general provider, most women sought clinic abortions. Some women offered reasons for preferring specialty care and others for preferring abortion from their general provider. Most women assumed their general provider did not "do abortion" and many believed those providers were opposed to abortion. Women who had delivered a baby were concerned with their image in their general provider's eyes. Two women were denied care by their general providers. CONCLUSION Women's preferences for abortion care centered on privacy, cost, empathy, ability to control their image, and desire for safe quality care. Two women who sought abortions through their general providers experienced negative repercussions. PRACTICE IMPLICATIONS General providers should proactively make patients aware of their positions on abortion and if supportive indicate that they can provide that care and/or a referral.
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Affiliation(s)
- Tracy Ann Weitz
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA 94612, USA.
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Abstract
BACKGROUND This audit established a recent picture of termination of pregnancy services in Wales, UK using the Royal College of Obstetricians and Gynaecologists' Guidelines as a baseline. The context of abortion is rapidly changing and services need to be adaptable to meet women's needs. METHODS A questionnaire survey was sent to all National Health Service (NHS) Trusts in Wales; 10 out of 13 responded. RESULTS In the nine Trusts performing abortions in Wales, medical abortions accounted for 57% and surgical abortions for 43%. Doctors in training were involved in six Trusts. All but one Trust complied with referral times. Five Trusts provided a dedicated clinic. Written information provided prior to abortion varied in accessibility and quality. Choice of abortion within gestation bands was limited in some Trusts with some only providing medical termination. Essential abortion aftercare was performed by Trusts, whereas follow-up and counselling were less comprehensive. DISCUSSION Trusts are willing to adapt to new methods of working with an increasing number of medical terminations, although this advantage was offset by a lack of choice of abortion methods offered by some Trusts. Doctors in training should be offered exposure to abortion procedures in all Trusts as this has been shown elsewhere to improve attitudes. Providing dedicated abortion clinics, quality written information and comprehensive abortion aftercare should improve compliance with the guidelines. CONCLUSION Overall, in Wales there is compliance with national guidelines, although for a number of the guideline recommendations there remains room for improvement.
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Affiliation(s)
- Allyson Lipp
- Faculty of Health, Sport and Science, Room 561, University of Glamorgan, Glyntaf, Pontypridd CF37 1DL, UK.
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Clark KA, Mitchell EHM, Aboagye PK. Return on investment for essential obstetric care training in Ghana: do trained public sector midwives deliver postabortion care? J Midwifery Womens Health 2010; 55:153-61. [PMID: 20189134 DOI: 10.1016/j.jmwh.2009.12.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Revised: 12/11/2009] [Accepted: 12/13/2009] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In Ghana, the provision of postabortion care (PAC) by trained midwives is critical to the efficient and cost-effective reduction of unsafe abortion morbidity and mortality. METHODS We performed a secondary analysis of provider data from a representative sample of Ghanaian health facilities in order to consider the determinants of PAC provision among both physicians and midwives. RESULTS In the previous 5 years, more than 58% of providers had participated in at least one type of essential obstetric training. Overall, 28% of clinicians were offering PAC services (80% of physicians as compared to 20% of midwives). Bivariately, the provision of PAC services was associated with in-service training. After adjusting for select provider and facility characteristics, PAC/MVA training, working in a facility with the National Reproductive Health Standards and Policy available, and not working in a publicly run facility were associated with midwives offering PAC services. DISCUSSION Although the provision of PAC by midwives is an efficient and cost-effective strategy for reducing maternal morbidity and mortality, clinical training of midwives leads to a lower yield of PAC providers when compared to physicians. Policy and practice should continue to support PAC expansion by trained midwives in the public sector and by understanding the barriers to provision of services by midwives working in public facilities.
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Kishen M, Stedman Y. The role of Advanced Nurse Practitioners in the availability of abortion services. Best Pract Res Clin Obstet Gynaecol 2010; 24:569-78. [PMID: 20385513 DOI: 10.1016/j.bpobgyn.2010.02.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2010] [Accepted: 02/08/2010] [Indexed: 11/22/2022]
Abstract
Despite the legalisation of abortion in many countries worldwide, access to abortion is often restricted in many ways. Lack of availability of trained and willing physicians, inadequate and poor infrastructure as well as affordability are issues that are still contributing to poor access to abortion for many women living in countries that have legalised abortion. Improving access to early abortion despite the declining number of doctors willing to provide abortions is being addressed in some countries by expanding the role of advanced nurse-midwife practitioners in this field. There is good evidence to suggest that the outcome of first-trimester abortions performed by suitably trained non-medical practitioners is comparable in terms of safety and efficacy to abortions performed by doctors. These mid-level practitioners also have a key role in providing post-abortion care and contraception to women. We need to address outdated laws and regulations as well as political challenges that restrict both the ability of advanced nurse-midwife practitioners to provide abortion care and the opportunities to train them appropriately.
