Over the past two decades, the health evidence, technologies and human rights rationale for providing safe, comprehensive abortion care have evolved greatly. Despite these advances, an estimated 22 million abortions continue to be performed unsafely each year, resulting in the death of an estimated 47000 women and disabilities for an additional 5 million women. Almost every one of these deaths and disabilities could have been prevented through sexual education, family planning, and the provision of legal and safe induced abortion. In nearly all developed countries, safe abortions are legally available upon request or under broad social and economic grounds, and services are generally easily accessible and available. In countries where induced abortion is legally highly restricted and/or unavailable, safe abortion has frequently become the privilege of the rich, while poor women have little choice but to resort to unsafe providers, causing deaths and morbidities that become the social and financial responsibility of the public health system.
In view of the need for evidence-based best practices for providing safe abortion care in order to protect the health and human rights of women, the World Health Organization (WHO) has updated its 2003 publication Safe abortion: technical and policy guidance for health systems, and developed recommendations for clinical care. In this process, the WHO standards for guideline development have been followed, including: identification of priority questions and outcomes; retrieval, assessment and synthesis of evidence; formulation of recommendations; and planning for dissemination, implementation, impact evaluation and updating. For the clinical recommendations presented in Chapter 2, evidence profiles related to the prioritized questions were prepared, based upon recent systematic reviews, most of which are included in the Cochrane Database of Systematic Reviews. In addition, Chapters 1, 3 and 4 of the original 2003 publication were reviewed and updated to reflect the latest estimates on unsafe abortion worldwide, new literature on the topic of service delivery, and new developments in international, regional and national human rights law. An international panel of experts reviewed and revised the draft recommendations based on the evidence profiles, through a participatory, consensus-driven process.
The target audience for this guidance is policy-makers, programme managers and providers of abortion care.
The recommendations presented in this document are briefly summarized next. Details of their development and application of the quality of evidence grading are found under the Methods section [in the full guidance document].
Participants in the technical consultation [in 2011 which led to the final recommendations] noted important knowledge gaps that need to be addressed through primary’research. Overall, the participants in the consultation placed a high value on research to de-medicalize abortion care.
1. Recommended methods for surgical abortion
Vacuum aspiration is the recommended technique of surgical abortion for pregnancies of up to 12–14 weeks gestational age. The procedure should not be routinely completed by sharp curettage. Dilatation and sharp curettage (D&C), if still practised, should be replaced by vacuum aspiration.
2. Recommended methods for medical abortion
Mifepristone + misoprostol
The recommended method of medical abortion up to 9 weeks of pregnancy is 200 mg mifepristone orally followed 24–48 hours later by 800 μg of misoprostol, administered either vaginally, buccally or sublingually.
For pregnancies of between 9–12 weeks, the recommended method is 200 mg mifepristone orally, followed 36–48 hours later by 800 μg of misoprostol, administered vaginally. Subsequent doses of misoprostol should be 400 μg, administered either vaginally or sublingually, every 3 hours, up to 4 further doses, until expulsion of the products of conception.
For pregnancies of between 12–24 weeks, the recommended medical method is 200 mg mifepristone orally, followed 36–48 hours later by either 800 μg misoprostol administered vaginally, or 400 μg of misoprostol administered orally. Subsequent doses of misoprostol should be 400 μg, administered either vaginally or sublingually, every 3 hours up to 4 further doses.
For pregnancies beyond 24 weeks, the dose of misoprostol should be reduced, due to the greater sensitivity of the uterus to prostaglandins, but the lack of clinical studies prohibits specific dosing recommendations.
Misoprostol alone
Where mifepristone is not available, for pregnancies up to 12 weeks, the recommended medical method is 800 μg of misoprostol, administered vaginally or sublingually. The dose can be repeated up to 3 times at intervals of at least 3 hours, but for no longer than 12 hours.
Where mifepristone is not available, for pregnancies over 12 weeks, the recommended medical method is 400 μg of misoprostol, administered vaginally or sublingually, every 3 hours for up to 5 doses.
3. Recommended methods of abortion for pregnancies of gestational age over 12 weeks
Dilatation and evacuation (D&E) and medical methods (mifepristone and misoprostol; misoprostol alone) are both recommended methods for abortion for gestation over 12 weeks. Facilities should offer at least one, and preferably both, methods if possible, depending on provider experience and the availability of training.
