Safe abortion

134 Pages·2012·1.47 MB·English

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For more information, please contact: n ffoorr hheeaalltthh ssyysstteemmss
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Department of Reproductive Health and Research fo
World Health Organization r h
Avenue Appia 20, CH-1211 Geneva 27, Switzerland e
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E-mail: [email protected] sy Second edition
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ISBN 978 92 4 154843 4

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tteecchhnniiccaall aanndd ppoolliiccyy gguuiiddaannccee
ffoorr hheeaalltthh ssyysstteemmss
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WHO is grateful for the technical contributions of the external experts who participated in the initial online
consultation, the technical consultation and the review of this guideline.
(Details of participants and additional external reviewers are provided in Annex 4.)
FFuunnddiinngg ssoouurrccee
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).
WHO Library Cataloguing-in-Publication Data
Safe abortion: technical and policy guidance for health systems – 2nd ed.
1.Abortion, Induced - methods 2.Abortion, Induced - standards. 3.Prenatal
care - organization and administration 4.Prenatal care - standards
5.Maternal welfare 6.Health policy 7.Guidelines. I.World Health Organization.
ISBN 978 92 4 154843 4 (NLM classification: WQ 440)
© World Health Organization 2012.
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Printed in
ii Safe abortion: technical and policy guidance for health systems
AAbbbbrreevviiaattiioonnss
D&C dilatation and (sharp) curettage
D&E dilatation and evacuation
EVA electric vacuum aspiration
GMP good manufacturing practice
GRADE Grading of Recommendations Assessment, Development and Evaluation
hCG human chorionic gonadotrophin
HIV human immunodeficiency virus
HLD high-level disinfection
ICPD International Conference on Population and Development
IUD intrauterine device
IV intravenous
KCl potassium chloride
LMP last menstrual period
MVA manual vacuum aspiration
NGO nongovernmental organization
PG prostaglandin
Rh Rhesus (blood group)
RTI reproductive tract infection
STI sexually transmitted infection
UN United Nations
UNFPA United Nations Population Fund
UNPD United Nations Population Division
USA United States of America
WHO World Health Organization
Safe abortion: technical and policy guidance for health systems iii
DDeeffiinniittiioonnss uusseedd iinn tthhiiss ddooccuummeenntt yy Medical methods of abortion (medical abortion):
use of pharmacological drugs to terminate preg-
yy Duration or gestational age of pregnancy (gesta-
nancy. Sometimes the terms “non-surgical abor-
tion): the number of days or weeks since the first
tion” or “medication abortion” are also used.
day of the woman’s last normal menstrual period
yy Menstrual regulation: uterine evacuation without
(LMP) in women with regular cycles (for women
laboratory or ultrasound confirmation of preg-
with irregular cycles, the gestational age may
nancy for women who report recent delayed
need to be determined by physical or ultrasound
menses.
examination). The first trimester is generally
considered to consist of the first 12 or the first 14 yy Osmotic dilators: short, thin rods made of sea-
weeks of pregnancy (see Table 1). weed (laminaria) or synthetic material. After place-
ment in the cervical os, the dilators absorb mois-
ture and expand, gradually dilating the cervix.
Table 1. Equivalent gestational ages in weeks
yy Routes of misoprostol administration:
and days during the first trimester
Weeks of gestation Days of gestation –– oral – pills are swallowed immediately;
<1 0–6
–– buccal – pills are placed between the cheek
1 7–13
and gums and swallowed after 30 minutes;
2 14–20
–– sublingual – pills are placed under the tongue
3 21–27
and swallowed after 30 minutes;
4 28–34
5 35–41 –– vaginal – pills are placed in the vaginal for-
6 42–48 nices (deepest portions of the vagina) and
7 49–55 the woman is instructed to lie down for
8 56–62 30 minutes.
9 63–69 yy Surgical methods of abortion (surgical abortion):
10 70–76 use of transcervical procedures for terminat-
11 77–83 ing pregnancy, including vacuum aspiration and
12 84–90 dilatation and evacuation (D&E). (See Chapter 2,
13 91–97 Section 2.2.4 for a more detailed description of
14 98–104 methods of surgical abortion.)
