Reproductive services for the patient at increased risk for morbidity and mortality during the second trimester.

Some complications of pregnancy that occur in the second trimester, such as preeclampsia, bleeding placenta previa, and preterm premature rupture of membranes, require delivery to avoid maternal morbidity and mortality. When these situations occur before fetal viability, pregnancy termination, either by induction of labor or dilation and evacuation, can be lifesaving. To optimize maternal health in these situations, Maternal Fetal Medicine providers should be trained to provide all needed medical services, including termination. Currently, only the minority of Maternal Fetal Medicine providers are skilled in dilation and evacuation. Training programs should focus on ways to facilitate training in second trimester dilation and evacuation to improve care access and quality when these medically necessary procedures are needed for women in whom a healthy pregnancy is no longer an option.

Exploring How Residents Who Partially Participate in Family Planning Training Determine Their Level of Participation.

OBJECTIVES: The Accreditation Council for Graduate Medical Education (ACGME) requires that obstetrics and gynecology residency programs provide access to abortion training, though residents may elect to opt out of participating due to religious or moral objections. While clinical benefits of partial participation have previously been explored, our study aimed to explore how residents navigate partial participation in abortion training and determine their limits. STUDY DESIGN: This study was qualitative in nature. Between June 2010 and June 2011, we conducted 26 semi-structured phone interviews with residents who opted out of some or all of the family planning rotation at 19 programs affiliated with The Ryan Residency Training Program. Faculty directors identified eligible residents, or residents self-reported in routine program evaluation. We analyzed data using the conventional content analysis method. RESULTS: We interviewed all 26 (46%) of 56 eligible residents willing to be interviewed. Three main categories constituted the general concepts concerning resident decision-making in training participation: (1) variation in timing of when residents determined the extent of participation, (2) a diversity of influences on the residents' level of participation, and (3) the perception of support or pressure related to their participation decision. CONCLUSIONS: The findings indicated that residents who partially participate in abortion training at programs with specialized opt-out family planning training weigh many factors when deciding under what circumstances, if any, they will provide abortions and participate in training.

Doctors or mid-level providers for abortion.

