Training mid-level providers to provide abortions and post-abortion care

Background: A severe imbalance exists between the shortage of physicians equipped to provide safe abortions and the overwhelming need for abortion services, particularly in rural regions of developing countries. Training a broader range of mid-level providers in the necessary skills to perform safe abortions is an urgent requirement to reduce preventable disability and death.

Methods: Literature on abortion provision and post-abortion care in developing countries from 1990 to 2009 was examined with a focus on how countries with restrictive abortion policies have found ways to train mid-level cadres to provide needed abortion care.

Findings: Evidence is rapidly accumulating to show that midlevel providers, such as nurses, midwives, and auxiliary nurse-midwives, if properly trained and supported, can be as effective (and sometimes more effective) than physicians in conducting manual vacuum aspiration and medical abortion. Mastering these two skill sets can enable midlevel cadres to safely provide both abortions and post-abortion care in low-resource settings, reducing costs and easing much of the burden that currently falls on the health care system. Training midlevel providers in abortion care may also help prevent repeat abortions because post-abortion contraceptive counseling is often of higher quality when conducted by health providers other than physicians.

Conclusions: Reducing global abortion-related morbidity and mortality requires greater flexibility in terms of where abortions (and post-abortion care) can be performed, and by whom. Evidence-based policy decisions to expand access to abortion-related care through training mid-level cadres, as seen in countries such as South Africa, Ethiopia, and Vietnam, are showing considerable promise.