Adapted from: International statistical classification of diseases
Human Rights terminology
and health related problems, 10th revision – ICD-10, Vol. 2,
2008 Edition. Geneva, World Health Organization, 2009.
yy International human rights treaty: also sometimes
called a Covenant or a Convention, is adopted by
the international community of States, normally
at the United Nations General Assembly. Each
treaty sets out a range of human rights, and cor-
responding obligations which are legally binding
on States that have ratified the treaty. Annex 7
includes a list of these treaties.
iv Safe abortion: technical and policy guidance for health systems
yy Treaty monitoring body: each of the international
human rights treaties is monitored by a desig-
nated treaty monitoring body (see Annex 7). The
treaty monitoring bodies are committees com-
posed of independent experts. Their main func-
tion is to monitor the States’ compliance with the
treaty in question, including through the examina-
tion of State reports.
yy General comments/recommendations: a treaty
monitoring body’s interpretation of the content
of human rights provisions on thematic issues
or its methods of work. General comments seek
to clarify the reporting duties of State parties
with respect to certain provisions and suggest
approaches to implementing treaty provisions.
yy Concluding observations: following submission
of a State report and a constructive dialogue with
the State party to the particular convention, treaty
monitoring bodies issue concluding observa-
tions to the reporting State, which are compiled
in an annual report and sent to the United Nations
General Assembly.
yy Regional human rights treaties: States adopted
human rights treaties in Africa, the Americas,
Europe and the Middle East. Regional human
rights bodies, such as the African Union, the
Organization of American States, the Council of
Europe, the European Union, and the League of
Arab States monitor States’ compliance with the
treaties. To date, there are no regional human
rights treaties in South-East Asia or the Western
Pacific. Annex 7 includes a list of regional human
rights treaties.
yy Human rights standards: the meaning and scope
of human rights as interpreted and applied by the
human rights bodies tasked with this work, e.g.
international, regional and national courts, and
human rights committees.
Safe abortion: technical and policy guidance for health systems v
vi Safe abortion: technical and policy guidance for health systems
CCOONNTTEENNTTSS
Executive summary 1
Process of guideline development 10
Background 10
Methods 10
Decision-making during the technical consultation 12
Document preparation and peer review 12
Dissemination of the guidance document 12
Updating the guidelines 13
Chapter 1 16
Safe abortion care: the public health and human rights rationale 17
1.1 Background 17
1.2 Public health and human rights 18
1.3 Pregnancies and abortions 19
1.4 Health consequences of unsafe abortion 19
1.5 Contraceptive use, accidental pregnancies and unmet need for family planning 22
1.6 Regulatory and policy context 23
1.7 Economic costs of unsafe abortion 26
Chapter 2 30
Clinical care for women undergoing abortion 31
2.1 Pre-abortion care 32
2.2 Methods of abortion 37
2.3 Post-abortion care and follow-up 52
Chapter 3 62
Planning and managing safe abortion care 63
3.1 Introduction 64
3.2 Constellation of services 64
3.3 Evidence-based standards and guidelines 65
3.4 Equipping facilities and training health-care providers 69
3.5 Monitoring, evaluation and quality improvement 72
3.6 Financing 79
3.7 The process of planning and managing safe abortion care 80
Safe abortion: technical and policy guidance for health systems vii
Chapter 4 86
Legal and policy considerations 87
4.1 Women’s health and human rights 87
4.2 Laws and their implementation within the context of human rights 90
4.3. Creating an enabling environment 98
Annex 1
Research gaps identified at the technical consultation 105
Annex 2
Final GRADE questions and outcomes 106
Annex 3
Standard GRADE criteria for grading of evidence 109
Annex 4
Participants in the technical consultation 110
Annex 5
Recommendations from the technical consultation for the second edition of
Safe abortion: technical and policy guidance for health systems 113
Annex 6
Post-abortion medical eligibility for contraceptive use 120
Annex 7
Core international and regional human rights treaties 122
viii Safe abortion: technical and policy guidance for health systems