Abortion care guideline

210 Pages·3.499 MB·English

by  World Health Organization

Abortion
care guideline

Abortion
care guideline
Abortion care guideline
ISBN 978-92-4-003948-3 (electronic version)
ISBN 978-92-4-003949-0 (print version)
© World Health Organization 2022
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Design and layout: Little Unicorns
Contents
Acknowledgements ...............................................................................................................................vii
Acronyms and abbreviations ..................................................................................................................xi
Glossary ...............................................................................................................................................xiii
Executive summary ..............................................................................................................................xix
Chapter 1. Introduction ............................................................................................................................1
1.1 Background and context ......................................................................................................................................1
1.2 Guideline objective, rationale, target audience, inclusivity and structure .......................................................2
1.2.1 Objective and rationale ...............................................................................................................................3
1.2.2 Target audience ..........................................................................................................................................3
1.2.3 Equity, inclusivity and people-centred care ...............................................................................................3
1.2.4 Conceptual structure of the guideline .......................................................................................................4
1.3 An enabling environment for comprehensive abortion care ............................................................................5
1.3.1 Human rights including a supportive framework of law and policy ...........................................................7
1.3.2 Availability and accessibility of information .............................................................................................12
1.3.3 Health system factors ...............................................................................................................................12
1.4 Health system considerations ...........................................................................................................................13
1.4.1 Universal health coverage and primary health care .................................................................................13
1.4.2 Health financing ........................................................................................................................................14
1.4.3. Health workforce competencies and training ........................................................................................16
1.4.4 Commodities .............................................................................................................................................16
1.4.5 Monitoring and evaluation of quality abortion care ................................................................................18
Chapter 2. Abortion regulation including relevant recommendations ....................................................21
2.1 Common approaches to abortion regulation ..................................................................................................22
2.2 Recommendations relating to regulation of abortion ....................................................................................22
2.2.1 Criminalization of abortion.......................................................................................................................24
2.2.2 Grounds-based approaches to controlling access to abortion .............................................................26
2.2.3 Gestational age limits .............................................................................................................................28
Chapter 3. Recommendations and best practice statements across the continuum of abortion care ......31
3.1 Background .......................................................................................................................................................32
3.1.1 Structure of information in this chapter ....................................................................................................32
3.1.2 Underlying principles and assumptions relating to recommendations on health worker roles ...........33
3.2 Services applicable across the continuum of care ..........................................................................................34
3.2.1 Providing information ................................................................................................................................34
3.2.2 Offering and providing counselling .........................................................................................................37
3.2.3 Links to additional services ....................................................................................................................40
3.3 Pre-abortion ......................................................................................................................................................41
3.3.1 Mandatory waiting periods imposed by States, health-care facilities or health workers ......................41
3.3.2 Third-party authorization for abortion ....................................................................................................42
3.3.3 Rh isoimmunization ..................................................................................................................................44
3.3.4 Antibiotic prophylaxis ..............................................................................................................................46
3.3.5 Determining gestational age of pregnancy ............................................................................................47
3.3.6 Pain management for abortion ...............................................................................................................49
3.3.7 Cervical priming prior to surgical abortion .............................................................................................54
3.3.8 Restrictions (in law or policy) on health workers who may lawfully provide abortion care .................59