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Laurant M, Harmsen M, Wollersheim H, Grol R, Faber M, Sibbald B. The impact of nonphysician clinicians: do they improve the quality and cost-effectiveness of health care services? Med Care Res Rev 2010; 66:36S-89S. [PMID: 19880672 DOI: 10.1177/1077558709346277] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Health care is changing rapidly. Unacceptable variations in service access and quality of health care and pressures to contain costs have led to the redefinition of professional roles. The roles of nonphysician clinicians (nurses, physician assistants, and pharmacists) have been extended to the medical domain. It is expected that such revision of roles will improve health care effectiveness and efficiency. The evidence suggests that nonphysician clinicians working as substitutes or supplements for physicians in defined areas of care can maintain and often improve the quality of care and outcomes for patients. The effect on health care costs is mixed, with savings dependent on the context of care and specific nature of role revision. The evidence base underpinning these conclusions is strongest for nurses with a marked paucity of research into pharmacists and physician assistants. More robust evaluative studies into role revision are needed, particularly with regard to economic impacts, before definitive conclusions can be drawn.
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Affiliation(s)
- Miranda Laurant
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands,
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Abstract
PURPOSE Clinical innovations have made it more feasible to incorporate early abortion into family medicine, yet the outcomes of early abortion procedures in this setting have not been well studied. We wished to assess the outcomes of first-trimester medication and aspiration abortion procedures by family physicians. METHODS Prospective observational cohort study conducted from August 2001 to February 2005 of 2,550 women who sought pregnancy termination in 4 clinical practices of family medicine departments and 1 private office/training site. RESULTS The rate of successful uncomplicated procedures for medication was 96.5% (95.5%-97.1% [corrected] confidence interval [CI], 95.5%-97.0%) and for aspiration was 99.9% (CI, 99.3%-1). Adverse events and complications of medication abortions were failed procedure (ongoing pregnancy; n = 19, 1.45%); incomplete abortion (n = 16, 1.22%); hemorrhage (n = 9, 0.69%); and patient request for aspiration (n = 1, 0.08%). One (0.08%) missed ectopic pregnancy was seen among patients receiving medication. Four types of adverse outcomes were encountered with aspiration: incomplete abortion requiring re-aspiration (n = 21, 1.83%); hemorrhage during the procedure (n = 4, 0.35%); missed ectopic pregnancy (n = 3, 0.26%); and minor endometritis (n = 1, 0.09%). Missed ectopic pregnancies were successfully treated in the inpatient setting without mortality (overall hospitalization rate of 0.16 of 100). All other complications were managed within outpatient family medicine sites. Rates of complication did not vary by experience of physician or by site of care (residency vs private practice). CONCLUSIONS Complications of medication and aspiration procedures occurred at a low rate, and most were minor and managed without incident.
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Affiliation(s)
- Ian M Bennett
- Department of Family Medicine and Community Health, University of Pennsylvania School of Medicine, 2nd Floor Gates Pavilion, 3400 Spruce St, Philadelphia, PA 19104-4283, USA.
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Weitz T, Anderson P, Taylor D. Advancing scope of practice for advanced practice clinicians: more than a matter of access. Contraception 2009; 80:105-7. [DOI: 10.1016/j.contraception.2009.04.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2009] [Accepted: 04/25/2009] [Indexed: 11/30/2022]
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Yarnall J, Swica Y, Winikoff B. Non-physician clinicians can safely provide first trimester medical abortion. Reproductive Health Matters 2009; 17:61-9. [DOI: 10.1016/s0968-8080(09)33445-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Taylor D, Safriet B, Weitz T. When politics trumps evidence: legislative or regulatory exclusion of abortion from advanced practice clinician scope of practice. J Midwifery Womens Health 2009; 54:4-7. [PMID: 19114233 DOI: 10.1016/j.jmwh.2008.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 06/24/2008] [Accepted: 09/14/2008] [Indexed: 11/21/2022]
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Berer M. Provision of abortion by mid-level providers: international policy, practice and perspectives. Bull World Health Organ 2009; 87:58-63. [PMID: 19197405 PMCID: PMC2649591 DOI: 10.2471/blt.07.050138] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Revised: 06/03/2008] [Accepted: 06/04/2008] [Indexed: 11/27/2022] Open
Abstract
Based on articles found on the PubMed and Popline databases on the provision of first-trimester abortion by mid-level providers, this article describes policies on type of abortion provider, comparative studies of different types of abortion provider, provider perspectives, and programmatic experience in Bangladesh, Cambodia, France, Mozambique, South Africa, Sweden, the United States of America and Viet Nam. It shows that it is safe and beneficial for suitably trained mid-level health-care providers, including nurses, midwives and other non-physician clinicians, to provide first-trimester vacuum aspiration and medical abortions. Moreover, it finds that projects in Kenya, Myanmar and Uganda have successfully trained nurse-midwives to provide post-abortion care for incomplete abortion with manual vacuum aspiration, and that studies in Ethiopia and India have recommended that providers such as auxiliary nurse-midwives should be trained in abortion service delivery to ensure that they provide safe abortions for low-income women. The paper recommends the authorization of all qualified mid-level health-care providers to carry out first-trimester abortions, and it also recommends the integration of training in providing first-trimester abortion care into basic education and clinical training for all mid-level providers and medical students interested in obstetrics and gynaecology. Finally, it calls for documentation of the role of mid-level providers in managing second-trimester medical abortions to further inform policy and practice.
