# Background and context
Sexual and reproductive health is fundamental to individuals, couples and families, and to the social and economic development of communities and nations (1). As provided in the Constitution of the World Health Organization (WHO), the organization's objective is "the attainment by all peoples of the highest possible level of health", and to fulfil that objective, WHO's functions include providing technical assistance to countries in the field of health (2, Articles 1 and 2). Universal access to sexual and reproductive health (SRH) information and services is central to both individual and community health, as well as the realization of human rights, including the right to the highest attainable standard of SRH (3). In addition, the increased SRH risks in humanitarian settings, including armed conflict, require specific attention from a human rights perspective (4 5, 6.
In the wake of the COVID-19 pandemic and based on lessons learnt from previous disease outbreaks -when SRH services have been severely disrupted, causing individuals to feel disempowered and be exposed to preventable health risks -WHO has included comprehensive abortion care in the list of essential health services in certain recent technical publications and guidance (7)(8)(9)(10)(11)(12). 1 Abortion care encompasses management of various clinical conditions including spontaneous and induced abortion (of both non-viable and viable pregnancies) and intrauterine fetal demise, and also post-abortion care, including management of incomplete abortion.
Strengthening access to abortion care within the health system is fundamental to meeting the Sustainable Development Goals (SDGs) relating to good health and well-being (SDG3) and gender equality (SDG5) (13). WHO's Global Reproductive Health Strategy, which seeks to accelerate progress towards achievement of international development goals, identifies elimination of unsafe abortion 2 as a priority mandate (1). The importance of quality abortion care to health is similarly underscored by the United Nations Global Strategy for Women's, Children's and Adolescents' Health, which includes evidence-based interventions for abortion and post-abortion care as one effective way to help individuals thrive and communities transform (14).
Quality abortion care is foundational to this guidance. Quality of care (see Glossary) encompasses multiple components: effectiveness, efficiency, accessibility, acceptability (e.g. patient centred), equity and safety. Effective care includes the delivery of evidence-based care that improves the health of individuals and communities, and is responsive to their needs. Efficient care optimizes resource use and minimizes waste. Quality abortion care must be both accessible (timely, affordable, geographically reachable, and provided in a setting where skills and resources are appropriate to medical need) and acceptable (incorporating the preferences and values of individual service users and the cultures of their communities). It is imperative that abortion care is equitable, and that health care does not vary in quality based on the personal characteristics of the person seeking care, such as their gender, race, ethnicity, socioeconomic status, education, if they are living with a disability, or based on their geographic location within a country. And finally, quality abortion care implies that it is safely delivered and minimizes risks and harms to service users (15). Underpinning these components is the principle that provision of quality abortion care would be in compliance with human rights.
Globally, abortion is a common procedure, with 6 out of 10 unintended pregnancies and 3 out of 10 of all pregnancies ending in induced abortion (16). When abortion is safe -defined as being carried out using a method recommended by WHO, appropriate to the gestational age, and by someone with the necessary skills (17) -the risks are very low. However global estimates demonstrate that 45% of all abortions are unsafe, including 14.4% considered to be "least safe" (18). This is a critical public health and human rights issue; unsafe abortion is increasingly concentrated in developing countries and among groups in vulnerable and marginalized situations.
In countries where induced abortion is highly restricted by law or unavailable due to other barriers, safe abortion has often become the privilege of the rich, while poor women have little choice but to resort to the services of unskilled providers in unsafe settings, or induce abortion themselves often using unsafe methods, leading to deaths and morbidities that become the social and financial responsibility of the public health system, and denial of women's human rights. The legal status of abortion has no effect on a woman's likelihood of seeking induced abortion, but it dramatically affects her access to safe abortion (19).
Between 4.7% and 13.2% of all maternal deaths are attributed to unsafe abortions (20,21). This equates to between 13 865 and 38 940 lives lost annually, due to the failure to provide safe abortion, with many more experiencing serious morbidities. Developing countries bear the burden of 97% of unsafe abortions (18). The proportion of abortions that are unsafe is also significantly higher in countries with highly restrictive abortion laws than in those with less restrictive laws (18). Over half (53.8%) of all unsafe abortions occur in Asia (the majority of those in south and central Asia), while another quarter (24.8%) occur in Africa (mainly in eastern and western Africa), and a further fifth (19.5%) in Latin America and the Caribbean (18). The subregions where the highest proportions of abortions have been categorized as "least safe" are northern, eastern, western and middle Africa (approximately 45-70% of all abortions are "least safe"), followed by the Caribbean, Oceania and Central America (approximately 25-30% of all abortions are "least safe") (18). A review of facility-based treatment for complications of unsafe abortion in 26 developing countries in 2012 indicated that 7 million women were treated in developing countries for complications of unsafe abortion that year -a rate of 6.9 per 1000 women aged 15-44 years (22).
Abortion, using medication or a simple outpatient surgical procedure, is a safe health-care intervention, when carried out with a method appropriate to the gestational age of pregnancy and -in the case of a facility-based procedure -by a person with the necessary skills. In these circumstances, complications or serious adverse effects are rare. Medical abortion has revolutionized access to quality abortion care globally. Studies have demonstrated that medicines for abortion can be safely and effectively self-administered outside of a facility (e.g. at home). Individuals with a source of accurate information and access to a trained health worker (in case they need or want support at any stage of the process) can safely self-manage their abortion process in the first 12 weeks of gestation. Service delivery with minimal medical supervision can significantly improve access, particularly in restricted settings and crisis situations, as well as improve privacy, convenience and acceptability of the abortion process without compromising safety and effectiveness (23).
However, in both low-and high-resource settings, law, policy and practical barriers can make it difficult to access quality abortion care. Multiple actions are needed at the legal, health system and community levels so that everyone who needs it has access to comprehensive abortion care (CAC), i.e. information, abortion management (including induced abortion, and care related to pregnancy loss/spontaneous abortion) and post-abortion care.

# Guideline objective, rationale, target audience, inclusivity and structure
Guidelines are the fundamental means through which WHO fulfils its technical leadership in health (24). WHO guidelines are subject to a rigorous quality assurance process that generates recommendations for clinical practice or public health policy with the aim of achieving the best possible individual or collective health outcomes. Towards this aim, WHO has made a commitment to integrate human rights into health-care programmes and policies at national and regional levels by looking at underlying determinants of health as part of a comprehensive approach to health and human rights.

