Comparison of the safety and satisfaction of first trimester abortions performed by
physicians and mid-level providers using MVA in South Africa
Hoffman M*, Harries J*, Morroni C*, Beksinka M**, Kunene B**, Warriner I.***
* Women’s Health Research Unit, University of Cape Town, South Africa
** Reproductive Health Research and HIV Unit, Durban, South Africa
*** World Health Organization, Geneva, Switzerland
Background: In countries where legislation permits the termination of early pregnancy,
limited resources, including available trained personnel, often restrict access to safe
abortion services. In some countries in order to improve access, trained mid-level
providers (nurses, midwives and physician assistants) perform first trimester abortions.
This WHO collaborative study was conducted in South Africa and Vietnam to evaluate the
safety and effectiveness of first trimester abortions performed by mid-level providers
(MLPs) as compared to those performed by physicians. The South African component of
the study will be presented.
Methods: A randomised controlled equivalence trial was conducted between September
2003 and June 2004 in four Marie Stopes International clinics in South Africa. All women
seeking a first trimester abortion were invited to participate in the study. Eligibility criteria
included: gestational age of no more than 12 weeks, age 18 years or above, and
willingness to return for a follow-up visit, or to have a telephone, home or outside clinic
interview. Women were randomly assigned to a mid-level provider or physician for the
abortion and were followed-up by study staff 14 days later. The primary outcomes of
interest were complications occurring within two weeks of the abortion procedure. These
complications, immediate or delayed, were clinically verified. Patients’ satisfaction with the
service was assessed.
Results: Six physicians and six MPLs participated in the study. A total of 1160 women
consented to participate, 581were randomised to a physician and 579 to a mid-level
provider. Six women withdrew from the study and one was lost to follow up. There were
no complications among the physicians and eight (seven retained products and one
infection) among the mid-level providers. Measures of equivalence of complication rate
between providers was 1.4% (95% CI 0.4-2.7) This was well below the a priori margin of
equivalence which was set at 4.8%. More than 96% of women reported satisfaction with
quality of care.
Conclusion: Overall the quality of care was excellent and there was no difference
between physicians and mid-level providers. The complication rate was low and met the
criteria for equivalence. Given appropriate training and in a supportive environment MLPs
provide first trimester MVAs as safely as physicians.
Marijke Alblas, Independent Consultant, South Africa
Co-authors: Kelly Blanchard, Ibis Reproductive and Health SA, Debbie Constant, Women's Health Research Unit University of Cape Town, Daniel Grossman, Ibis Reproductive Health SA, Jane Harries,
Women's Health Research Unit University of Cape Town, Naomi Lince, Ibis Reproductive Health SA
To examine efficacy, safety and acceptability of two 2nd trimester abortion techniques used in South Africa: medical induction (MI) with misoprostol alone and dilation and evacuation (D&E).
In February-July 2008, we enrolled 304 adult women undergoing abortion at 13-20 weeks at 5 hospitals around Cape Town in a cross-sectional, observational study. 220 underwent D&E with misoprostol cervical priming (up to 3 doses) and paracervical block, and 84 underwent MI. Information was obtained about the procedure and immediate complications, and women were interviewed after recovery.Data were analyzed using SPSS v14.
Median age was 25 years, median parity 1, and median education grade 12. Median gestational age was different between D&E and MI clients (16.0 weeks vs. 18.1 weeks, p<0.001). D&E was more effective than MI (99.5% vs. 50.0% of cases completed on-site and without unplanned surgical procedure, p<0.001). Complications were common (43.8% D&E vs. 52.4% MI, p=0.2). Fetus was expelled prior to procedure in 43.3% of D&E cases. In addition to incomplete abortion, there were 3 MI cases with blood transfusion, 1 hemorrhage without transfusion and 1 fever. 98.8% MI and no D&E clients needed overnight stay. Most women were somewhat-very satisfied with their experience (95% D&E vs. 95.9% MI). More D&E clients compared to MI reported moderate-extreme physical pain (75.7% vs. 59.5%, p=0.007) and moderate-extreme emotional discomfort (49.8% vs. 33.8%, p=0.017).
D&E was more effective, required shorter hospital stay and had fewer severe complications. Second trimester abortion services can be improved in South Africa by expanding D&E training, altering the cervical priming protocol for D&E, improving pain management, and introducing mifepristone.
Training midwives and doctors in post-termination
of pregnancy care in Gabon and Cameroon
Alblas, M; Ndembi, AP; Pheterson, G; Mbia, C;
Middle Africa Network for Women’s Reproductive Health: Gabon,
Cameroon and Equatorial Guinea
The NGO Middle Africa Network for Women’s Reproductive
Health: Gabon, Cameroon and Equatorial Guinea – GCG is
devoted to research, education and training to understand
obstacles to better health care. This presentation focuses on one
central part of the mission: training midwives and doctors in
post-termination of pregnancy (TOP) care, mainly manual
vacuum aspiration. After a needs assessment initial ﬁeld trip in
2009 it became clear that the morbidity and mortality among
women due to unsafe TOP is high in rural areas in Northern
Gabon, southern Cameroon and eastern Equatorial Guinea.
When complications from back street TOP arise, women arrive
late (or never) for emergency hospital care because they know
TOP is illegal and highly stigmatised, and often they have no
money either for transport to the hospital or for the medical aid
they need. If a doctor is present, he/she can do a sharp curettage
under general anesthesia, but this is expensive and in the more
rural areas often there is no doctor. Pregnancy and birth are
typically the domain of midwives, but they are not trained in
treating TOP-related complications since procedures such as MVA
or misoprostol use are not institutionally recognised, and only
doctors perform D&Cs.
Recently one of our trained midwives has been appointed by
the Ministry of Health to train all the midwives in the country in
post-TOP MVA. In the last 3 years this network has made a
signiﬁcant ﬁrst step in demonstrating that also in a country where
TOP is illegal, one can build capacity, mobilise attitude change
and enlist institutional support.