Anneli Pehrsson et al.

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    Pilot project: potential for midwives to manage medical abortions independently

    Anneli Pehrsson and Pia Karlsson, Licensed Midwives; Karolinska University Hospital, Sweden

    Background: According to rules issued by Sweden’s National Board of Health and Welfare, Advice on Abortions 2004: Section 4; Chapter 2, when a woman has made the decision to have an abortion it should be carried out at the earliest possible time.

    Our previous routines could not adequately address the waiting times for the required ultrasound examination by physicians. Not every woman who had contacted the clinic <9 weeks gestation could be offered medical abortion. Hence, a project was initiated to train two midwives in transvaginal ultrasonography.

    In 2007, the National Board of Health and Welfare decided to make the regulatory changes necessary to broaden the authority of midwives in this context.

    Aims: - To train and certify midwives to independently manage medical abortions, perform dating scans by transvaginal ultrasonography, and prescribe mifepristone and misoprostol.

    - To provide women with rapid and effective care.

    - To be able to offer a medical abortion to any healthy woman <9 weeks gestation.

    - To ensure continuity, i.e. the woman meets one and the same person during the entire abortion process.

    Methods: - Auscultation/training in transvaginal ultrasonography, at IVF clinic.

    - Individual training and supervision in ultrasonography, Center for Fetal Medicine.

    - Individual training and supervision in transvaginal ultrasonography, by Prof. Seth Granberg.

    - Transvaginal ultrasonography with the department’s gynecologists. Images were reviewed, commented on, and approved by Prof. Seth Granberg. Accompanied by theoretical studies.

    - Ten cases of abortion counseling with ultrasound examinations, supervised by C. Rasmussen (Section Chief at the time).

    Results: - For the past 2 years we have performed transvaginal ultrasonography in healthy women early in pregnancy. We have been delegated authority to prescribe mifepristone and misoprostol, to prescribe contraceptives, and to deliver patient care encompassing the abortion itself and follow-up visits.

    - We have shortened the waiting times at the clinic; freed time for physician appointments; increased the number of medical abortions; and reduced the demand on surgical time and recovery unit beds.

    - We can offer medical abortion to all healthy women who request it, and most can begin the abortion with the first visit.

    Conclusions: - Midwives with adequate education have the capability to independently manage healthy women requesting an abortion early in pregnancy. Usually the problems are more of a psychosocial than medical nature. The abortion is not the problem, but often the solution to the woman’s problem.

    - In the past 2 years we have become proficient in performing and assessing ultrasonography and detecting anomalies, whereupon we contact the attending physician.

    It is important for midwives and physicians to collaborate in the care of these women. It must not become a matter of prestige.