Original research articleClinical diagnosis of completeness of medical abortion by nurses: a reliability study in Mozambique☆
Introduction
Medical abortion holds great promise to reduce the occurrence of unsafe abortion and its sequela where it remains highest in less-developed countries [1]. The provision of medical abortion, however, necessitates the confirmation of complete expulsion of pregnancy particularly because the abortion regimens carry risk of teratogenicity [2]. Methods used to confirm complete abortion include patient history, direct tissue inspection, pelvic examination, human chorionic gonadotropin testing and ultrasonographic evaluation.
While ultrasonogrpahy is often considered to be the standard of care in medical abortion in most developed countries, its routine use is questionable. It is argued that most women might not require an ultrasonograph to confirm pregnancy expulsion; appropriate clinical history alone or in combination with physical examination may be sufficient [3], [4], [5], [6], [7]. When performed at earlier gestational ages or soon after administration of medical abortion, ultrasonograph findings are often hard to interpret and misdiagnosis occurs frequently, leading to unnecessary interventions [8]. Similarly, ultrasonography has proven to be an imperfect standalone diagnostic test for diagnosis of medical abortion completeness, with reliability varying from 66% to 89% [9], [10], [11].
The routine dependence on ultrasound will definitely exclude most African countries, which potentially could have benefitted from the introduction and scale up of medical abortion, as ultrasonography in these places is not widely available [12]. Furthermore, equipping all facilities with ultrasound and trained sonographers is beyond the current financial capacity of most of the health systems. This barrier could especially inhibit the use of misoprostol, a prostaglandin shown to be up to 87% effective in first-trimester-induced abortion, which has the advantage of being low-cost and relatively available in many countries [13], [14], [15], [16], [17].
Experts are often nonspecific on which techniques can safely replace ultrasonography in low resource settings and have called for further research on alternative approaches of assessing completeness of pregnancy expulsion that do not rely on ultrasonography, highly specialized clinicians or repeated office visits [18], [19]. In the present study, we evaluated whether or not training nurses on obtaining relevant clinical history and performing bimanual pelvic examination, applied at a follow-up visit of 2 to 3 weeks postadministration of vaginal misoprostol, is an effective strategy for diagnosing completion of abortion. We compared their performance with ultrasonography assessment carried out by gynecologists.
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Study participants
A consecutive series of 718 women, who consented for misoprostol medical abortion, were included in the study in five public hospitals, in Maputo City, Mozambique, from May 2005 to December 2006. The criteria for inclusion were as follows: (a) less than 12 weeks of gestation, (b) hemoglobin of ≥10 g/dL, (c) residence in area close to the health facility, (d) willing to complete abortion with manual vacuum aspiration (MVA) if necessary and (e) willing to have home visit, if patient fails to
Results
The demographic and baseline characteristics of study participants are presented in Table 1. Youth younger than 25 years (48%) and students (57%) comprised the majority of the study participants. Fifty-four percent were single and about 85% of all the participants had attained secondary or higher education level. Almost all (91%) were black and about 60% were of Catholic denomination.
Table 2 shows the distribution of cases evaluated by each of the nurse–gynecologist pairs. Of the total cases
Discussion
This study was conducted to examine whether involving midlevel cadres (in particular, nurses) as the main providers of medical abortion without the aid of high technology equipment such as ultrasonography is a viable option in low-resourced settings where access to doctors is limited. The midlevel cadre is often the most common health professional staffing health clinics and primary health centers that are most accessible to women in their communities. As medical abortion technologies are
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Financial support for this study was provided by the Rockefeller Foundation Africa Regional Office, the Department for International Development of the United Kingdom and an anonymous donor.