3.3.9 Conscientious objection or refusal by health workers to provide abortion care .................................60
3.4 Abortion ............................................................................................................................................................62
3.4.1 Methods of surgical abortion ...................................................................................................................63
3.4.2 Medical management of induced abortion .............................................................................................67
3.4.3 Missed abortion ........................................................................................................................................74
3.4.4 Intrauterine fetal demise (IUFD) ...............................................................................................................76
3.5 Post-abortion.....................................................................................................................................................79
3.5.1 Follow-up care after abortion ...................................................................................................................79
3.5.2 Incomplete abortion .................................................................................................................................81
3.5.3 Management of non-life-threatening complications: infection and haemorrhage ...............................85
3.5.4 Post-abortion contraception ...................................................................................................................88
3.6 Service-delivery options and self-management approaches ........................................................................94
3.6.1 Supported service-delivery approaches .................................................................................................94
3.6.2 Self-management approaches for medical abortion in whole or in part ..............................................98
3.6.3 Self-management approaches for post-abortion contraception ..........................................................100
Chapter 4. Dissemination, applicability, research gaps and future
updates of the guideline and recommendations .................................................................................105
4.1 Dissemination ...................................................................................................................................................105
4.2 Implementation and impact evaluation of the guideline...............................................................................105
4.3 Research gaps/topics for further research.....................................................................................................106
References ..........................................................................................................................................109
Annex 1. External experts and WHO staff involved in guideline development .......................................120
Annex 2. Selected human rights treaties and their treaty monitoring bodies .......................................128
Annex 3. References for the glossary ...................................................................................................129
Annex 4. Guideline development methods and process .......................................................................130
Annex 5. Health worker categories and roles .......................................................................................139
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Annex 6. Monitoring and evaluation of quality abortion care: identification of indicators ....................140
Annex 7. Systematic reviews and links to PICOs and recommendations ...............................................141
Annex 8. Law and policy domain PICO questions .................................................................................145
Annex 9. Clinical services domain PICO questions ...............................................................................151
Annex 10. Service delivery domain PICO questions ..............................................................................160
Annex 11. Details about guideline dissemination and updating ............................................................169
Supplementary materials and web annexes available online:
• Web annex A. Key international human rights standards on abortion:
https://apps.who.int/iris/bitstream/handle/10665/349317/9789240039506-eng.pdf
• Web annex B. Technical meetings during guideline development:
https://apps.who.int/iris/bitstream/handle/10665/349318/9789240039513-eng.pdf
• Supplementary material 1. Evidence-to-Decision frameworks for the law and policy recommendations:
https://www.who.int/publications/i/item/9789240039483
• Supplementary material 2. Evidence-to-Decision frameworks for the clinical service recommendations:
https://www.who.int/publications/i/item/9789240039483
• Supplementary material 3. Evidence-to-Decision frameworks for the service delivery recommendations
and best practice statements: https://www.who.int/publications/i/item/9789240039483
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Acknowledgements
The UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training
in Human Reproduction (HRP) and the World Health Organization (WHO) gratefully acknowledges the contributions
of many individuals and organizations to the development of this consolidated guideline.
WHO extends sincere thanks to the chair and members of the Guideline Development Group (GDG): Laura
Castleman (Chair) and Fauzia Akhter Huda, Karla Berdichevsky, Marge Berer, Michalina Drejza, Joanna Erdman,
Kristina Gemzell Danielsson, Caitlin Gerdts, Laura Gil, Selma Hajri, Guyo Jaldesa, Godfrey Kangaude, Vinoj
Manning, Hiromi Obara, Alongkone Phengsavanh, Akila Radhakrishnan, Michelle Remme and Chi Chi Undie;
and also the human rights adviser for the GDG meeting and all three Evidence and Recommendation Review
Group (ERRG) meetings: Christina Zampas. Sincere thanks also to the following additional ERRG members: Nana
Yaa Appiah, Suchitra Dalvie, Jemima Araba Dennis-Antwi, Surendra Dhital, Daniel Maceira, Sybil Nkeiru, Karan
Parikh, Dhammika Perera, Judiac Ranape, Kitihoun Serge and Karthik Srinivasan; and to the following human
rights advisers who contributed to the ERRG on law and policy: Abhijit Das, Sara Hossain, Karima Khalil, Primah
Kwagala, Monica Arango Olaya and Xian Warner. Thanks are also due to the members of the External Review
Group: Safia Ahsan, Traci Baird, Sharon Cameron, Jane Harries, Thoai Ngo, Yvette Raphael, Mariana Romero,
Rachel Simon-Kumar and Beverly Winikoff. Institutional affiliations for these and other contributors are provided in
Annex 1 of this guideline.
