Who can provide effective and safe termination of pregnancy care? A systematic review*.

BACKGROUND: Unsafe termination of pregnancy is a major contributor to maternal morbidity and mortality. Task sharing termination of pregnancy services between physicians and mid-level providers, a heterogeneous group of trained healthcare providers, such as nurses, midwives and physician assistants, has become a key strategy to increase access to safe pregnancy termination care. OBJECTIVES: To systematically review the evidence to assess whether termination of pregnancy services by nonphysician providers can be performed safely and effectively. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, MEDLINE in process and other nonindexed citations and POPLINE. SELECTION CRITERIA: We included randomised controlled trials (RCTs), as well as clinical studies, using study designs that compared efficacy, safety and acceptability of termination of pregnancy services by physicians versus other provider groups. Data collection and analysis Two reviewers independently extracted the data, and we performed a meta-analysis where appropriate using RevMan. Quality assessment of the data used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: We identified five controlled studies comprising 8908 women undergoing first-trimester surgical termination of pregnancy (one RCT and three prospective cohort studies) and medical termination of pregnancy (one RCT). The mid-level provider group included midwives, nurses, auxiliary nurse midwives and physician assistants trained in termination of pregnancy services. Safety and efficacy outcomes, including incomplete termination of pregnancy, haemorrhage, injury to the uterus or cervix, did not differ significantly between providers. AUTHOR'S CONCLUSIONS: Limited evidence indicates that trained mid-level providers may effectively and safely provide first-trimester surgical and medical termination of pregnancy services. Data are limited by the scarcity of RCTs and biases of the cohort studies.

Informational factors influencing patient's childbirth preferences after prior cesarean.

OBJECTIVE: A recent National Institutes of Health conference on cesarean concluded that the literature is lacking with regard to patients' childbirth preferences. The goal of this study was to examine how information patients received in pregnancy affects childbirth preferences and satisfaction. STUDY DESIGN: In this cross-sectional study, questionnaires were issued to English- or Spanish-speaking women with prior cesarean, delivering by either vaginal birth after cesarean or repeat cesarean, at a large U.S. university hospital postpartum unit. Questions evaluated the adequacy of and satisfaction with information provided in counseling with regard to mode of delivery. RESULTS: Eighty of 92 women approached completed the survey. The majority reported receiving no or too little information about forceps or vacuum delivery, future problems with urine or stool, fetal death, and injury. CONCLUSION: Information that patients receive in pregnancy influences their childbirth preferences and satisfaction. Women wanted more information; particularly about urinary and fecal incontinence.

Phenoxy and picolinic acid herbicides and small-intestinal adenocarcinoma in sheep.

A study of age and sex matched groups of adult female sheep from 88 flat, hill, and high-country farms was conducted in the South Island of New Zealand to investigate the influence of breed and certain environmental factors on the prevalence rate of small-intestinal adenocarcinoma (SIA). 20 678 female sheep aged 5.5-7.5 years were examined at slaughter, 125 cases of SIA were found (6 per thousand) in animals from 61 farms (69%) and the prevalence rate for individual farm groups varied from 0 to 38 per thousand. Differences in tumour rate between breed groups were significant but differences between farm type were not. Exposure to phenoxy (Ph), picolinic acid (Pi) herbicides, or both (PhPi) was associated with significant increases in tumour rate. The increase in rate was significant for exposure to each of the 3 herbicide groups. Exposure to recently sprayed feed stuffs was associated with a significantly larger increase in tumour rate than exposure to less recently sprayed food. There was no difference between tumour rates of sheep exposed to Ph herbicides with or without 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD). Rates rose significantly with the total number of Ph, Pi, PhPi sprays used on the farm. The variation in rates associated with herbicides is sufficient to explain the breed differences recorded.