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Affiliation(s)
- Marge Berer
- Reproductive Health Matters Journal, 53-79 Highgate Road, London NW5 1TL, England.
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35
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Abstract
Abortion is controversial and often sparks polemic debate. Nevertheless, theatre staff need to know the different methods of abortion, to be aware of the current UK legal position and possible future directions. Theatre staff must be mindful of their own ethical and emotional position in order to play a vital role in making women attending for this surgery feel at ease during such an emotionally charged event.
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Affiliation(s)
- Allyson Lipp
- Faculty of Health, Sport and Science, University of Glamorgan, Glyntaf, Pontypridd CF 37 1DL.
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36
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Affiliation(s)
- Allyson Lipp
- Faculty of Health, Sport and Science, University of Glamorgan, Glyntaff, Pontypridd, CF37 1DL
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Abstract
Although abortion is one of the most common surgical procedures performed in the United States, the number of abortion providers is declining. Advanced practice clinicians, including nurse practitioners and certified nurse-midwives, may help to alleviate this shortage. However, some states bar nonphysicians from performing abortions. Not only should training in abortion techniques be made available to nonphysician providers who desire it, but legal obstacles must also be overcome in order to allow advanced practice clinicians the right to provide abortion services.
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Affiliation(s)
- Julie Balch Samora
- Center for Interdisciplinary Research in Cardiovascular Sciences, Robert C. Byrd Health Sciences Center at the West Virginia University School of Medicine, Morgantown, WV 26505, USA
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Affiliation(s)
- Vincent Argent
- Addenbrooke's Cambridge University Teaching Hospital, Cambridge, UK.
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Affiliation(s)
- Yap-Seng Chong
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Hospital, 119074 Singapore.
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Warriner IK, Meirik O, Hoffman M, Morroni C, Harries J, My Huong NT, Vy ND, Seuc AH. Rates 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 trial. Lancet 2006; 368:1965-72. [PMID: 17141703 DOI: 10.1016/s0140-6736(06)69742-0] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We assessed whether the safety of first-trimester manual vacuum aspiration abortion done by health-care providers who are not doctors (mid-level providers) is equivalent to that of procedures done by doctors in South Africa and Vietnam, where mid-level providers are government trained and accredited to do first-trimester abortions. METHODS We did a randomised, two-sided controlled equivalence trial to compare rates of complication in abortions done by the two groups of providers. An a-priori margin of equivalence of 4.5% with 80% power and 95% CI (alpha=0.05) was used. 1160 women participated in South Africa and 1734 in Vietnam. Women presenting for an induced abortion at up to 12 weeks' gestation were randomly assigned to a doctor or a mid-level provider for manual vacuum aspiration and followed-up 10-14 days later. The primary outcome was complication of abortion. Complications were recorded during the abortion procedure, before discharge from the clinic, and at follow-up. Per-protocol and intention-to-treat analyses were done. This trial is registered at with the identifier . FINDINGS In both countries, rates of complication satisfied the predetermined statistical criteria for equivalence: rates per 100 patients in South Africa were 1.4 (eight of 576) for mid-level providers and 0 for doctors (difference 1.4, 95% CI 0.4 to 2.7); in Vietnam, rates were 1.2 (ten of 824) for mid-level providers and 1.2 (ten of 812) for doctors (difference 0.0, 95% CI -1.2 to 1.1). There was one immediate complication related to analgesics. Delayed complications were caused by retained products and infection. INTERPRETATION With appropriate government training, mid-level health-care providers can provide first trimester manual vacuum aspiration abortions as safely as doctors can.
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Affiliation(s)
- I K Warriner
- UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research, WHO, Geneva 1211, Switzerland.
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Foster AM, Polis C, Allee MK, Simmonds K, Zurek M, Brown A. Abortion education in nurse practitioner, physician assistant and certified nurse–midwifery programs: a national survey. Contraception 2006; 73:408-14. [PMID: 16531177 DOI: 10.1016/j.contraception.2005.10.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2005] [Revised: 10/26/2005] [Accepted: 10/26/2005] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study was undertaken to examine the inclusion and extent of abortion education in accredited nurse practitioner (NP), physician assistant (PA) and certified nurse-midwifery (CNM) programs in the United States. METHODS In January 2000, a confidential survey requesting information about the curricular inclusion of eight reproductive health topics was mailed to program directors at all 486 accredited NP, PA and CNM programs in the United States. RESULTS Two hundred two surveys were returned, with a response rate of 42%. Overall, 53% of programs reported didactic instruction on surgical abortion, manual vacuum aspiration or medication abortion and 21% reported including at least one of these three procedures in their routine clinical curriculum. CONCLUSION Abortion education is deficient in NP, PA and CNM programs in the United States. As integral components of women's health care, abortion, pregnancy options counseling and family planning merit incorporation into routine didactic and clinical education.
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