URGENT SOLIDARITY REQUEST:
PLEASE SIGN AN AMICUS LETTER FOR A COURT CASE IN GUYANA
Sent: 10 March 2014
Cc: Fred Nunes (firstname.lastname@example.org); email@example.com
Subject: Support for court case in Guyana
Next week the high court in English Gyuana will hear a case from the FGAP to let nurses and other midlevel health care providers provide medical abortions under the supervision of a medical doctor as is allowed under the law of Guyana. However the health authorities of Guyana claim that supervision means the doctor first has to see the patient and look over te shoulder of the “medical assistant” as they call it.
I wrote a amicus letter for the lawyers, who I include as CC. I would like to ask all of you to sign this letter for the courts. Please return your signature to me, Rebecca Gomperts, and cc. your answer to Fred Nunes and Karam, the lawyer at the above email addresses.
REBECCA Gomperts (firstname.lastname@example.org)
TEXT OF THE LETTER:
To the high court of the supreme court of judicature Civil jurisdiction in Guyana:
Hereby the undersigned would like to declare that mid-level healthcare providers, including nurses, midwives, medical assistants and pharmacists can safely provide medical abortions directly to women.
Unsafe abortion is one of the main causes of maternal mortality. Complications from unsafe abortion accounted for an estimated 13% of all maternal deaths worldwide. (1) A shortage of health workers (for legal or geographic reasons) has hindered efforts to reduce maternal mortality and the provision of universal access to reproductive health as formulated in Millennium Development Goal 5. Task shifting and sharing may increase access to and availability of abortion services with the same quality of care and may be cost effective. (2)
Because mid-level health care providers often work in rural or remote areas where there are no doctors and few surgical facilities, allowing them to provide medical abortion could improve access to safe abortion services. (3)
Multiple studies have proven that manual vacuum aspiration by midlevel providers are as safe and effective as by doctors and two studies have been published that shows that medical abortions provided by doctors or nurses have the same outcome. (4)
The WHO also advises making abortion services available athealthcare provider, as effective health system interventions to improve access to safe abortion. (5)
Supervision by a doctor is not required medically. If required by law, supervision does not mean the definition used by the Guyanese Health Authorities: “the actual presence of a doctor nor the requirement of his/her to meet with the patient in order to determine the method of termination, perform any examination required, give instructions to the medical assistant for carrying out the termination and to manage, direct and oversee persons administering medical abortions. The medical assistant should be able to consult or call upon the medical practitioner for assistance from the beginning till the end of the treatment, if he cannot be physically present at all times.”
The difference between medical supervision and medical direction as the Guyanese health authorities seem to want is well described in the paper by:
The generally accepted definitions of clinical supervision are:
1 - “The indirect oversight of multiple procedures performed by others.”
2 - “An exchange between practising professional to enable the development of professional skills.” (Butterworth, 2001).
3 - “Facilitated learning in relation to live practical issues.” (Burton and Launer (2003) (http://www.faculty.londondeanery.ac.uk/e-learning/supervision/clinical-and-educational-supervision)
4 - “The provision of monitoring, guidance and feedback on matters of personal, professional, and educational development in the context of the (trainee’s) care of patients.” Review Effective supervision in clinical practice settings: a literature review. Kilminster SM, Jolly BC Med Educ. 2000 Oct; 34(10):827-40.
5 - “A formal process of professional support and learning which enables the individual practitioners to develop knowledge and competence, assume responsibility for their own practice and enhance consumer protection and safety of care in complex clinical situations.” (http://www.5boroughspartnership.nhs.uk/library/documents/5bpt3clinicalsupervision.pdf)
Futhermore the Guyanese health authorities refer in their objection to the provision of medical abortion of a medical assistant. However midlevel health professionals like nurses, midwifes and other midlevel health professionals are specially educated and licensed health personnel and this is not the same as medical assistants. As we can read in the document of board of registered nursing of USA, medical assistants are unlicensed personnel who perform non-invasive routine technical support services under the supervision of the physician and surgeon, or podiatrist in a medical office or clinic setting. ……… the nurse practitioner, nurse-midwife, or physician assistant may provide the supervisory function for the medical assistant when the supervising physician is not on site.” (http://www.rn.ca.gov/pdfs/regulations/npr-b-41.pdf)
So nurses can even provide medical supervision to medical assistants.
Medical abortion is one of the safest procedures in contemporary medical practice, with minimal morbidity and a negligible risk of death. Medical abortion can be done with several medicines and protocols but use of the combination of 200 mg mifepristone and 24 to 36 hours later 800 mcg misoprostol sublingual, vaginal or buccal is proven to be the most effective, with few serious complications and success rates of 95-98% when used in the first 9 weeks of pregnancy. (5)
Evidence shows that it is safe to perform a medical abortion procedure at home up to nine weeks of gestation. The risk of serious complication is exceptionally low compared with other medical interventions, and very few patients require emergency referral. Today, the clinical practice in many countries is that women administer misoprostol themselves at home. Women can safely handle the treatment and most stages of the termination process themselves. (6,7)
Mifepristone and misoprostol have been on the list of essential medicines of the World Health Organization since 2005. (8)
Medical abortion is a revolution for women. To take a pill they just need correct information about the best use and access to emergency care in case of a complication. Medical abortion gives women the possibility to take their lives in their own hands.
Increased use of medication abortion worldwide has likely contributed to declines in the proportion of illegal abortions that result in severe morbidity and maternal death. (9)
We urge the court of Guyana to acknowledge the enormous scientific advancement of medical abortion and the safe and effective use by mid-level healthcare providers.
1 - World Health Organization. Unsafe abortion incidence and mortality. Global and regional levels in 2008 and trends during 1990-2008 (2012). Available through: http://apps.who.int/iris/bitstream/10665/75173/1/WHO_RHR_12.01_eng.pdf
2 - Angela J. et al Task shifting and sharing in maternal and reproductive health in low-income countries: a narrative synthesis of current evidence. Health Policy Plan. (2013)
3 - Yarnall J, Swica Y, Winikoff B. Non-physician clinicians can safely provide first trimester medical abortion. Reprod Health Matters. 2009 May;17(33):61-9.
4 - Warriner IK et al. Can midlevel health-care providers administer early medical abortion as safely and effectively as doctors? A randomised controlled equivalence trial in Nepal Lancet. 2011 Apr 2;377(9772):1155-61.)
5 - World Health Organization. Safe abortion: technical and policy guidance for health systems (2012). Second edition. Available through: http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf., (accessed 2-1-2014)
6 - Swica Y, Chong E, Middleton T, et al. Acceptability of home use of mifepristone for medical abortion. Contraception 2013; 88(1): 122-127.
7 - Ngo TD, Park MH, Shakur H, Free C. Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review. B World Health Organ 2011; 89(5): 360-370.
8 - http://apps.who.int/iris/bitstream/10665/93142/1/EML_18_eng.pdf accessed 3-1-2014
9 - Guttmacher Institute. Facts on induced abortion worldwide (2012). Available through: http://www.guttmacher.org/pubs/fb_IAW.pdf. (accessed: 2-1-2014)