July 25, 2013 — Summary of "Nurse Practitioners, Certified Nurse-Midwives, and Physician Assistants Can Safely Perform First-Trimester Aspiration Abortions," Niemczyk, Journal of Midwifery & Women's Health, May/June 2013.
Nancy Niemczyk, a certified nurse-midwife (CNM), summarizes the findings of a study that evaluated the safety of aspiration abortions performed by CNMs, nurse practitioners (NPs) and physician assistants (PAs) trained through a pilot project in California.
She explains that more than one-third of U.S. women live in a county with no abortion provider. Limited access to abortion can lead to more women obtaining the procedure in the second trimester of pregnancy, which is riskier and more costly than in the first trimester.
Physicians perform most abortions in the U.S., but expanding the types of health care providers who can offer the procedure could help increase access, Niemczyk writes.
The study involved providers trained through a Health Workforce Pilot Project under a California legal waiver. For the project, an authorized physician trainer trained 40 CNMs, NPs and PAs from four Planned Parenthood affiliates and Kaiser Permanente of Northern California on aspiration abortion care.
After the training, the providers, as well as 96 physicians, participated in a four-year prospective, observational cohort study to evaluate the safety of their care. Women in the study could agree to be treated by one of the newly trained providers, if available, or opt to be seen by a physician. In total, physicians cared for 5,812 women, while the CNMs, NPs and PAs cared for 5,675. The two groups of patients were generally similar, with most women in each group having had at least three pregnancies, at least one live birth and no prior abortions.
To compare the safety of the two groups, the researchers reviewed the women's charts for complications two to four weeks after the procedure and also had the women complete a follow-up survey. Complications were considered major if they required a hospital admission, surgery or blood transfusion, and minor if a patient required outpatient treatment.
Niemczyk explains that the research was designed as a noninferiority study, meaning that "the goal was not to demonstrate that the NPs, CNMs, and PAs were safer abortion providers than the physicians, but that they were not less safe." Given that the physicians had years' more experience than the new providers, the researchers decided that a less than 2% difference in complications four weeks after the procedure would demonstrate that the CNMs, NPs and PAs were competent.
The incidence of complications in both groups was low, Niemczyk writes. Among the women cared for by the CNMs, NPs and PAs, 1.8% experienced a complication, compared with 0.9% in the physician group, meaning that the difference was "within the 2% range determined to demonstrate noninferiority and ... lower than most published rates for complications from first-trimester abortions."
In addition, major complications were "very rare" (0.001%), with no difference between the two groups, Niemczyk writes. The major complications included one hemorrhage, two uterine perforations and three infections. The minor complications were mostly other infections, incomplete or failed abortions, or hematometra.
Niemczyk writes that the "ambitious, well-designed study" has two major implications.
First, "it demonstrates that NPs, CNMs, and PAs can safely perform aspiration abortion." Second, it shows "that if states allow NPs, CNMs, and PAs to perform abortions, this may increase access to first-trimester abortion services and reduce the number of riskier second-trimester abortions," she concludes.