Special thanks are due to the Evidence Synthesis Teams, who prepared the Grading of Recommendations
Assessment, Development and Evaluation (GRADE) systematic reviews, especially the lead researchers: Alison
Edelman, Taylor King, Makalapua Motu’apuaka, Robyn Paynter, Maria Rodriguez (Clinical services domain);
Nicholas Henschke, Yanina Sguassero and Gemma Villanueva (Service delivery domain); Scott Burris, Amanda
Cleeve, Fiona de Londras and Maria Rodriguez (Law and policy domain). Special thanks also to the guideline
methodologists, Jeppe Schroll (Clinical services domain); Nicholas Henschke, Yanina Sguassero and Gemma
Villanueva (Service delivery domain), and Maria Rodriguez (Law and policy domain). We also thank the team from
the London School of Hygiene and Tropical Medicine, led by Veronique Filippi, for their work on monitoring and
evaluation issues related to quality abortion care. We thank the “Economics of abortion” review team, led by
Ernestina Coast, Samantha Lattof, Brittany Moore and Yana Rodgers, for their collaboration and contributions to
the guideline. We also extend our thanks to the International Youth Alliance for Family Planning (IYAFP) for their
close collaboration and contributions from their Youth Taskforce members to the guideline development process.
We acknowledge the following GDG meeting observers including representatives from United Nations
agencies: Patricia Lohr (British Pregnancy Advisory Service, and member of the Royal College of Obstetricians
and Gynaecologists [RCOG] Making Abortion Safe Programme Advisory Group), Jaydeep Tank (Federation of
Obstetrics and Gynaecological Societies of India and International Federation of Obstetrics and Gynaecology
[FIGO] Working Group for safe abortion, India), Francelle Toedtli (United Nations Population Fund, USA), Ann
Yates (International Confederation of Midwives, the Netherlands); and the following individual reviewers from
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implementing organizations who provided feedback on the draft guidelines: Bethan Cobley (MSI Reproductive
Choices, United Kingdom), Rasha Dabash (Ipas, USA), Eva Lathrop (Population Services International, USA), Steve
Luboya (Pathfinder, USA) and Rebecca Wilkins (International Planned Parenthood Federation, United Kingdom of
Great Britain and Northern Ireland).
The following WHO staff members contributed as members of the WHO Guideline Steering Group, which
managed the guideline development process (all from WHO’s Department of Sexual and Reproductive Health and
Research [SRH], Prevention of Unsafe Abortion [PUA] Unit): Mekdes Daba Feyssa (provided support for the clinical
services domain and overall guideline development process), Bela Ganatra (PUA Unit head, co-lead coordinator
for the service delivery domain), Heidi Johnston (provided support for the service delivery domain, especially
monitoring and evaluation work), Caron Kim (responsible technical officer, lead coordinator for the clinical services
domain and co-lead for the service delivery domain, and overall coordinator for the guideline development
process), Antonella Lavelanet (lead coordinator for the law and policy domain and human rights). During initial
stages of guideline planning, Steering Group members also included Roopan Gill and Lemi Tolu (formerly with the
PUA Unit) and Rajat Khosla (formerly with the Office of the SRH Department’s Director).
Writing was provided by Fiona de Londras, Bela Ganatra, Heidi Johnston, Caron Kim, Antonella Lavelanet,
Jane Patten and Maria Rodriguez. WHO administrative support was provided by Claire Garabedian and Hannah
Hatch, and communications support was provided by Sarah Kessler and Elizabeth Noble, all from the SRH
Department, with additional communications support from Laura Keenan and Sarah Russell of the WHO Director
of Communications Office and from Helen Palmer of Weber Shandwick. We are grateful to the following additional
WHO headquarters staff and consultants, who provided input at various stages during the development of the
guideline: Laurence Codjia, Fahdi Dkhimi, Carolin Ekman, Veloshnee Govender, Lisa Hedman, Laurence Läser,
Bruno Meessen, Ulrika Rehnström Loi, Marta Schaaf, Patricia Titulaer; and also colleagues from WHO regional
offices: Chilanga Asmani, Ibadat Dhillon, Rodolfo Gómez Ponce de León and Nilmini Hemachandra. Review and
comments were kindly provided by Ian Askew, Director of the SRH Department.
Special acknowledgement to the Office of the United Nations High Commissioner for Human Rights (OHCHR) for
their review of the final draft of the guideline, in particular on the aspects relevant to international human rights
standards and the integration of a human rights-based approach.
Special thanks to the WHO Guidelines Review Committee (GRC) and in particular to the WHO GRC Secretariat,
Rebekah Thomas-Bosco, Marion Blacker and Maria Pura Solon, for their valuable feedback at every stage of the
guideline development process.
Editing and proofreading was provided by Green Ink, United Kingdom.
Funding for the development of the guideline was provided by HRP, a cosponsored programme executed by
the WHO.
viii Abortion care guideline