Despite the legalisation of abortion in many countries worldwide, access to abortion is often restricted in many ways. Lack of availability of trained and willing physicians, inadequate and poor infrastructure as well as affordability are issues that are still contributing to poor access to abortion for many women living in countries that have legalised abortion. Improving access to early abortion despite the declining number of doctors willing to provide abortions is being addressed in some countries by expanding the role of advanced nurse-midwife practitioners in this field. There is good evidence to suggest that the outcome of first-trimester abortions performed by suitably trained non-medical practitioners is comparable in terms of safety and efficacy to abortions performed by doctors. These mid-level practitioners also have a key role in providing post-abortion care and contraception to women. We need to address outdated laws and regulations as well as political challenges that restrict both the ability of advanced nurse-midwife practitioners to provide abortion care and the opportunities to train them appropriately.
Scope of the problem
Obtaining accurate data for abortions is challenging, and especially so for unsafe abortion and its consequences. Each year, there are an estimated 19 million unsafe abortions worldwide. Nearly 7000 women die each year as a result of illegal, unsafe abortions, mostly in developing countries, making this a significant cause of maternal mortality. In addition, annually, an estimated 8 million women experience complications related to unsafe abortion that need medical treatment. These estimates have hardly changed over the past 10 years. Data suggest that even though, globally, the overall abortion rate has declined, the proportion of unsafe abortion is on the rise, especially in the developing world. In countries with restrictive abortion laws, untrained providers and poor access to high-quality abortion services, women are much more likely to experience immediate complications, long-term disabilities or, sometimes, death due to unsafe abortions.
Background
Why has the number of maternal deaths from unsafe abortions remained unchanged over the past decade, despite increasing legalisation of abortions? To answer this question we need to analyse the available, albeit incomplete, data worldwide relating all aspects of abortion.
Legalisation of abortion is a fundamental step towards addressing access to abortion care but such services ultimately depend on a number of factors, including the availability of affordable clinicians who are skilled and willing to provide abortions within realistic travelling distances for women. Even in countries with liberal abortion laws and safe abortion services, access to abortion is influenced by the availability of trained clinicians willing to offer this service. Early abortion is one of the safest surgical procedures, yet it carries a significant stigma for both women and health-care providers. This is evident in the United States where access to abortion services has become increasingly limited due to the decline in the number of abortion providers. The thinning ranks of abortion providers in the United States are the result of a number of factors. Vociferous religious and anti-abortion pressure groups harass physicians and their families, including the sending of death threats and, tragically, even the murder of abortion providers. Poor financial remuneration as well as failure of post-graduate medical training programmes to routinely include abortion training have both contributed to the current situation in the United States. In other countries, abortion providers face similar pressures and, on occasion, are shunned by their professional peers and have been excommunicated by the Church , all of which impacts on the number of physicians prepared to provide abortion care.
Training in first- and second-trimester abortion provision is becoming increasingly optional, as opposed to routine, in obstetrics and gynaecology training programmes in some countries such as the United States. It is often forgotten that even in developed countries, before abortion was made legal, unsafe abortion claimed the lives of many women. It is estimated that, in the 1930s when abortion was illegal in Britain, ∼15% of maternal deaths in the country were related to illegal abortion. Many younger doctors working in developed countries today have never seen or treated the direct consequences of illegal abortion and hence may lack the personal commitment to provide safe abortion care. Ambivalence of society and political correctness seem to prevent robust discussion of this issue. Whatever the reasons, the increasing shortage worldwide of gynaecologists trained and willing to do abortions is currently raising interest in the role of other clinicians such as family physicians, other primary women’s health-care doctors, nurse practitioners and physician-assistants in abortion provision. The reasons for the willingness of some health-care professionals to provide abortion services, whilst others opt out, is interesting to ponder but beyond the scope of this article.
Background
Why has the number of maternal deaths from unsafe abortions remained unchanged over the past decade, despite increasing legalisation of abortions? To answer this question we need to analyse the available, albeit incomplete, data worldwide relating all aspects of abortion.
Legalisation of abortion is a fundamental step towards addressing access to abortion care but such services ultimately depend on a number of factors, including the availability of affordable clinicians who are skilled and willing to provide abortions within realistic travelling distances for women. Even in countries with liberal abortion laws and safe abortion services, access to abortion is influenced by the availability of trained clinicians willing to offer this service. Early abortion is one of the safest surgical procedures, yet it carries a significant stigma for both women and health-care providers. This is evident in the United States where access to abortion services has become increasingly limited due to the decline in the number of abortion providers. The thinning ranks of abortion providers in the United States are the result of a number of factors. Vociferous religious and anti-abortion pressure groups harass physicians and their families, including the sending of death threats and, tragically, even the murder of abortion providers. Poor financial remuneration as well as failure of post-graduate medical training programmes to routinely include abortion training have both contributed to the current situation in the United States. In other countries, abortion providers face similar pressures and, on occasion, are shunned by their professional peers and have been excommunicated by the Church , all of which impacts on the number of physicians prepared to provide abortion care.