# Objective and rationale
The objective of this guideline is to present the complete set of all WHO recommendations and best practice statements relating to abortion, with the goal of enabling evidence-based quality abortion care globally.
This guideline updates and replaces the recommendations in the following previous WHO guidance:
- Safe abortion: technical and policy guidance for health systems, second edition (2012)
- Health worker roles in providing safe abortion care and post-abortion contraception (previously known as the "task sharing" guidance) (2015), and
- Medical management of abortion (2018).
This guideline is intended to provide concrete information and guidance, integrating aspects of care across all domains needed to provide quality abortion care: Law and policy, Clinical services and Service delivery. This guidance contains new recommendations consolidated with existing recommendations that remain unchanged and some that have been updated after re-assessment, using the same rigorous methods for both new and updated recommendations (see Annex 4: Methods). Among the recommendations are seven concerning the laws and policies that should or should not be in place, in order to fully implement and sustain quality abortion care: three recommendations relating to abortion regulation are presented in Chapter 2 and four more relating to laws and policies affecting clinical and health worker practices are presented in Chapter 3. All the other recommendations address methods of abortion and related clinical care as well as service delivery by a range of health workers and approaches, including self-management by the abortion seeker, reflecting recent changes in all these aspects of abortion care. Emerging areas of interest and research priorities in abortion care are identified in Chapter 4.
As a key part of the rationale for developing this updated and consolidated guideline, important contextual information -which is integral to this guidance, as context for the recommendations and best practice statements -is presented in the remainder of this first chapter. This information is not in the form of WHO recommendations but rather it describes the underlying determinants of quality abortion care, and thus must be carefully considered. Section 1.3 below describes an enabling environment for comprehensive abortion care (i.e. a law and policy framework supportive of human rights; access to information; and health system factors) and section 1.

# Target audience
This guidance seeks to provide recommendations for national and subnational policy-makers, implementers and managers of sexual and reproductive health (SRH) programmes, members of nongovernmental organizations and other civil society organizations and professional societies, as well as health workers and other stakeholders in the field of sexual and reproductive health and rights (SRHR), to support them in ensuring that evidence-based, quality abortion care is available and accessible globally.

# Equity, inclusivity and people-centred care
The needs of all individuals with respect to abortion are recognized and acknowledged in this guidance. A human rights approach that advances gender equality is essential and must be applied in all contexts providing services to people seeking health care. To provide quality abortion care throughout the health system, services should also be integrated where possible with other SRH services, such as evidence-based HIV and sexually transmitted infection (STI) testing and treatment, and family planning/contraception, and should be friendly and welcoming to youth and people from sexual and gender minorities, people living with disabilities, and all groups in vulnerable and marginalized situations.
WHO guidelines systematically incorporate consideration of the values and preferences of end-users of the recommended or suggested interventions into the process of developing the guidance. To gain more in-depth understanding of the values and preferences of individuals seeking abortion care, WHO conducted a global Chapter 1. Introduction survey and convened a technical meeting on this subject with stakeholders in September 2019 attended by 19 participants from 15 different countries/organizations. The key themes that emerged were the importance of equity, inclusivity and meeting the needs of those living in the most vulnerable and marginalized situations. In addition, a youth-led technical meeting was convened in April 2021 with 16 youths (representing 13 countries across all WHO regions) from the Youth for Abortion Task Force, to learn about the concerns of youth. The Task Force was formed by the International Youth Alliance for Family Planning (IYAFP) -a collective of young individuals, youth associations, organizations and communities with a common mission to support provision of and access to comprehensive reproductive health services (see Web annex B: Technical meetings during guideline development). Women living with HIV are one example among many of a marginalized population with unique vulnerabilities in the context of abortion care. Women living with HIV face unique challenges and are vulnerable to SRH-related human rights violations within their families and communities, as well as at health-care facilities where they seek care. An enabling environment is essential to promote more effective interventions and better health outcomes for all abortion seekers (see section 1.3).
All individuals have the right to non-discrimination and equality in SRH care and services. The right to be free from discrimination is stated in the Universal Declaration of Human Rights and in other universal human rights treaties and regional human rights instruments. It has been affirmed that the right to non-discrimination guaranteed by the International Covenant on Economic, Social and Cultural Rights (ICESCR) includes sexual orientation, gender identity and sex characteristics. The international human rights system has been strengthening the promotion and protection of human rights without distinction. The protection of persons based on their sexual orientation and gender identity are based on international law, complemented and supplemented by State practice (27). As stated in the 2018 report of the Independent Expert on protection against violence and discrimination based on sexual orientation and gender identity to the United Nations General Assembly, "The right to effective recognition of one's gender identity is linked to the right to equal recognition before the law" (28, para. 20).
In this guideline, we recognize that most of the available evidence on abortion can be assumed to be derived from research among study populations of cisgender women, and we also recognize that cisgender women, transgender men, nonbinary, gender-fluid and intersex individuals with a female reproductive system and capable of becoming pregnant may require abortion care. To be concise and facilitate readability of this guideline, when referring to all gender diverse people who may require abortion care, we use the word "women" most often, although we also variously use the terms "individual", "person" and "abortion seeker". Providers of SRH services, including abortion care, must consider the needs of -and provide equal care to -all individuals; gender identity or its expression must not lead to discrimination.
This guideline takes an integrated, people-centred approach to health services (29). People-centred care requires that individuals have the education and support they need to make decisions and participate in their own health care (30). Individual health preferences may vary; no one model of abortion care will meet the needs of everyone seeking abortion care. The core values of dignity, autonomy, equality, confidentiality, communication, social support, supportive care, and trust are foundational to abortion care and are reflected throughout this guidance (31).

# Conceptual structure of the guideline
As illustrated in Figure 1.1, this guideline is centred on the values and preferences of abortion seekers, and considers them as active participants in as well as beneficiaries of health services. This guidance emphasizes that -as a woman, girl or other pregnant person moves through the abortion care pathway (pre-abortion, abortion, post-abortion) -health services must be integrated within the health sector to ensure that service delivery meets their needs equitably and without discrimination. As each individual moves through this pathway, the guideline provides specific recommendations on the interventions needed (i.e. the "what"), and guidance on the individuals who may safely carry them out (i.e. the "who"). The guideline also provides information on the locations where services can be provided (i.e. the "where") and outlines service-delivery models that can be used (i.e. the "how"). The enabling environment, described in the remainder of this chapter, provides the context for the effective implementation of these interventions.

# An enabling environment for comprehensive abortion care
A person's environment plays a crucial role in shaping their access to care and influencing their health outcomes. An enabling environment is the foundation of quality, comprehensive abortion care. The three cornerstones of an enabling environment for abortion care are outlined in Box 1.1 and elaborated in the text of this section:
- respect for human rights including a supportive framework of law and policy 2. the availability and accessibility of information, and 3. a supportive, universally accessible, affordable and well functioning health system.
For clarification, this section of the guideline document does not provide recommendations -rather it details the components and aspects that would comprise an overall enabling environment for quality abortion care, based on WHO best practices, which would provide the ideal context to best facilitate the recommendations in the later sections of this chapter and in Chapter 3. While this enabling environment represents an ideal context, complete implementation of the components of this enabling environment is not necessarily a precondition to implementation and application of the recommendations contained in this guideline.
Chapter 1. Introduction BOX 1.1: Core components of an enabling environment for abortion care
Respect for human rights including a supportive framework of law and policy
- Countries ratify international and regional human rights treaties and conventions addressing health, including sexual and reproductive health (SRH).
- Laws and policies promote SRH for all, and are consistent with sexual and reproductive health and rights.
- There are appropriate administrative, political and judicial arrangements to facilitate quality abortion care, including accessible, transparent and effective mechanisms providing remedies. These include:
 accessible mechanisms for women to challenge denial of abortion in a timely manner, and  appropriate monitoring mechanisms for failure to facilitate quality care, including regular review and reform of law and policy to recognize and remove barriers to quality abortion care.
- Policies minimize the rate of unintended pregnancy by providing quality contraceptive information and services, including a full range of contraceptive methods (emergency, short-acting and long-acting methods).
- All people and communities receive the health services they need, without suffering financial hardship and without any discrimination.