BACKGROUND: The World Health Organization recommends that abortion can be provided at the lowest level of the healthcare system. Training mid-level providers, such as midwives, nurses and other non-physician providers, to conduct first trimester aspiration abortions and manage medical abortions has been proposed as a way to increase women's access to safe abortion procedures. OBJECTIVES: To assess the safety and effectiveness of abortion procedures administered by mid-level providers compared to doctors. SEARCH METHODS: We searched the CENTRAL Issue 7, MEDLINE and POPLINE databases for comparative studies of doctor and mid-level providers of abortion services. We searched for studies published in any language from January 1980 until 15 August 2014. SELECTION CRITERIA: Randomised controlled trials (RCTs) (clustered or not clustered), prospective cohort studies or observational studies that compared the safety or effectiveness (or both) of any type of first trimester abortion procedure, administered by any type of mid-level provider or doctors, were eligible for inclusion in the review. DATA COLLECTION AND ANALYSIS: Two independent review authors screened abstracts for eligibility and double-extracted data from the included studies using a pre-tested form. We meta-analysed primary outcome data using both fixed-effect and random-effects models to obtain pooled risk ratios (RR) with 95% confidence intervals (CIs). We carried out separate analyses by study design (RCT or cohort) and type of abortion procedure (medical versus surgical). MAIN RESULTS: Eight studies involving 22,018 participants met our eligibility criteria. Five studies (n = 18,962) assessed the safety and effectiveness of surgical abortion procedures administered by mid-level providers compared to doctors. Three studies (n = 3056) assessed the safety and effectiveness of medical abortion procedures. The surgical abortion studies (one RCT and four cohort studies) were carried out in the United States, India, South Africa and Vietnam. The medical abortion studies (two RCTs and one cohort study) were carried out in India, Sweden and Nepal. The studies included women with gestational ages up to 14 weeks for surgical abortion and nine weeks for medical abortion.Risk of selection bias was considered to be low in the three RCTs, unclear in four observational studies and high in one observational study. Concealment bias was considered to be low in the three RCTs and high in all five observational studies. Although none of the eight studies performed blinding of the participants to the provider type, we considered the performance bias to be low as this is part of the intervention. Detection bias was considered to be high in all eight studies as none of the eight studies preformed blinding of the outcome assessment. Attrition bias was low in seven studies and high in one, with over 20% attrition. We considered six studies to have unclear risk of selective reporting bias as their protocols had not been published. The remaining two studies had published their protocols. Few other sources of bias were found.Based on an analysis of three cohort studies, the risk of surgical abortion failure was significantly higher when provided by mid-level providers than when procedures were administered by doctors (RR 2.25, 95% CI 1.38 to 3.68), however the quality of evidence for this outcome was deemed to be very low. For surgical abortion procedures, we found no significant differences in the risk of complications between mid-level providers and doctors (RR 0.99, 95% CI 0.17 to 5.70 from RCTs; RR 1.38, 95% CI 0.70 to 2.72 from observational studies). When we combined the data for failure and complications for surgical abortion we found no significant differences between mid-level providers and doctors in both the observational study analysis (RR 1.36, 95% CI 0.86 to 2.14) and the RCT analysis (RR 3.07, 95% CI 0.16 to 59.08). The quality of evidence of the outcome for RCT studies was considered to be low and for observational studies very low. For medical abortion procedures the risk of failure was not different for mid-level providers or doctors (RR 0.81, 95% CI 0.48 to 1.36 from RCTs; RR 1.09, 95% CI 0.63 to 1.88 from observational studies). The quality of evidence of this outcome for the RCT analysis was considered to be high, although the quality of evidence of the observational studies was considered to be very low. There were no complications reported in the three medical abortion studies. AUTHORS' CONCLUSIONS: There was no statistically significant difference in the risk of failure for medical abortions performed by mid-level providers compared with doctors. Observational data indicate that there may be a higher risk of abortion failure for surgical abortion procedures administered by mid-level providers, but the number of studies is small and more robust data from controlled trials are needed. There were no statistically significant differences in the risk of complications for first trimester surgical abortions performed by mid-level providers compared with doctors.

Dilation and evacuation training in maternal-fetal medicine fellowships.

OBJECTIVE: Many maternal-fetal medicine (MFM) specialists provide dilation and evacuation (D&E) procedures for their patients with fetal or obstetric complications. Our study describes the D&E training opportunities that are available to MFM trainees during their fellowship. STUDY DESIGN: National surveys of MFM fellows and fellowship program directors assessed the availability of D&E training in fellowship. Univariate and multivariate comparisons of correlates of D&E training and provision were performed. RESULTS: Of the 270 MFM fellows and 79 fellowship directors who were contacted, 92 (34%) and 44 (56%) responded, respectively. More than one-half of fellows (60/92) and almost one-half of fellowship programs (20/44) report organized training opportunities for D&E. Three-quarters of fellows who were surveyed believe that D&E training should be part of MFM fellowship, and one-third of fellows who have not yet been trained would like training opportunities. Being at a fellowship that offers D&E training is associated with 7.5 times higher odds of intending to provide D&E after graduation (P = .005; 95% confidence interval, 1.8-30). CONCLUSION: MFM physicians are in a unique position to provide termination services for their patients with pregnancy complications. Many MFM subspecialists provide D&E services during fellowship and plan to continue after graduation. MFM fellows express a strong interest in D&E training; therefore, D&E training opportunities should be offered as a part of MFM fellowship.

Opting out of abortion training: benefits of partial participation in a dedicated family planning rotation for ob-gyn residents.