Training in first- and second-trimester abortion provision is becoming increasingly optional, as opposed to routine, in obstetrics and gynaecology training programmes in some countries such as the United States. It is often forgotten that even in developed countries, before abortion was made legal, unsafe abortion claimed the lives of many women. It is estimated that, in the 1930s when abortion was illegal in Britain, ∼15% of maternal deaths in the country were related to illegal abortion. Many younger doctors working in developed countries today have never seen or treated the direct consequences of illegal abortion and hence may lack the personal commitment to provide safe abortion care. Ambivalence of society and political correctness seem to prevent robust discussion of this issue. Whatever the reasons, the increasing shortage worldwide of gynaecologists trained and willing to do abortions is currently raising interest in the role of other clinicians such as family physicians, other primary women’s health-care doctors, nurse practitioners and physician-assistants in abortion provision. The reasons for the willingness of some health-care professionals to provide abortion services, whilst others opt out, is interesting to ponder but beyond the scope of this article.
Legal issues
A recent report by the Alan Guttmacher Institute estimates that, globally, 40% of women of childbearing age live in countries with highly restrictive abortion laws (those that prohibit abortion altogether, or allow the procedure only to save a woman’s life or to protect her from physical or mental health). Nearly 60% of the world’s population lives in countries where abortion is legally allowed for a broad range of reasons. Even in these countries, there are varying restrictions on abortion access. Countries such as France and Great Britain have gestational limit requirements. A married woman in Turkey may not have an abortion without the permission of her husband and, in Belgium and Germany, women are required to obtain counselling and wait for a certain period before having the abortion.
The situation is compounded by the failure of politicians and health professionals to rise to the challenge of providing this very necessary and important aspect of reproductive health care to women. Legal requirements in many countries specify both the type of medical facility in which abortions must be performed and the type of health professional permitted to perform them. In many countries, such as Great Britain, India and South Africa, abortions must take place in a government hospital or an authorised health-care facility. In most countries where abortion is legal, only doctors, in some cases, specially certified gynaecologists, are allowed to perform even first-trimester abortions. Only a few countries, such as South Africa, China, Vietnam and Cambodia, have allowed health-care providers who are not doctors, such as nurses, midwives and doctor-assistants to undertake abortions.
Abortion is an emotive issue for the general public as well as for individual health professionals. Therefore, laws relating to abortion and clinical practice, in most countries, have evolved rarely out of medical evidence but often out of religious, ethical and political considerations. It should be remembered that even seemingly minor restrictions in this area of health care might violate the rights of women, influence medical decision making and compromise the quality of care, since the laws were not written with women’s health as the priority.
An international perspective
The United States of America
Advanced Practice Clinicians (APCs) have been providing abortions in two American states, Vermont and Montana, since 1973 when abortion was legalised in the country. However, many other states changed their laws after 1973, to restrict legal abortion provision to physicians only. More recently, the decline in the number of physicians providing abortions and the subsequent reduction in abortion access, especially in rural counties in the United States, has led to a revival of interest in the role of mid-level providers (MLPs) in abortion provision. APCs are now increasingly being licensed in more number of states to perform first-trimester abortions. Medical abortion is also generating greater interest in the role of non-medical providers in early abortion care, being potentially more accessible to clinicians working outside of hospitals. On 1 January 2003, a new state law, referred to as the Reproductive Privacy Act, Senate Bill 1301, came into effect in the state of California, permitting APCs to provide medical abortion. As of January 2004, trained APCs were routinely performing medical abortions in 14 American states and surgical abortions in six.
‘Advanced Practice Clinician’ is a term used in the United States to encompass nurse practitioners, certified nurse-midwives and physician-assistants, who have a distinct professional role in the American health-care system. Much of primary health care in the United States is provided by APCs who may specialise in specific health areas, including women’s health or obstetrics and gynaecology. They have to undergo specific training programmes to equip them with competencies to function independently or collaboratively with physicians (who are responsible for their work) who may or may not be on site. The arrangements depend entirely on the Advanced Practitioner’s ‘approved scope of practice’, often referred to as ‘practice agreements’ which are approved by state-level medical or nursing boards. The amount of supervision required for each professional group is regulated by practice acts developed in each state. These regulatory acts within different states vary considerably. In most states, APCs work under statutes that allow them to administer drugs and provide gynaecological services, including surgical procedures, comparable to surgical abortion, provided they are properly trained. However, in some states, abortion-related care is interpreted as outside the scope of their practice, irrespective of their level of training and competence.