# Availability and accessibility of information
- Evidence-based comprehensive sexuality education (CSE) is provided for all individuals and made available in multiple and accessible forms and languages.
- Accurate, non-biased and evidence-based SRH information, including on abortion and contraceptive methods, is widely available in multiple and accessible forms and languages.
Supportive, universally accessible, affordable and well functioning health system
- Universal health coverage (UHC) ensures that all individuals can receive the care they need without financial hardship (see section 1.4.1).
- The health system is adequately resourced, meaning that resources including essential medicines, supplies, equipment, workforce and financial allocations are available, accessible, acceptable, affordable and of good quality.
- Equitable access to quality-assured essential medicines and health products is ensured.
- Leadership and clinical standards promote evidence-based SRH services.
- The organization of the health system ensures respect for SRH and human rights, including nondiscrimination and equality, and for autonomy in decision-making.
- The workforce is robust and receives competency-based training and is skilled in the provision of evidence-based SRH counselling and service delivery.
- In addition to technical training, SRH services are provided by persons who are trained in the content and meaning of the law and trained and empowered to interpret and apply law and policy in rights-compliant ways.
- Confidentiality and privacy of care are ensured, and there are efforts to counteract abortion stigma.
- There is access to safe and timely comprehensive abortion care and women do not have to resort to unsafe abortion.
- Health financing policies should avoid making access to SRH services conditional on direct payment from patients at the point of service.
- Care is always provided respectfully and with compassion.
- Communities are engaged and supportive.

# Human rights including a supportive framework of law and policy
An enabling environment is one in which the human rights of individuals are respected, protected and fulfilled. This entails regular review and, where necessary, revision of regulatory, law and policy frameworks, and the adoption of measures to ensure compliance with evolving international human rights standards (see Annex 2).
Throughout this guideline we refer to human rights standards in international law, the applicability of which in a specific setting will depend on factors such as the State's ratification of relevant human rights instruments. The sources of these human rights standards are detailed in Web annex A: Key international human rights standards on abortion.

# (i) Sexual and reproductive health and rights
Sexual and reproductive health and rights are grounded in a range of human rights recognized and guaranteed in national and international law, and are inextricably linked to the achievement of public health policy goals, including the SDGs (32,33). People have a range of sexual and reproductive rights, which are relevant to information and services across the continuum of care for abortion (see Box 1.2). Overarching all of them are principles of non-discrimination and equality, and the right to the highest attainable standard of physical and mental health, including in the provision of SRH services (3, para. 7). These are all underpinned by States' obligations to ensure that laws and policies, institutional arrangements and social practices do not prevent people from the effective enjoyment of their right to SRH (3, para. 8).
Box 1.2 provides a general description of certain human rights as established by international law instruments and their associated obligations and principles relevant to SRH.

# (ii) Prevention of unsafe abortion and reduction of maternal mortality and morbidity
Taking measures to prevent unsafe abortion is a core obligation of the right to SRH (3, para. 49). International human rights law requires States to take steps to reduce maternal mortality and also to effectively protect women from the physical and mental risks (morbidity) associated with unsafe abortion (43, paras 6, 9, 24, 30-33). Treaty monitoring bodies (see Annex 2) have confirmed that States must revise their laws to ensure this protection (36, para. 8). Thus, the United Nations Committee on Economic, Social and Cultural Rights (CESCR) has confirmed that States must liberalize restrictive abortion laws, guarantee access to quality abortion and post-abortion care, and respect the right of women to make autonomous decisions about their SRH (3, para. 28). In all situations, States have a duty under international human rights law to ensure that the regulation of abortion (see Chapter 2) does not cause women and girls to resort to unsafe abortions (36, para. 8). As a matter of international human rights law, States must provide essential medicines listed under WHO's Action Programme on Essential Drugs (46, para. 12a).
States must also take steps to prevent the stigmatization of people seeking abortion (36, para. 8). In addition, policies must seek to minimize the rate of unintended pregnancy by ensuring provision of quality contraceptive information and services, including a full range of contraceptive methods (emergency, short-acting and longacting methods).

# (iii) Rights-based regulation of abortion
The right to SRH requires States to ensure that health-care facilities, goods and services are available, accessible, acceptable and of good quality (46, paras 8, 12). This should inform all parts of the regulation of abortion.
Treaty monitoring bodies have called for the decriminalization of abortion in all circumstances. They have further clarified States' human rights obligations in relation to abortion. These include that:
- States may not regulate pregnancy or abortion in a manner that runs contrary to their core obligation to ensure that women and girls do not have to resort to unsafe abortions. If they do, their restrictions on access to abortion must be revised (36, para. 8).
- The regulation of abortion must not jeopardize the lives of pregnant women, subject them to physical or mental pain or suffering (including where this constitutes torture or cruel, inhuman or degrading treatment or punishment), discriminate against them, or interfere arbitrarily with their privacy (36, para. 8).
- The regulation of abortion must be evidence based and proportionate to ensure respect for human rights (37, para. 18). - States have an obligation to respect, protect and fulfil the right of everyone to sexual and reproductive health and rights (34,Article 12). This includes:
 the removal of legal provisions, including criminal laws, which penalize women who have undergone abortion or medical practitioners who offer these services (3,(35)(36)(37)(38);
 ensuring that women are not prevented from accessing health services by health professionals' exercise of conscientious objection (e.g. where abortion is legal, if a doctor refuses to perform it, the health system must provide a referral to an alternative health-care provider) (3, 39);
 eliminating barriers to the provision of abortion services including barriers that lead women to resort to unsafe abortions -this should include eliminating unacceptable delays in providing medical attention (3,36,38,(40)(41)(42);
 undertaking measures to prevent unsafe abortions and ensure access to post-abortion care in all circumstances, on a confidential basis and without the threat of criminal prosecution or punitive measures (3, 36-38, 40, 41, 42 ;
 undertaking measures to prevent and eliminate discrimination, stigmatization and negative stereotyping that hinder access to sexual and reproductive health (SRH), including against people seeking abortion and health-care providers offering abortion care services (36,38). - States must ensure that sexual and reproductive health-care facilities, goods and services are available, acceptable and of good quality. This includes:
 ensuring an adequate number of sexual and reproductive health-care facilities, goods and services (e.g. trained and skilled medical and health-care personnel  and scientifically approved and unexpired medicines for abortion and post-abortion care as well as the availability of safe abortion in cases of rape and incest;
 ensuring that health care and services, including SRH and essential medicines are physically and geographically accessible and affordable to all individuals, either provided at no cost or based on ensuring that health expenses do not expose individuals to suffering financial hardship (46);  ensuring that information about SRH is accessible (3, 52) (e.g. institutions and individuals should be able to provide accurate health-care information, including information on abortion, without fear of criminal sanction;
 ensuring that delivery of services is respectful of the culture of individuals, minorities, peoples and communities, and sensitive to gender, age, disability, sexual diversity and life-cycle requirements (53, para. 20).