BACKGROUND: This study was conducted to describe the experiences of residents who opt out of some components of a dedicated abortion rotation. STUDY DESIGN: Eligible residents at programs receiving funding from the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning were invited to complete a cross-sectional, online survey. RESULTS: The majority of residents who opted out of some portion of the family planning training reported that the rotation positively affected skills in pregnancy options counseling, cervical dilation, first-trimester ultrasound, techniques of first-trimester uterine evacuation and other skills. Twenty-one of the 65 (31%) did an elective abortion, and 56 (84%) completed aspirations for at least one non-elective indication including therapeutic abortion and miscarriage. While no resident desired additional elective abortion training, 11 (16%) wanted additional uterine aspiration and 14 (21%) wanted additional second-trimester uterine aspiration training for non-elective indications. CONCLUSION: Providing access to an abortion rotation for residents who do not plan to do elective abortions gives them the opportunity to improve their skills in family planning, therapeutic abortion and miscarriage management.

Abortion training in United States obstetrics and gynecology residency programs.

OBJECTIVE: To identify characteristics of programs which provide training in abortion, to calculate the number of procedures done during training, and to compare the availability of abortion training in 2004 with that of prior national surveys. METHODS: An investigator-designed questionnaire about abortion training in obstetrics and gynecology residency programs was mailed to all U.S. residency directors. Collected data included program information, abortion training, and numbers of residents trained. Data were analyzed to estimate differences in abortion training by region, program size, and type of training offered. RESULTS: Of the 252 questionnaires mailed, 185 (73%) were returned. Of the 185, 94 (51%) program directors reported routine instruction in elective abortion, 72 (39%) optional training, and 19 (10%) no training. Large programs and programs located in the Northeast and West Coast were significantly more likely to offer routine training in terminations (P < .01). In the programs offering routine training, more than 50% of residents received instruction in termination practices. Of those practices, the most common were first-trimester surgical abortion (85% of programs), followed by medical abortion (59%), second-trimester induction (51% of programs), and dilation and extraction (36%). As compared with those in programs with optional training, residents in programs with routine training were significantly more likely to receive instruction in all modalities of abortion provision and performed proportionally more first- and second-trimester terminations (P < .01). CONCLUSION: Routine training in elective abortion resulted in greater exposure to abortion practices and greater experience in more complicated abortion techniques during residency.

Abortion training in Canadian obstetrics and gynecology residency programs.

OBJECTIVE: To study abortion training in Canadian obstetrics and gynecology (ob-gyn) residency programs. METHODS: An anonymous questionnaire was sent to all postgraduate year (PGY)-4 and PGY-5 ob-gyn residents (n=130) and residency program directors (n=16) in Canada. The questionnaires inquired about demographic information, details of abortion training, resident participation in training, and intention to provide abortions after residency. RESULTS: Ninety-two of 130 residents (71%) and 15 of 16 program directors (94%) responded. Abortion training is considered routine in approximately half of programs and elective in half. The majority of residents (71%) participated in abortion training, and half plan to do elective abortions after residency. More than half of residents felt competent after training to perform first-trimester aspiration and second-trimester inductions but did not feel competent in first-trimester medical abortions or dilation and evacuation (D&E). Residents were more likely to participate in training if the program arranged the training for residents (P=.04) and were more likely to intend to provide abortions if the training was considered routine (P=.02), while controlling for all significant demographic and training variables. CONCLUSION: Most Canadian ob-gyn programs offer some training in elective abortion, but only half include it routinely in training, and the minority of residents feels competent in D&E and medical abortion. Integrated abortion training was associated with greater resident participation in training and increased likelihood of intention to provide abortions after residency.

[Prevention of abortion]. / Profilaktyka aborcji.

At work the subject of abortion has been taken up. We took into account the history of this phenomenon, medical and legal aspects. We showed the reasons for abortion. We analysed abortion: permitted by law and illegal. We paid a lot attention to preventive actions taken in order to prevent women and families from harmful consequences of abortion.