Canada
Canada is the only country to date which has decriminalised abortion entirely. Since 1988, abortion has been normalised and de-politicised, bringing it in line with all other medical procedures. This has made good medical practice and quality of care in service provision the only issues involved in abortion care. However, abortions must be performed by a doctor and, in many hospitals, by an obstetrician or gynaecologist. Abortion is also the only medical procedure with a ‘conscience clause’ that allows doctors in Canada to refuse to participate in the care of a patient. Canada is also facing a situation similar to the USA in terms of availability of trained physicians willing to carry out abortions and looking to expand the role of non-doctors in early abortion care.
Europe
Abortion in Great Britain is regulated by the 1967 Abortion Act (as amended by the Human Fertilisation and Embryology Act 1990). Abortion is legal up to the 24th week of pregnancy in England, Wales and Scotland but remains illegal in Northern Ireland, where the 1967 Abortion Act does not apply. Current UK legislation requires that an abortion must be conducted by a ‘registered medical practitioner’. However, in 1981, the House of Lords ruled that, for medical abortion, the medical practitioner is not required to perform personally each and every action needed for the treatment. Therefore, nurses in the UK do have legal authority to be involved in medical abortion procedures, including issuing of drugs, as long as a registered medical practitioner is on call and responsible for the care of the woman throughout the abortion. This clarification of the Abortion Act of 1967 was set out in the House of Lords case RCN v. DHSS (1981) 1 All ER 545. Many abortion services in the UK currently rely on nurses to run their medical abortion units, but anomalously neither does the law permit nurses to sign the authorisation forms or prescribe the necessary medication nor are they allowed to perform early surgical abortions.
According to the Swedish Abortion Act of 1974, abortions must be performed at a public hospital by a qualified medical doctor. However, in Sweden today, the physicians’ main role in the provision of medical abortion is to estimate the duration of pregnancy by ultrasound and to serve as consultants and supervisors. Midwives are responsible for counselling women and administering the medical abortion drugs. In addition, in France, legally, abortions must be performed by a qualified medical doctor. In reality, physicians confirm the pregnancy and conduct the follow-up visit but nurses are often responsible for all the other procedures involved in a medical abortion. Thus, although by law only physicians are entitled to perform abortion in many European countries, nurse-midwives’ responsibilities for counselling and care during medical abortions have steadily increased.
Africa
In South Africa, up to 12 weeks of pregnancy, abortion is performed at the request of the woman. The country’s 1996 Choice of Termination of Pregnancy Act, making abortion legal, also allows the procedure to be performed by a registered midwife during the first-trimester. Abortions in later gestation are permitted if (1) there is a risk to the woman’s physical or mental health, (2) there is a substantial risk of foetal abnormality, (3) the pregnancy resulted from rape or incest or (4) the pregnancy would significantly affect the woman’s social or economic circumstances. In addition, a termination must be approved by one medical practitioner. After the 20th week, abortion is permitted if continuing the pregnancy would endanger the woman’s life, if there is a substantial risk of foetal abnormality; in addition, two medical practitioners, or one medical practitioner and a registered midwife, need to concur with the decision for abortion.
In Zambia, where abortion has been legal on socioeconomic grounds since 1994, women must obtain the consent of three physicians; many doctors refuse to perform abortion on religious or other ethical grounds; and the cost of a legal abortion in the few hospitals that offer the service is prohibitively high.
Asia
In India, only doctors are legally allowed to carry out abortion procedures. Despite 30 years of liberal legislation, the majority of women in India still lack access to safe abortion care. This is a result of not just a physician-only policy that excludes MLPs but also poor regulation of both public and private sector services. India has a much lower availability of registered facilities for abortions in rural, as compared to urban, areas. There are only 10 abortion centres per 1 million people in India, and most are located in urban areas, even though >70% of Indian women live in rural areas. Despite legalisation of abortion, a recent analysis estimated that, in India, three unsafe abortions are performed for every two safe ones due to poor access to services for less affluent women living in rural areas. One in seven maternal deaths in India is currently attributable to unsafe abortion.
In Bangladesh, although the law permits induced abortion only to save the life of the woman, menstrual regulation is legally available. As early as 1978, a large-scale menstrual regulation-training programme was organised for government physicians and family-welfare visitors. Today, menstrual regulation using vacuum aspiration is widely available in Bangladesh through public, non-governmental organisation (NGO) and private sector facilities and is permitted at a woman’s request up to 10 weeks of pregnancy (i.e., 12 weeks from first day of the last menstrual period). The government collaborates with NGOs to train female paramedics called ‘family-welfare visitors’ to perform ‘menstrual regulation’ with manual vacuum aspiration.
Abortion has been legal in Vietnam since 1945 and a doctor, a doctor-assistant or a trained-midwife may undertake the procedure. The abortion law in Cambodia establishes women’s rights to first-trimester abortion on any grounds, performed by a qualified doctor, medical assistant or midwife at public or private health facilities licensed by the Ministry of Health.
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