# The right to non-discrimination and equality
- States must ensure that individuals enjoy equal access to the same range, quality and standard of SRH information, goods and services (36,45,52). - States must acknowledge and take measures to address access to safe abortion and post-abortion care for particular groups of individuals, especially those who are marginalized, have limited resources, live in rural areas, and/or are from minorities, as they are more likely to experience intersecting forms of discrimination (3, 36-38, 40, 41, 42 43-47, 49, 54. - States must repeal or reform discriminatory laws, policies and practices that nullify or impair the ability of individuals to access SRH, such as criminalization of abortion and restrictive abortion laws (3, 35-38, 41, 42 55). - States must remove all legal, procedural, practical and social barriers impeding individuals' equal and nondiscriminatory access to SRH, including abortion, and should repeal measures such as third-party authorization requirements (i.e. from husbands, partners, parents or guardians, or health authorities), biased counselling, mandatory waiting periods, and restrictions based on being an unmarried woman (3,(35)(36)(37)(38). - States must take steps to prevent the imposition of forced abortion, in particular on women and girls from marginalized groups (37,40,47,52,56).

# The right to life
- States must ensure that measures designed to regulate access to abortion do not jeopardize the life of the woman, girl or other pregnant person, subject them to physical or mental pain or suffering or discriminate against them, or arbitrarily interfere with their privacy (36). - States must provide effective and confidential access to safe, legal abortion where the life or health of the woman, girl or other pregnant person is at risk, or where carrying a pregnancy to term would cause the pregnant individual substantial pain or suffering, and in cases where the pregnancy is the result of rape or incest or where the pregnancy is not viable (36). - States must take steps to reduce maternal morbidity and mortality, including addressing unsafe abortion, taking into account exacerbated challenges in certain settings (3, 36-38, 40, 43).

# Human right Selected human rights principles and obligations relevant to abortion
The right to privacy - States must respect the right of individuals to make autonomous decisions about their sexual and reproductive health, including whether or not to undergo an abortion (35,36,57). - SRH services including abortion and post-abortion care must be provided in a way that respects fully the woman's, girl's or other pregnant person's privacy and guarantees confidentiality (35,36). - Medical and health-care professionals must not be required or mandated to report cases of women who have undergone abortions (36,37,40,48). - Denial of therapeutic abortion may interfere arbitrarily with the right to privacy (57).
- Third-party authorization requirements may violate the right to privacy (3,36,38).

# The right to be free from torture, cruel, inhuman and degrading treatment and punishment, including the right to physical and mental integrity
- Forced abortion, criminalization of abortion, denial or delay of safe abortion care and/or post-abortion care, and abuse and mistreatment of women and girls seeking SRH information, goods and services are forms of gender-based violence (44,55), which -depending on the circumstances -may amount to torture, cruel, inhuman or degrading treatment (55). - States must ensure that measures regulating abortion do not subject individuals to substantial physical or mental pain or suffering, such as where a pregnancy is the result of rape (36). - State laws and policies must not permit abortions without the free and informed consent of the concerned individual (40,41,48,52,56,58). - States must prevent and prosecute forced abortions conducted by public officials and private actors, including when conducted on women with disabilities or according with coercive family planning laws and policies as well as in the context of a conflict (40,41,48,52,56,58). - States should ensure that individuals seeking a safe legal abortion are not subjected to humiliating and judgemental attitudes leading to the denial or delay of such services in a context of extreme vulnerability for these individuals and where timely health care is essential (35). - Criminalization of abortion may amount to torture, cruel, inhuman or degrading treatment, including the practice of extracting confessions for prosecution purposes from individuals seeking emergency medical care because of illegal abortion in a particular context (55).
The right to decide freely and responsibly on the number, spacing and timing of children and to have the information and means to do so
- States must ensure access to family planning and SRH information and services, including affordable contraceptive methods to enable women and adolescents to make autonomous and informed decisions on their reproductive health (42 49. - States must ensure that women with disabilities can exercise their right to decide on the number and spacing of children (52,59.

# The right to information and education including on sexual and reproductive health
- States must take measures to ensure up-to-date, accurate information on SRH is publicly available and accessible to all individuals, in appropriate languages and formats (3,(50)(51)(52). - States must ensure that educational institutions incorporate unbiased, scientifically accurate, evidence-based, age-appropriate and comprehensive sexuality education into their required curricula (3, para. 63). - States must make accurate, evidence-based abortion information available to individuals on a confidential basis (3. - This information must be presented in a way that can be understood by the person receiving it (3,52).
- The choice by an individual to refuse information when offered must be respected.
- States must ensure that informed consent is provided freely, safeguarded effectively, and based on complete provision of high-quality, accurate and accessible information.

# The right to benefit from scientific progress and its realization
- States must ensure adequate access to essential medicines in an affordable manner (46,49,54).
- States must ensure access to necessary, up-to-date scientific technologies, in particular contraception and medicines for abortion, without discrimination (42,49).
Note: For further information, see Web annex A: Key international human rights standards on abortion. Wording used in this box reflects original language used in the source documents (human rights treaties).

# Chapter 1. Introduction
- Access to abortion must be available when carrying a pregnancy to term would cause the woman substantial pain or suffering. This includes but is not limited to situations where her life and health are at risk, where the pregnancy is the result of rape or incest, or where the pregnancy is not viable (36, para. 8).
Treaty monitoring bodies have also recommended making abortion available in cases of fetal impairment, while putting in place measures to protect against discrimination on the basis of disability in society (60).
- States should not criminalize having an abortion, those who have an abortion, or those who support someone having an abortion (3 36 55 61 62 63.
- States should not require health workers to report women who have had or who are suspected to have had an abortion (40, para. 20).
- States must provide essential primary health care (64, para. 10) (see also section 1.4.1: Universal health coverage and primary health care; section 1.4.4: Commodities; Annex 2: Selected human rights treaties and their treaty monitoring bodies; and also Web annex A: Key international human rights standards on abortion).

# (iv) Accessibility of abortion care
Where it is lawful, abortion must be accessible in practice. This requires both ensuring that health-care facilities, commodities and services are accessible (including sufficient providers; see section 3.3.8 on provider restrictions), and that law and policy on abortion is formulated, interpreted and applied in a way that is compatible with human rights. Thus, where abortion is currently available on the basis of grounds, meaning under specified circumstances, and in anticipation of moving to a system of abortion on request as recommended (see Recommendation 2: Grounds-based approaches, section 2.2.2), those grounds must be defined and interpreted in a way that gives full effect to women's human rights and that aligns with the following WHO definitions:
Health: a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (2).
Mental health: a state of well-being in which every individual realizes their own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to their community (65).
States must take effective steps to prevent third parties (e.g. parent, spouse, health authority) undermining a person's enjoyment of their right to SRH (see section 3.3.2: Third-party authorization) (3, para. 59), and must also ensure that provider refusal is not a barrier to accessing abortion care (see section 3.3.9: Conscientious objection) (3 39.

