摘要：Objectives . We compared complication rates after surgical abortions performed by physician assistants with rates after abortions performed by physicians. Methods . A 2-year prospective cohort study of women undergoing surgically induced abortion was conducted. Ninety-one percent of eligible women (1363) were enrolled. Results . Total complication rates were 22.0 per 1000 procedures (95% confidence interval [CI] = 11.9, 39.2) performed by physician assistants and 23.3 per 1000 procedures (95% CI = 14.5, 36.8) performed by physicians (P = .88). The most common complication that occurred during physician assistant–performed procedures was incomplete abortion; during physician-performed procedures the most common complication was infection not requiring hospitalization. A history of pelvic inflammatory disease was associated with an increased risk of total complications (odds ratio = 2.1; 95% CI = 1.1, 4.1). Conclusions . Surgical abortion services provided by experienced physician assistants were comparable in safety and efficacy to those provided by physicians. The legal induced abortion rate rose during the 1970s, stabilized between 1980 and 1992, and has declined in the years since. 1, 2 In 1997, 1 186 039 legal induced abortions were reported to the Centers for Disease Control and Prevention from all 52 US reporting areas, making abortion one of the most common surgical procedures for women of reproductive age. 1– 3 The 1997 abortion rate of 20 abortions per 1000 women aged 15 to 44 years is the lowest recorded since 1975. 1 The majority of abortions are first-trimester procedures performed by physicians in an outpatient setting. 2 Soon after its legalization, abortion became a safer procedure as a result of increased provider experience and training; improvements in the type of procedure used, including a change from sharp curettage to suction curettage; and improved access to services, enabling women to seek abortions at earlier gestational ages. 2, 4, 5 However, during the past 15 years the climate of controversy and episodes of violence directed toward women seeking abortions and the clinics that perform them have compromised the availability of competent care, and safe abortion has again become a critical public health issue. 6 One restrictive factor is the decreasing number of trained physicians who are willing to perform abortions. 7 For example, in 1996, 86% of counties had no abortion facilities, and 32% of US women aged 15 to 44 years resided in a county without an abortion provider. 8 According to a 1991–1992 survey of US obstetrics and gynecology residency programs, routine training in first-trimester abortion practice was provided by only 12% of programs (a decrease from 23% of residency programs in 1985), with 30% of programs providing no training in first-trimester abortions as part of their curricula. 9– 11 However, in 1996, abortion training requirements were included as part of the Accreditation Council for Graduate Medical Education guidelines as a standard part of obstetrics and gynecology residency training. Perhaps as a result, a recent survey reported that 46% of programs now offer routine training. 12 When access to safe abortion services declines and the number of trained physicians willing to perform abortions decreases, public health practitioners are faced with the prospect of an increase in morbidity and mortality from both legal and illegal abortion procedures. One solution to address limited access to services is to expand abortion practice to include provision by midlevel clinicians—that is physician assistants, nurse practitioners, and certified nurse midwives. 13– 16 Physician assistants are licensed by each state to practice medicine with physician supervision. On graduation from an accredited physician assistant program, physician assistants take a national certification examination developed by the National Commission on Certification of Physician Assistants in conjunction with the National Board of Medical Examiners. Physician assistants complete 100 hours of continuing medical education every 2 years and take a recertification examination every 6 years. The scope of physician assistant practice varies, depending on the supervising physician and state law. In contrast with bachelor’s-level nursing training, physician assistants are trained to conduct physical examinations, diagnose and treat illnesses, order and interpret medical tests, assist in surgical procedures, and, in many states, write prescriptions. 17, 18 The goal of the 2-year prospective study described here was to compare the frequency and type of complications after surgical abortion procedures performed at 2 clinics, 1 at which abortions were performed by physician assistants and 1 at which abortions were performed by physicians. The study also addressed access to abortion services, patients’ and practitioners’ experiences of care, and practitioners’ conformance to clinical guidelines. The results of those analyses are reported elsewhere. 19
