Comparison of the Safety and Efficacy of Medical Abortion Provided by Physicians and Midlevel Providers in Nepal
Condition: Medical Abortion
Study type: Interventional

Summary: 
      The purpose of the study is to compare the safety, effectiveness, and acceptability of
      medical abortion provided by doctors and midlevel providers in a developing country where
      doctors are scarce, such as Nepal. This study is the first to evaluate the independent
      provision of medical abortion by trained nurses and auxiliary nurse midwives compared to
      doctors by assessing differences in safety, clinical outcomes, case management
      decision-making, and acceptability. This study provides scientifically valid data on the
      administration of medical abortion by midlevel providers working independently in a
      low-resource, developing country setting. The evidence generated by the study will assist
      policy makers in developing countries interested in expanding safe abortion services by
      eliminating the legal requirement limiting prescription of medical abortion to doctors where
      medical abortion is not restricted by law.
    

Detailed description: 
      Each year, some 210 million women throughout the world become pregnant and nearly one in five
      chooses to terminate the pregnancy (Singh et al., 2009). Approximately, 22 million
      pregnancies are terminated unsafely; of these, the vast majority (98%) take place in
      developing countries (WHO, Forthcoming). Access to safe abortion services is a challenge for
      many women with unwanted pregnancies in developing countries because of restrictive
      legislation, a shortage of skilled staff or other barriers.

      Non-surgical methods of abortion, known as medical abortion, have been developed that use
      safe and effective drug-based methods for induced abortion. Prescribing authority is
      generally limited to doctors, however. As a result, medical abortion remains under-utilized
      and is often inaccessible for many women in developing countries seeking public sector
      providers trained in medical abortion in areas where there are no doctors.

      Midlevel providers (non-physician clinicians such as nurses and midwives) have the potential
      to provide accessible, low-cost, and safe abortion services in many countries, especially in
      the developing world. They are more cost-effective to employ than doctors and often work in
      areas where doctors are in short supply, providing much needed health services to
      under-served areas while conserving resources. Training midlevel providers in the independent
      provision of medical abortion with appropriate referral systems would expand access to safe
      abortion services to lower levels of the health care system where there is no doctor and
      complement a global health systems trend towards task-shifting where doctors are costly and
      scarce (WHO, 2007).

      The overall objective of the study is to obtain evidence on the safety and effectiveness of
      medical abortions performed by government trained and certified midlevel providers and
      physicians to inform policy makers interested in or committed to expanding and decentralizing
      medical abortion services.
    

Intervention name(s): Type of provider
Intervention type(s): Other
Intervention description(s): Different types of clinicians have different types of medical training. This study tested whether midlevel providers were as safe and effective in administering medical abortion as doctors. All types of providers underwent the same training in medical abortion and used the same medical abortion regimen.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: medical abortion; Nepal; midlevel providers