# (v) Free and informed consent
International human rights law requires that the provision of abortion be based on the free and informed consent of the person having the abortion with no further authorization required.
International human rights law obliges States to ensure that accurate, evidence-based abortion information (3 36 is available to individuals on a confidential basis (36 43), and also that their choice to refuse such information when offered is respected (58, para. 15). Receipt of such information is vital as this underpins the right and the ability to make informed decisions and choices about matters regarding one's body and SRH, and to give informed consent (see also section 1.3.2 below).
As a matter of international human rights law, States are obligated to ensure that "informed consent" is:
- documented in advance of a health-care intervention, and provided without coercion, undue influence or misrepresentation (58, para. 13);
- safeguarded through legislative, political and administrative means (58, para. 7), as a fundamental aspect of a range of human rights (i.e. the rights to health, information, freedom from discrimination, and security and dignity of the person);
- based on provision of complete information about the associated benefits, risks and alternatives;
- based on information that is of high quality, accurate and accessible (including ensuring it is available in a range of formats and languages, and in forms that make it accessible to people with reduced capacity), and presented in a manner acceptable to the person consenting.
Further relevant information is provided in section 3.2 on information provision and counselling related to abortion for individual abortion seekers, and in section 3.5.1 on follow-up care and section 3.5.4 on post-abortion contraception.
States are obliged to protect women from arbitrary interference when they seek SRH services, and to ensure respect for autonomous decision-making by women, including women with disabilities, regarding their SRH and well-being (60).
Even though women have a right to accurate information, some health workers who object to abortion on the basis of conscience either provide deliberately misleading information or refuse to provide any information about abortion (66)(67)(68). States where health workers are allowed to invoke conscientious objection (3, para. 43) must regulate and monitor such refusals of abortion care to ensure that women can access accurate information and appropriate services (refer to section 3.3.9: Conscientious objection).
As a matter of international human rights law, States may not restrict women's access to health services on the ground that they do not have the authorization of husbands, partners, parents/guardians or health authorities, because they are unmarried, or because they are women (39 3. For adolescents, the authorization or consent of parents should not be required before the provision of abortion care (see also section 3.3.2: Third-party authorization). As a general matter, States must recognize children's and adolescents' evolving capacity and their associated ability to take decisions that affect their lives (69,Article 5). In order to ensure protection of adolescents' sexual and reproductive health and rights, the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health has suggested that States should consider introducing "a legal presumption of competence that an adolescent seeking preventive or time-sensitive health goods or services, including for sexual and reproductive health, has the requisite capacity to access such goods and services" (35, para. 60). The United Nations Committee on the Rights of the Child (CRC) has also urged States to "review and consider allowing children to consent to certain medical treatments and interventions without the permission of a parent, caregiver or guardian, such as ... sexual and reproductive health services, including ... safe abortion" (45, para. 31).
People with disabilities have a right to autonomy (59, Article 3a), but face continuing and systemic discrimination in access to SRH services. States are obliged to prohibit and prevent discriminatory denial of SRH services to people with disabilities (70, para. 66). States may not undertake, and must take steps to prevent forced or coerced abortion (40, para. 11), which constitutes torture, cruel, inhuman or degrading treatment (40 52.

# (vi) Post-abortion care
Provision of post-abortion care is a core obligation of States under the right to SRH (3, para. 49e). Regardless of whether abortion is legal or restricted, States are required to ensure access to post-abortion care (45, para. 70). Such care must be available on a confidential basis, without discrimination, and without the threat of criminal prosecution or other punitive measures (36, para. 8). States must also ensure access to a wide range of modern, safe and affordable contraceptive methods (36 49.

# (vii) Accountability for human rights violations
Accountability mechanisms are essential to the protection, respect and fulfilment of sexual and reproductive health and rights. Monitoring and accountability for human rights compliance takes place at national, regional and international levels, as appropriate to the law in question. Monitoring and accountability involve a variety of actors, such as the State itself, civil society organizations, national human rights institutions or international or regional human rights mechanisms. Some such accountability mechanisms include administrative mechanisms for recording and monitoring relevant health outcomes relating to abortion law and policy, and including them in reports to human rights institutions (39, Ch.1, paras 9, 10, 12, 17) (see also section 1.4.5 on monitoring and evaluation of abortion care). States must ensure that all persons have access to justice and to a meaningful and effective remedy where their human rights are violated (39,Ch.1,para. 13). These remedies can include adequate, effective and prompt reparation in the form of restitution, compensation, rehabilitation, satisfaction and guarantees of non-repetition (3, para. 64), including by reform of law and policy. Mindful of the above, an enabling environment for abortion care would ensure that there are appropriate accountability mechanisms for failures to facilitate quality abortion care, including accessible, transparent and effective accountability mechanisms for women to challenge denial of abortion in a timely manner. In addition, an enabling environment would include appropriate remedies for failure to facilitate quality abortion care, including regular review and reform of law and policy to recognize and remove barriers to quality abortion care. As confirmed by the Committee on the Elimination

# Availability and accessibility of information
An essential first step in improving access to and quality of abortion care is ensuring that all individuals can access relevant, accurate and evidence-based health information and counselling if and when desired. This is required by international human rights law -grounded in the right to information and the right to privacy (see Box 1.2) -and facilitates individual decision-making relating to SRH services, including abortion. Two different types of information about abortion must be available: (i) information of a general nature for the public (described below), and (ii) specific information tailored to be relevant to each person seeking abortion (see section 3.2.1) and underpinning free and informed consent, which was described in section 1.3.1(v).
States parties are to ensure that everyone has a right to receive accurate, non-biased and evidence-based information on SRH. Relatedly, as part of their obligation to reduce maternal mortality and morbidity, States must ensure the provision of comprehensive, non-discriminatory, scientifically accurate and age-appropriate education on sexuality and reproduction, including information on abortion, both in and out of schools (46,71 72) and must ensure that comprehensive sexuality education (CSE) is available to minors without the consent of their parents or guardians (45, para. 31). In an enabling environment all persons would be provided with all the necessary information to make an informed decision regarding the use of contraception, including information on where and how to obtain an abortion or contraception, the costs of services, and the specifics of any local laws. The growing use of self-management of abortion (see section 3.6.2) underlines the need to ensure that accurate information about abortion is available to all who may seek it.
As a matter of international human rights law, the provision of information on abortion should not be criminalized, even in contexts where the procedure itself may be illegal (see section 2.2.1: Criminalization of abortion). To ensure that accurate information is broadly accessible, including for those with low literacy, an enabling environment would provide that such information is shared using a variety of formats/media as appropriate for the intended audience (e.g. videos, social media). The United Nations CESCR has confirmed that "he dissemination of misinformation and the imposition of restrictions on the right of individuals to access information about SRH also violates the duty to respect human rights. ... Such restrictions impede access to information and services, and can fuel stigma and discrimination" (3, para. 41).

