Nearly all (98%) of the 22 million unsafe abortions each year take place in developing countries. Despite early first-trimester medical abortion being a safe and effective alternative to surgical abortion, it remains underused in many developing countries partly because only doctors are currently authorised to administer medical abortion services. However, midlevel health-care workers such as midwives and nurses could have an important role in expanding access to low-cost, life-saving abortion services in developing countries where abortion is legally permitted under broad conditions or on request and doctors are scarce.
Dr IK Warriner from the World Health Organisation, Geneva, Switzerland and colleagues designed a trial to establish whether medical abortions can be provided as safely and effectively by midlevel healthcare workers as doctors in Nepal.
Between April 2009 and March 2010, women seeking early abortion from five rural district hospitals in Nepal were randomly assigned to receive medical abortion by a midlevel healthcare worker (542) or a doctor (535 women).
The clinical outcomes were similar with 97.3% complete abortions performed by midlevel healthcare workers and 96.1% by doctors, and no serious complications were recorded.
The authors say: "Appropriately trained providers can administer safe, low-technology medical abortion services for women who might otherwise turn to unsafe abortion, exposing themselves to the risks of disabilities and death."
In a Comment, Yap-Seng Chong from the National University of Singapore in Singapore and Eng-Kien Tan from The National University Hospital, Singapore point out: "For many routine but potentially life-saving medical services, the best health-care provider might not always be a doctor. Experience, commitment, training, and, most important, availability are often more crucial than is a medical qualification. As we begin the countdown to 2015, task-shifting to midlevel health-care providers and the upgrading of their skills to provide safer care in pregnancy and reproductive health could be key to achievement of the fifth UN Millennium Development Goal."
*Early first-trimester medical abortion is available up to 9 week's of pregnancy and involves the administration of two sets of pills, an antiprogestagen (mifepristone) followed by a prostaglandin analogue (usually misoprostol).