Provision of medical abortion by mid-level healthcare providers in Kyrgyzstan: testing an intervention to expand safe abortion services to under-served rural and peri-urban areas

Abstract

Objectives: To demonstrate the feasibility and safety of training mid-level healthcare providers (midwives and family nurses) to provide medical abortion and post-abortion contraception in under-served areas in Kyrgyzstan.

Study design: This was an implementation study at four referral facilities and 28 Felsher Obstetric Points in two districts to train their midwives and family nurses to deliver safe and effective abortion care with co-packaged mifepristone-misoprostol and provide contraceptives post-abortion. The outcome of abortion - complete abortion, incomplete abortion, or on-going pregnancy - was the primary endpoint measured. An international consultant trained 18 midwives and 14 family nurses (with midwifery diplomas) to provide medical abortion care. Supervising gynaecologists based in the referral centres and study investigators based in Bishkek provided monthly monitoring of services and collection of patient management forms. A voluntary self-administered questionnaire at the follow-up visit documented women's acceptability of medical abortion services. All study data were cross-checked and entered into an online data management system for descriptive analysis.

Results: Between August 2014 and September 2015, midwives provided medical abortion to 554 women with a complete abortion rate of 97.8%, of whom 62% chose to use misoprostol at home. No women were lost to follow-up. Nearly all women (99.5%) chose a contraceptive method post-abortion. 61% of women receiving services completed the acceptability form, of whom more than 99% indicated a high level of satisfaction with the service and would recommend it to a friend.

Conclusion: This study demonstrates that trained Kyrgyz midwives and nurses can provide medical abortion safely and effectively. This locally generated evidence can be used by the Kyrgyz Ministry of Health to reduce unintended pregnancy and expand safe abortion care to women in under-served peri-urban and rural settings.

Implications: Success in scaling up midwife/nurse provision of medical abortion in Kyrgyzstan will require registration of mifepristone-misoprostol, regulations permanently allowing midwife/nurse provision, strengthened procurement and distribution systems to prevent stockouts of supplies, pre-service training of midwives/nurses and their involvement in district level supervision, monitoring and reporting, and support from supervisors.

Comment: This paper by Ronnie Johnson of the World health Organization shows that even when medical abortion is legal, and if there are providers willing to administer it, there is still a lot to be done before full implementation. This is a great reference for anyone who wants to start such a program. (HMV).