# Health system factors
Within the health system, multiple actions are needed to realize human rights obligations. Actions to facilitate and strengthen abortion-related service delivery should be based on human rights, local health needs and a thorough understanding of the service-delivery system and the broader social, cultural, political and economic context. National standards and guidelines for abortion care should be evidence based and periodically updated, and should provide the necessary guidance to achieve equal access to comprehensive abortion care. Leadership should also promote evidence-based SRH services according to these standards and guidelines.
The right to the highest attainable standard of physical and mental health includes the right to respectful health care as well as the right to be free from violence and discrimination (73). The right to benefit from scientific progress and its realization entitles women to access to up-to-date scientific technologies necessary for women. This means States must ensure access to modern and safe forms of contraception (including emergency contraception), abortion medicines, assisted reproductive technologies, and other SRH goods and services, on the basis of nondiscrimination and equality (49, para. 33). To achieve a high standard of respectful care, health systems should be organized and managed in a manner that ensures respect for people's SRH and human rights (73). Respectful health care recognizes individuals' rights, respects their agency and autonomy in decision-making, and incorporates their values and preferences into care.
In addition to policy and regulatory barriers, other barriers may further limit the availability of abortion services, including: stigma; formal and informal costs; lack of commodities, services, trained providers and information; and/ or the unwillingness of some health workers to provide care. This leaves particular groups of people -such as those living in rural settings, those facing financial hardship, adolescents, unmarried, transgender or nonbinary individuals, those with less access to education and those living with HIV -disproportionately vulnerable to Abortion stigma is common, and has negative psychological consequences for individuals seeking abortion and health workers providing abortion care (31,74,75), and can also be detrimental to health outcomes. Abortion stigma is a social process, and is dependent upon the context, but may be considered as an exercise of power and control of one group over members of a less powerful group, who are considered different, negatively stereotyped, discriminated against and marginalized within society (75,76). Work is needed across sectors to counteract stigma; health systems should recognize the risks and effects of stigma, and implement solutions to not only ensure privacy and confidentiality, but also to support health workers. Care should always be provided respectfully and with compassion. In an enabling environment, communities are also engaged and supportive.
Those who assist and support abortion seekers -their partners, friends, family members -also require support within the health system and broader environment.
More in-depth consideration of key health system factors is provided in section 1.4 below.

# Health system considerations
The health system refers to all organizations, people and actions whose primary intent is to promote, restore or maintain health (77). The health system consists of the six core building blocks, as listed in Figure 1.2, which support four overall goals and outcomes, as shown below. This section addresses in detail health system considerations relevant to an enabling environment for abortion care. A well functioning health system, with all the "blocks" working in harmony, depends upon having trained and motivated health workers, a well maintained infrastructure and a reliable supply of medicines and technologies, backed by adequate financing, strong health plans and evidence-based policies. Health-care services provided via the health system are not restricted to those provided at a health-care facility; health care and services can also be received through community-based providers (e.g. health visitors, pharmacists), digital interventions or self-care approaches (e.g. telemedicine).

# Universal health coverage and primary health care
Universal health coverage (UHC) means ensuring that all people have access to the promotive, preventive, curative, rehabilitative and palliative health services they need, which must be of sufficient quality to be effective, while also ensuring that the use of these services does not expose any users to financial hardship (30). UHC is integral to the achievement of SDG target 3. essential medicines and vaccines for all. The aim of this target is to accelerate efforts to ensure that all people and communities receive the full spectrum of essential, quality health services they need across the life course, without suffering financial hardship.
To establish an enabling environment, there is a need for abortion care to be integrated into the health system across all levels (including primary, secondary and tertiary) -and supported in the community -to allow for expansion of health worker roles, including self-management approaches. Such integration is a complex process that can occur through service delivery, financing mechanisms and/or inclusion in health benefits packages. While inclusion in health benefits packages may enhance access to and delivery of abortion care, in many countries abortion care is not explicitly recognized in the standard package, contributing to inequitable access to services (78).
From a health financing perspective, improving access to comprehensive abortion care, as part of UHC, requires shifting the burden of financing away from individuals towards domestic public funding, which combines tax revenue and prepayment schemes to cover the costs of care (78). Further information is provided in section 1.4.2 below. Meanwhile, from a service-delivery perspective, integrating abortion care within national maternal care and family planning programmes is technically the most straightforward option as abortion services require few, if any, additional provider skills, medicines, equipment or supplies. Furthermore, it is the most efficient option, as it minimizes any additional/marginal costs of implementing abortion services.
Health systems strengthening, by improving performance across all six health system building blocks (see above), is essential to progress towards UHC (77). The use of new and innovative technologies and approaches for providing, facilitating or supporting abortion services must be incorporated into country programmes and health benefits packages. WHO's UHC Compendium provides a list of all interventions related to abortion care to be considered for inclusion within a country's UHC package (79). 3 To ensure both access to abortion and achievement of UHC, abortion must be centred within primary health care (PHC), which itself is fully integrated within the health system, facilitating referral pathways for higher-level care when needed. PHC is a multisectoral, societal approach to health that aims to ensure the highest possible level of health and well-being for all individuals, by focusing on people's needs and preferences (as individuals, families and communities) along the continuum of care from health promotion and disease prevention to treatment, rehabilitation and palliative care (30). Quality PHC is evidence-informed, community-delivered and personcentred. Making abortion available and accessible within PHC is a safe and effective strategy to advance equitable access to, and provide an enabling environment for, abortion.

# Health financing
Health financing is a core function of health systems that can enable progress towards UHC by improving effective service coverage and financial protection. To improve effective service coverage, health financing arrangements for abortion services should ensure the production costs are met so that health-care providers have the means to carry out these activities without financial constraints. To improve financial protection, the health system must guarantee that the share of the costs -production costs and the costs of access to services -borne by patients is not a barrier to full use of services. WHO's approach to health financing focuses on the following core functions:
- raising revenue -establishing sources of funds, including government budgets, compulsory or voluntary prepaid insurance schemes, direct out-of-pocket payments by users, and external aid;
- pooling funds -the accumulation of prepaid funds on behalf of some or all of the population; and
- purchasing services -the payment or allocation of resources to health-care providers.
In addition, all countries have policies indicating which services the population is entitled to, even if not explicitly stated by the government, and by extension any services not covered are usually paid for out of pocket by patients as user fees or co-payments.
To provide an enabling environment, financing of abortion services should take into account costs to the health system while ensuring that services are free or affordable and readily available to all who need them, in support of the goal of achieving UHC. A recent scoping review captured the costs to the health system and to the woman by categorizing the economic consequences of abortion and abortion policies through three levels: micro-, meso-and macroeconomic. Assessment of the micro-, meso-and macroeconomic levels provided insight into the documented economic consequences of abortions at the individual, community and health system levels (80)(81)(82).

# Cost to the facility or health system
In regard to costs to the health-care facility and health system, the findings of the review on the mesoeconomic outcomes confirmed that limited resources negatively affect facilities' ability to meet demand and provide quality services (81). Furthermore, the costs of post-abortion care, including treatment of post-abortion complications, consume a disproportionate amount of facilities' resources in many settings, posing a burden to health systems by further depleting their overstretched resources. Therefore, financial savings can be made by maintaining or even improving the quality of abortion care services, and also by decentralizing services and legalizing abortion, as indicated in the macroeconomic assessment (82).
Providing access to quality abortion care is considerably less costly than treating the complications of unsafe abortion (83)(84)(85)(86)(87). Costs for providing abortion care with vacuum aspiration include infrequent, modest capital investments, such as purchase of a suction machine for electric vacuum aspiration (EVA) or manual vacuum aspiration (MVA) equipment, an examination table, a steam sterilizer or autoclave, and possibly also renovation of waiting, consultation and recovery rooms, and toilets. Recurrent costs for surgical or medical abortion include those associated with purchasing instruments and supplies that will need to be restocked regularly, such as cannulae and MVA aspirators, antiseptic solutions and high-level disinfectants used for instrument processing, and medicines for pain management, infection prevention and medical abortion.
Decisions about which abortion methods to offer and how to organize services directly influence the cost of providing services and their affordability. Two organizational issues are of particular importance for both increasing safety and reducing costs: (i) preferential use of either vacuum aspiration or medical abortion, and (ii) facilitating the provision of abortion (e.g. improved access to abortion services, integration into primary health care). Expanding the role of health workers in abortion provision and exploring innovative modes of servicedelivery, such as telemedicine and hotlines, have also been identified as cost-saving strategies for national health systems (82).

# Making services affordable for women
In countries where legal access to abortion is available, it remains a challenge to provide abortion services that are publicly funded and free at the point of care (88). Furthermore, in some settings, financial protection is restricted to specific demographic groups of individuals seeking abortion or certain legal categories of abortion. Abortion seekers may be charged substantial additional fees (on top of the official charges), creating a barrier for many, especially when combined with travel expenses and opportunity costs, such as time lost from paid and unpaid work. In some settings, reimbursement rates for private or public providers working with nongovernmental organizations are well below the cost of providing care. The barrier of high costs of abortion medicines and/or services is likely to generate higher costs for the health system, since these costs force many -especially among the adolescent population (89) -to present at a later gestational age or to use unsafe providers or methods, thus increasing the rates of hospitalization for serious complications (80,(90)(91)(92). Higher rates of complications, additional fees and high costs all also contribute to the stigmatization of abortion.
Respect, protection and fulfilment of the right to health requires States to guarantee, at a minimum, universal and equitable access to affordable, acceptable and quality SRH services, goods and facilities, in particular for women and disadvantaged and marginalized groups (3, para. 49). Thus, in order to provide an enabling environment for abortion care, ability to pay should not have any bearing on women's ability to access legal abortion services (3 35 39.
As part of an enabling environment, considerations of gender equality, human rights and equity should guide the design of health financing policy to reduce if not eliminate the financial barriers for the most vulnerable, and to ensure equitable access to good-quality services (93). The CEDAW Committee has described fees for abortion as being burdensome to women's informed choice and autonomy (94, para. 37). Where user fees are charged for abortion, this should be based on careful consideration of ability to pay, and fee waivers should be available for those who are facing financial hardship and adolescent abortion seekers. It should be noted, however, that evidence on the success of fee waivers in addressing financial barriers and improving access to quality Chapter 1. Introduction abortion care is mixed and inconclusive (95). Numerous treaty monitoring bodies (see Annex 2) have recognized that abortion services must be economically accessible, recommending that States lower the cost of abortion or otherwise provide financial support when needed (96 97 98.
Relatedly, the Committee against Torture (CAT) has called on States to ensure free access to abortion in cases of rape (99, para. 15a). With the above in mind, as far as possible, abortion services and supplies should be mandated for coverage under insurance plans as inability to pay is not an acceptable reason to deny or delay abortion care. Furthermore, having transparent procedures in all health-care facilities can ensure that informal charges are not imposed by staff.

# Health workforce competencies and training
Health workers are all people engaged in actions whose primary intent is to enhance health (100). The delivery of high-quality care requires an adequate supply of competent health workers, who are equitably distributed, and with an optimal skills mix at the facility, outreach and community levels (101). All health workers need to be adequately supported to provide competent care. The competencies required to provide or support abortion care align with competencies required in many different areas of health (102,103). WHO is currently developing a global competency framework for universal health coverage (UHC), which identifies the required competencies for primary health care workers to provide the full spectrum of promotive, preventive, diagnostic, curative and palliative care (104,105).
Delivery of care and treatment services should be accomplished in a people-centred, non-judgemental and nondirective way, allowing individuals to lead the decision-making about their own care in an informed and supported fashion (106). As part of ensuring an enabling environment, it is particularly important that training for health workers involved with SRH services incorporates:
- the unique competencies required for SRH services, in particular for abortion care;
- provision of people-centred care;
- human rights, and the content and meaning of the law, and how to interpret and apply law and policy in rights-compliant ways;
- communication to enable informed decision-making;
- values clarification;
- interprofessional teamworking; and
- empathetic and compassionate approaches to care (105).
These skills should be included in training programmes and promoted by professional societies. It is especially critical that the attitudes and behaviours of health workers be inclusive, non-judgemental and non-stigmatizing, and that they promote safety and equality. Managers of health care -whether in the public or private sectorare responsible for delivering services appropriately and meeting standards based on professional ethics and internationally agreed human rights principles.
Provision of primary health care includes access to safe, effective, quality-assured and affordable medicines, including medicines for abortion and post-abortion care (i.e. antibiotics and pain control medicines as well as abortion medicines and post-abortion contraceptives).
The WHO Model List of Essential Medicines (also known as the Essential Medicines List, or EML) includes the minimum medicines needed for a basic health-care system, listing the most efficacious, safe and cost-effective medicines for priority conditions. Priority conditions are selected based on current and estimated future public health relevance, and potential for safe and cost-effective treatment. Both mifepristone and misoprostol have been included in the WHO Model Lists of Essential Medicines since 2005. In 2019, these medicines were moved from the complementary to the core list of essential medicines in the 21st EML and the requirement for "close medical supervision" for their use was removed (107). The relevant abortion medicines included in the 21st EML and also the more recent 22nd EML are indicated in

# Induced abortion
- Mifepristone (200 mg) and misoprostol (200 g)
- The medicines are available individually or co-packaged.
- The EML specifically mentions the following co-packaged formulation: 1 tablet mifepristone (200 mg) + 4 tablets misoprostol (200 g).

