Medical termination of pregnancy service delivery in the context of decentralization: social and structural influences

Abstract

BackgroundMedical termination of pregnancy (MToP) is a safe and acceptable abortion option. Depending on country context, MToP can be administered by general practitioners and mid-level healthcare providers in the first and second trimesters of pregnancy. Like other high-income countries, a range of social and structural barriers to MToP service provision exist in Australia. To counter some of these barriers, geographic decentralization of MToP was undertaken in rural Victoria, Australia, through training service providers about MToP to increase service delivery opportunities. The aim of this study was to investigate the factors that enabled and challenged the decentralization process.MethodsFace-to-face and telephone interviews were undertaken between April and June 2016 with a purposeful sample of six training providers and 13 general practitioners (GP) and nurse training participants. Study participants were asked about their perceptions of motivations, enablers and challenges to MToP provision. A published conceptual framework of synergies between decentralization and service delivery was used to analyse the study findings.ResultsThree key themes emerged from the study findings. First, the effort to decentralize MToP was primarily supported by motivations related to making service access more equitable as well as the willingness of training providers to devolve their informal power, in the form of MToP medical expertise, to training participants. Next, the enablers for MToP decentralization included changes in the regulatory environment relating to decriminalization of abortion and availability of required medication, formation of partnerships to deliver training, provision of MToP clinical resources and local collegial support. Finally, challenges to MToP decentralization were few but significant. These included a lack of a state-wide strategy for service provision, provider concerns about coping with service demand, and provider stigma in the form of perceived negative community or collegial attitudes. These were significant enough to create caution for GPs and nurses considering service provision.ConclusionsDecentralization concepts offer an innovative way for reframing and tackling issues associated with improving MToP service delivery. There is scope for more research about MToP decentralization in other country contexts. These findings are important for informing future rural MToP service expansion efforts that improve equity in service access.

The role of nurses and midwives in the provision of abortion care: A scoping review

“…Nurses and midwives worked in obstetric and gynaecological wards, operating theatres, primary practice, community sexual and reproductive health centres, telemedicine clinics, pharmacies and stand‐alone abortion clinic contexts across metropolitan rural and remote areas. The broad skill sets of nurses and midwives were seen as helpful in the provision of comprehensive abortion care (CAC; Freedman & Levi, 2014; Hulme‐Chambers, Clune, & Tomnay, 2018; Taylor, Safriet, & Weitz, 2009; Yarnall, Swica, & Winikoff, 2009).…”

“…Abortions must be performed by a medical doctor. Nurses and midwives assist in the care of the woman during the procedure (Dawson et al, 2016; Hulme‐Chambers et al, 2018).…”

“…The routine nursing and midwifery tasks described in the articles were pregnancy diagnosis and options counselling (Levi et al, 2009), pharmacological and nonpharmacological pain relief (Lindström, Wulff, Dahlgren, & Lalos, 2011), administration of anti‐D, and antibiotic prophylaxis (Cappiello, Beal, & Simmonds, 2011), handling the products of conception (Andersson, Gemzell‐Danielsson, & Christensson, 2014; Mauri, Ceriotti, Soldi, & Guerrini Contini, 2015; Michalik et al, 2019; Mizuno, 2011; Nicholson, Slade, & Fletcher, 2010), gestational dating, bimanual examination (Averbach, Puri, Blum, & Rocca, 2018) screening for domestic violence, postabortion contraception care (Purcell, Cameron, Lawton, Glasier, & Harden, 2016), referrals (Grace, 2016), health education (Cappiello et al, 2011; Halldén, Lundgren, & Christensson, 2011), counselling (Hulme‐Chambers et al, 2018), prescription of abortion drugs (Simmonds, Beal, & Eagen‐Torkko, 2017), administration of abortion drugs, manual vacuum aspiration abortions (MVA) (Berer, 2009; Bridgman‐Packer & Kidanemariam, 2018; Paul, Gemzell‐Danielsson, Kiggundu, Namugenyi, & Klingberg‐Allvin, 2014), postabortion phone counselling (Dawson, Bateson, Estoesta, & Sullivan, 2016), peer education (Puri, Regmi, Tamang, & Shrestha, 2014; Puri, Tamang, Shrestha, & Joshi, 2015), care of or referral for postabortion complications (Hulme‐Chambers et al, 2018; Yegon et al, 2019), screening and treatment of sexually transmitted infections and human immunovirus (Yegon et al, 2019) and management of postabortion complications (Cleeve et al, 2019; Paul et al, 2014; Yarnall et al, 2009; Yegon et al, 2019). These tasks were not ubiquitous.…”

Snapshot of medication abortion provision in the primary health care setting of regional and rural Victoria

“…Previous research suggests that Australian GPs anticipate negative publicity and reactions from conservative members of the community as well as from other health professionals, if they were to provide abortion services. Community‐level abortion stigma as well as practice restrictions, imposed by ideologically opposed colleagues, thus might influence health workers in their decision to provide abortion care, especially in rural and regional communities where sexual and reproductive health, including abortion, is still a highly contentious topic .…”

“…Further, few primary health care nurses (PHCNs) are currently involved in the medication abortion process, a strategy that has globally become a key solution to improve women's access to safe abortion services . Previous Australian research was limited to studies exploring the provision of MA service, as experienced by women and qualitative studies exploring factors affecting the MA uptake from the perspectives of primary health care providers . To add to the existing literature, this study used a quantitative approach to identify enablers and barriers that determine the decision of GPs and PHCNs from regional and rural areas of Victoria to become an MA provider.…”