4. Recommendations for care preceding induced abortion
Cervical preparation
Prior to surgical abortion, cervical preparation is recommended for all women with a pregnancy over 12 to 14 weeks of gestation. Its use may be considered for women with a pregnancy of any gestational age.
All women undergoing dilatation and evacuation (D&E) with a pregnancy over 14 weeks of gestation should receive cervical preparation prior to the procedure.
Ultrasound scanning
Use of routine pre-abortion ultrasound scanning is not necessary.
Prophylactic antibiotics
All women having surgical abortion, regardless of their risk of pelvic inflammatory infection, should receive appropriate prophylactic antibiotics pre- or peri-operatively.
For women having medical abortion, routine use of prophylactic antibiotics is not recommended.
Pain management
All women should be routinely offered pain medication (e.g. nonsteroidal anti-inflammatory drugs) during both medical and surgical abortions.
General anaesthesia is not recommended routinely for vacuum aspiration or dilatation and evacuation (D&E).
Remarks: Medication for pain management for both medical and surgical abortions should always be offered, and provided without delay to women who desire it. In most cases, analgesics, local anaesthesia and/or conscious sedation supplemented by verbal reassurance are sufficient, although the need for pain management increases with gestational age.
5. Recommendations for care post-abortion
Contraception
Women may start hormonal contraception at the time of surgical abortion, or as early as the time of administration of the first pill of a medical abortion regimen. Following medical abortion, an intrauterine device (IUD) may be inserted when it is reasonably certain that the woman is no longer pregnant.
Follow-up
There is no medical need for a routine follow-up visit following uncomplicated surgical abortion or medical abortion using mifepristone followed by misoprostol. However, women should be advised that additional services are available to them if needed or desired.
Incomplete abortion
If uterine size at the time of treatment is equivalent to a pregnancy of gestational age 13 weeks or less, either vacuum aspiration or treatment with misoprostol is recommended for women with incomplete abortion. The recommended regimen of misoprostol is a single dose given either sublingually (400 μg) or orally (600 μg).
6. Recommendations for health systems
To the full extent of the law, safe abortion services should be readily available and affordable. This means services should be available at primary-care level, with referral systems in place for all required higher-level care.
Actions to strengthen policies and services related to abortion should be based on the health needs and human rights of women and a thorough understanding of the service-delivery system and the broader social, cultural, political and economic context.
National standards and guidelines for safe abortion care should be evidence-based and periodically updated, and should provide the necessary guidance to achieve equitable access to good-quality care.
New policy and programme interventions should be based on evidence-based best practices. Complex service-delivery interventions require local evidence of feasibility and effectiveness through pilot-testing on a small scale prior to investing resources in scaling-up.
Training of abortion providers must ensure that they have the competencies to provide good-quality care in accordance with national standards and guidelines.
Ensuring good quality abortion care requires ongoing supervision, quality assurance, monitoring and evaluation.
Financing of abortion services should take into account costs to the health system while ensuring that services are affordable and readily available to all women who need them. Costs of adding safe abortion care to existing health services are likely to be low, relative to the costs to the health system of treating complications of unsafe abortion.
Successful scaling-up requires systematic planning, management, guidance and support for the process by which pilot interventions are both expanded and institutionalized. It also requires sufficient human and financial resources to support the process.
7. Recommendations related to regulatory, policy and human rights considerations
Laws and policies on abortion should protect women's health and their human rights.
Regulatory, policy and programmatic barriers that hinder access to and timely provision of safe abortion services should be removed.
An enabling regulatory and policy environment is needed to ensure that every woman who is legally eligible has ready access to good-quality abortion services. Policies should be geared to respecting, protecting and fulfilling the human rights of women, to achieving positive health outcomes for women, to providing good-quality contraceptive information and services, and to meeting the particular needs of poor women, adolescents, rape survivors and women with HIV.
Dissemination of the guidance
In addition to distribution of the print version, a series of regional workshops will be organized on applying the WHO Strategic Approach to strengthening sexual and reproductive health policies and programmes to the issue of unsafe abortion. The aim of the workshops will be to develop proposals based on the guidance that can strengthen safe abortion care within sexual and reproductive health programmes. The workshops will include pre-selected country teams with representatives from ministries/departments of health, including a variety of health-service providers and programme managers, and representatives from NGOs, professional associations and UN organizations.
This text is based on the Executive Summary of the guidance.
The guidance will be available first in English on the WHO website at: http://bit.ly/WHOsafeabortionguidelines and then in print. It will also be translated and printed in French, Russian and Spanish.
The development of these guidelines was supported by the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP).