Nurses and Doctors are Equally Capable Abortion Providers, Indian Study Indicates
Nurses and physicians are equally capable of assessing a woman’s eligibility for manual vacuum aspiration (MVA), performing the procedure safely and effectively, and determining its completeness, according to a prospective study conducted in India.1 All of the women who had the procedure were satisfied with it, regardless of their provider; moreover, all of those whose provider was a nurse said they would be willing to have a nurse perform any abortions they might have in the future.
India prohibits nurses and physicians who are not obstetrician-gynecologists and have not been certified to provide abortions from performing the procedures, which may compel women in rural areas—where registered abortion providers are scarce—to delay their abortion or seek one from an unauthorized provider, thus risking complications. Using a two-sided equivalence design, investigators assessed and compared the safety and efficacy of first-trimester MVAs performed by nurses with those done by identically trained physicians. The study was conducted in two of India’s poorest states, Bihar and Jharkhand, where access to health services is limited. Investigators recruited 20 female providers (10 physicians and 10 nurses) from medical and nursing colleges, through local newspaper ads and from a nongovernmental organization that operates reproductive health clinics. None of the providers had experience performing abortions prior to the study, but all received 12 days of MVA training, which included doing pelvic exams to assess gestational age and abortion completeness, as well as a one-week field placement.
From July 2009 to January 2010, the providers screened 1,089 women at five clinics that mainly served low-income patients. Women who came to the clinics seeking an abortion were eligible for the study if they had been pregnant for no more than 10 weeks, had not tried to terminate their pregnancy in the previous week, lived within one hour of the clinic and were willing to return one week after the abortion for a follow-up exam. Of the 897 women who met these criteria, 449 received MVAs from nurses and 448 from physicians. Although the study was not a true randomized trial, only one provider type was present at each clinic at any given time, and women did not know in advance whether a nurse or doctor would be performing their abortion.
The study entailed two clinic visits, each of which included an exit interview. At the first visit, the provider and a supervisor independently screened the woman for eligibility; the woman then received an MVA, and the provider and supervisor assessed its completeness. The provider observed the woman for 2–3 hours and discharged her with a supply of antibiotics, information about common complications and side effects, and instructions to call with any concerns. At the second visit, the woman received separate pelvic exams from the provider and supervisor to verify the abortion’s completeness. Women with an incomplete abortion had a resuction by the supervisor.
The providers were evaluated on their ability to accurately assess gestational age, women’s overall eligibility for abortion and the completeness of abortions. Their assessments were compared with those of the supervisor, which were considered the "gold standard." Other outcomes examined by the researchers were complication rates and women’s overall satisfaction with their provider and the services they received.
Overall, the two provider types had equivalently low failure rates. Women’s eligibility was incorrectly assessed in 4% of cases screened by nurses and 3% of those screened by physicians; most of these errors, if not detected by the supervisor, would have resulted in the erroneous inclusion of ineligible women. However, in 99% of cases, the provider’s assessments of abortion completeness matched the supervisor’s. In 2–3% of procedures, the provider asked for help from the supervisor, who in most cases provided support but did not intervene.
Of the 865 women who returned for the one-week follow-up, 1% from each provider group had had an incomplete abortion, but none had experienced a serious complication that required a blood transfusion or hospitalization, or that resulted in injury to the cervix, uterus or bowel. Fewer than 1% of women treated by either type of provider experienced adverse symptoms, such as cramping, abdominal pain, fever, minor bleeding or vaginal discharge. Finally, 100% of women reported satisfaction with their abortion at both exit interviews, regardless of their provider, and 98% were satisfied with the services they had received. All of the women whose provider had been a nurse said they would be willing to have a nurse perform an abortion for them in the future.
The investigators note that the study’s limitations include its lack of randomization, as well as the bias that the supervisor’s input may have introduced. Although the study was not truly randomized, the social and demographic characteristics of patients in the two provider groups were similar, suggesting that no systematic bias in group assignment occurred. The investigators conclude that the findings make "a compelling case" for amending India’s abortion law to allow nurses to perform the procedure. Such a change in the law, they assert, would have "huge potential to reduce the incidence of unsafe abortion and its negative consequences for women’s health."
1. Jejeebhoy SJ et al., Can nurses perform manual vacuum aspiration (MVA) as safely and effectively as physicians? Evidence from India, Contraception, 2011, 84(6):615–621.