Nurses can provide early medication abortion as well as physicians, according to a randomized controlled noninferiority trial conducted at three Ministry of Health facilities in Mexico City.1 Virtually all of the medication abortions provided by nurses and physicians were successful (98% and 99%, respectively), and only 10% of women needed surgery or additional medication to complete the procedure. Regardless of the type of provider they used, the vast majority of women received a prescription for contraceptives (99%), and 97% of them left the facility with a method; 99% of women were comfortable with their nurse or physician.
Although abortion was legalized in Mexico City in 2007, demand for the procedure has exceeded the capacity of physicians to provide it. Allowing midlevel providers to perform abortions may help increase availability. To examine whether nurses’ medication abortion care was comparable with that of physicians, the researchers conducted a randomized trial from November 2012 to January 2013 at two clinics and a hospital that collectively provided half of legal abortions in Mexico City. Women with a gestational duration of up to 70 days who were seeking an abortion were eligible if they were at least 18 years old; had never had a legal medication abortion and were willing to undergo one; had no medical history of contraindications for the procedure; and provided their social and demographic characteristics and follow-up contact information. Some 1,017 women were randomized; the 884 who returned for follow-up were included in the primary (intention-to-treat) analysis and received abortion care from either a physician (450) or a nurse (434).
The two provider groups comprised seven nurses and eight physicians who had never provided a medication abortion or had done so only under supervision. Each group was trained in medication abortion provision and related skills, such as abdominal and transvaginal ultrasound, for about two weeks.
Women had similar characteristics across provider groups. Two-thirds were aged 20–29, about half were single and four in 10 had attended at least some high school or technical school. Roughly equal proportions were students (25%), homemakers (29%) or workers (33%). The average duration of gestation was 50 days. At women’s first visit, per Ministry of Health guidelines, providers performed an ultrasound to assess gestational age, had women take a 200-mg dose of oral mifepristone and gave them 800 mg of misoprostol to take at home after 24 hours. To help women avoid having an unwanted pregnancy in the future, providers also presented several postabortion contraceptive options for women to consider.
Follow-up visits took place one to two weeks later. In addition to verifying that the abortion was complete (via ultrasound, a symptom checklist and questions about women’s bleeding history), providers offered women their chosen contraceptive method, if any, or told them where it was available. Women then completed a survey assessing their satisfaction with their care. In some cases, women required manual vacuum aspiration or more medication (800 mg misoprostol) to complete the abortion; nurses chose to administer additional misoprostol more often than physicians (10% of cases vs. 5% of cases).
Nurses and physicians alike achieved high success rates: Among women treated by physicians, 99% had a medication abortion with no follow-up surgery, as did 98% of women treated by nurses. The difference in rates was well within the preset noninferiority margin of 5%. When the analysis was limited to women who completed treatment according to study protocols, the results confirmed that nurses were as competent as physicians in their management of medication abortion care (98% vs. 99% success rates).
Similar proportions of women received a prescription for contraceptives from physicians and nurses (99% in each group); most women chose the pill, the IUD or the injectable. At the follow-up visit, almost all women in both groups received one or more methods (97% of each group), but a higher percentage of women in the physicians’ group than of their counterparts in the nurses’ group obtained an IUD (31% vs. 24%), while women in the nurses’ group were more likely than those treated by physicians to receive condoms (19% vs. 11%) or emergency contraceptive pills (2% vs. 0%). Three-quarters of women in each group were very satisfied with their care; nearly all felt comfortable with their nurse or physician (99%) and had confidence in their technical skills (99%).
While nurses performed as well as physicians in all aspects of medication abortion management, contraceptive counseling and method provision, the researchers explain that nurses may have preferred to take a conservative approach toward treating possibly incomplete abortions, and therefore prescribed an extra dose of misoprostol more frequently than did physicians. Because nurses tended to give their patients the methods they routinely offered during their regular duties (i.e., condoms and emergency contraception), the researchers recommend that nurses be trained in IUD insertion to increase their confidence in prescribing and providing this method. Potential study limitations include the possibility that nurses consulted physicians at their facility, thus “contaminating” the results. However, the authors note that discussions between participating nurses and physicians were unlikely, since the two types of providers were working in separate rooms, and add that any impact on the study would have been mitigated by the benefits of having had all providers work under the same conditions. Overall, they conclude, the findings are consistent with those of previous studies that assessed midlevel providers’ performance of tasks traditionally limited to physicians, and indicate that nurses can successfully augment physician provision of medication abortion care in Mexico and “help address the high demand for safe abortion” in the country.—S. Ramashwar
1. Diaz Olavarrieta C et al., Nurse versus physician-provision of early medical abortion in Mexico: a randomized controlled non-inferiority trial, Bulletin of the World Health Organization, 2015, 93(4):249–258.