PRIMARY LEVEL ABORTION SERVICES – Systematic review of early abortion services in low- and middle-income country primary care: potential for reverse innovation and application in the UK context

by Jacy Zhou, Rebecca Blaylock, Matthew Harris

Globalization and Health, 30 September 2020

In the UK, according to the 1967 Abortion Act, all abortions must be approved by two doctors, reported to the Department of Health and Social Care, and be performed by doctors within licensed premises. Removing abortion from the criminal framework could permit new service delivery models. We explore service delivery models in primary care settings that can improve accessibility without negatively impacting the safety and efficiency of abortion services. Novel service delivery models are common in low-and-middle income countries (LMICs) due to resource constraints, and services are sometimes provided by trained mid-level providers via “task-shifting”. The aim of this study is to explore the quality of early abortion services provided in primary care of LMICs and explore the potential benefits of extending their application to the UK context.

We searched MEDLINE, EMBASE, Global Health, Maternity and Infant Care, CINAHL, and HMIC for studies published from September 1994 to February 2020, with search terms “nurses”, “midwives”, “general physicians”, “early medical/surgical abortion”. We included studies that examined the quality of abortion care in primary care settings of low-and-middle-income countries (LMICs),* and excluded studies in countries where abortion is illegal, and those of services provided by independent NGOs. We conducted a thematic analysis and narrative synthesis to identify indicators of quality care at structural, process and outcome levels of the Donabedian model.**

A total of 21 indicators under eight subthemes were identified to examine the quality of service provision: law and policy, infrastructure, technical competency, information provision, client-provider interactions, ancillary services, complete abortions, client satisfaction. Our analysis suggests that structural, process and outcome indicators follow a mediation pathway of the Donabedian model. This review showed that providing early medical abortion in primary care services is safe and feasible, and “task-shifting” to mid-level providers could effectively replace doctors in providing abortion.

The way services are organised in LMICs, using a task-shifted and decentralised model, results in high quality services that should be considered for adoption in the UK. Collaboration with professional medical bodies and governmental departments is necessary to expand services from secondary to primary care.

* Studies examined were from the following countries: Bangladesh, Ethiopia, India, Kyrgyzstan, Nepal, Nigeria, North Korea, and South Africa (Table 2).

**The Donabedian model is a conceptual model that provides a framework for examining health services and evaluating quality of health care. According to the model, information about quality of care can be drawn from three categories: “structure,” “process” and “outcomes”. (Wikipedia) In this paper, the indicators of high quality care examined included law and policy infrastructure, technical competency, information provision, client-provider interactions, ancillary services, abortion outcomes, and client satisfaction (Table 1).