# Management of incomplete abortion and miscarriage - Misoprostol (200 g)
Source: WHO EML -21st list, 2019 (107), 22nd list, 2021 (108).
Within a country, the key elements of a commodity strategy include policy, regulation, procurement and supply chain, as well as links to financing and reimbursement systems (109).
Mifepristone and misoprostol should be listed in relevant national EMLs (NEMLs) or their equivalent, and should be included in the relevant clinical care/service delivery guidelines. In the case of pregnancy tests and MVA equipment, countries may have an Essential Medical Devices List or a similar list for medical devices. Pregnancy tests and quality MVA devices should be included on these lists as part of a commodity strategy.
Inclusion in the NEML is one important component of ensuring that quality medicines are available. Misoprostol, mifepristone, surgical abortion equipment and other relevant health products should be included in national procurement tenders as well as in supply chain monitoring activities. Procurement activities should include forecasting methods that are appropriate to the products and to the country context with a goal of ensuring continuous supply (110). Central Medical Stores (CMS) entities should ensure that specifications for the procurement of safe abortion medicines are coordinated with national medicines regulatory authorities (NMRAs) and that they clearly specify quality assurance standards and all other requirements, such as strength, packaging and shelf life.
WHO recommends that the highest level of quality assurance be pursued but recognizes that risk-based approaches may be needed in countries where access to international markets is limited. Risk-based approaches will depend on the context of a given country but may include exceptions based on prior information about a manufacturer, or reliance on information from other regulators (111). Quality-assured medicines include those approved by stringent regulatory authorities (SRAs) (112) 4 or listed through WHO Prequalification (PQ). 5 Where such medicines are not available, approval by an NMRA that includes inspection and testing according to accepted standards should be undertaken for mifepristone and misoprostol. 6 NMRAs are the bodies that provide registration and market authorization for specific products. The NMRA reviews the safety, efficacy and quality of medicines as part of granting market authorization. Such authorization is specific to each medicine made in a particular location by a particular manufacturer. Market authorizations are granted based on an evaluation of a technical dossier presented by the manufacturer, or their agent, confirming the efficacy, quality and safety of the product. Through prequalification, WHO supports a regulatory reliance mechanism where it provides detailed assessment information to NMRAs on products that have been prequalified by WHO, so that the regulatory decision can be made based on WHO's assessment rather than having to duplicate it. Based on the same principle, WHO also supports the sharing of assessment information for SRA-approved products. These processes are both known as WHO Collaborative Registration Procedures (CRPs). 7 Regulators make determinations regarding the authority to prescribe and dispense medicines. There are examples, including emergency contraception, where regulators have made decisions to change the prescribing authority to improve access and appropriate use, including "over the counter" sales or prescription by a pharmacist without physician consultation. The information that is typically considered includes whether a condition can be reasonably self-diagnosed, the overall safety of the medicine, and the likelihood of misuse 4 SRAs are listed at this web page: . In the cited reference (pp. 34-35), SRAs are defined as "a regulatory authority which is a member or an observer of ICH or is associated with an ICH member through a legally-binding mutual recognition agreement" (as before 23 October 2015). 5 WHO Prequalification is one standard for all types of products, including medicines (pharmaceuticals and biotherapeutics), vaccines and immunization devices, in vitro diagnostics and vector control products. This listing implies a recommendation but not market authorization. 6 For further information, refer to The International Pharmacopoeia, available at: #p/home 7 For further information, see:  Chapter 1. Introduction or complications with less supervised or unsupervised use of the medicine, among others (113,114). National programmes should work with regulators to determine the most appropriate evidence-based prescribing and dispensing authorities for the medicines. Restrictions on prescribing authority for some categories of health workers may need to be modified or other mechanisms put in place to make the medicines available for these health workers within the regulatory framework of the health system.
A comprehensive commodity strategy and effective approach to access will require: inclusion of the necessary commodities in the NEML; approval from the NMRA (i.e. market authorization or registration); development of mechanisms for forecasting, procurement, distribution and guidance on prescribing and dispensing; and a plan for post-marketing surveillance.

# Monitoring and evaluation of quality abortion care
Effective monitoring and evaluation (M&E) are essential for measuring abortion quality and trends, as a basis for policy dialogue and evidence-based decision-making to further improve service delivery and quality. To support national scale M&E of the quality of abortion care, WHO is developing a quality abortion care M&E framework based on WHO's Monitoring and evaluation of health systems strengthening: an operational framework (115). The structure, domains and indicator areas of the framework, categories for inequality disaggregation and standard data sources are presented in Table 1.2. A set of abortion care indicators is under development and will be published in the near future (see Annex 6 for a summary about the progress of this M&E work).
The quality abortion care M&E framework will support M&E at the levels of health system input, service delivery, population outcome and impact. M&E of abortion-related services remains weak in most national health systems. Specific gaps in data collection and use must be identified and addressed.
Health system input monitoring covers governance, health financing, health workforce, health commodities and health information. Within these five categories, quality abortion care health system inputs to track over time include among others: - Health commodities: inclusion in national essential medicines lists (NEMLs) of mifepristone and misoprostol, monitoring of stock-outs of abortion service commodities at service-delivery points (see section 1.4.4);
- Health management information systems (HMIS): integration of indicators for quality abortion care into the national HMIS.
For this level of input monitoring, data are typically available from administrative sources, including national policy documents, health finance tracking systems, national curricula, logistics management information systems (LMIS) and HMIS.
Service-delivery monitoring tracks the availability of providers trained in and providing induced abortion care, availability of necessary medicines and products at service-delivery points, readiness of the system to provide abortion care to a defined minimum standard, and quality of service delivery, including person-centred care, assessed in part through user and community perspectives. National-level abortion service-delivery monitoring data should be included in health-care facility-level assessments, HMIS and population-based surveys.
Population outcome monitoring for abortion care assesses coverage including (i) access to quality, affordable abortion care, and (ii) population knowledge of access to quality, affordable abortion care. Efforts should be made to disaggregate data by dimensions of inequality, such as ability, age, caste, education, ethnicity, gender, geography and wealth. Population outcome data sources typically include health-care facility-level assessments and population-based surveys and can include HMIS and education management information systems. In many settings, abortion-related population outcome data is a neglected area of data collection and reporting.
Impact measurement for quality abortion care includes abortion-related mortality and morbidity. Estimates in these areas should be disaggregated by dimensions of inequality as much as possible. Data sources include population-based surveys, HMIS and civil registration and vital statistics (CRVS) registries.
Where gaps in data availability are identified, investment should be made to address these. In the short term, statistical modelling may be required to estimate indicator values, particularly at the impact level. Chapter 2.

# Abortion regulation including relevant recommendations
As outlined in Chapter 1, section 1.3, one element of an enabling environment is that law and policy promote and protect sexual and reproductive health and rights (SRHR). A number of common approaches to law and policy on abortion mentioned in Chapter 1 (section 1.3.1) pose barriers to access to abortion, are inconsistent with international human rights legal instruments, and can have negative effects on the exercise of human rights. This chapter reflects evidence on the impacts of these law and policy approaches, considers their human rights implications, and presents evidence-based recommendations to improve law and policy relating to abortion as part of an enabling environment for universal access to quality abortion care. Box 2.1 summarizes the principles of abortion law and policy that would be consistent with key principles of human rights law.
BOX 2.1: Abortion law and policy that are consistent with key principles of human rights law
States must respect, protect and fulfil abortion seekers' rights, including their sexual and reproductive health and rights (SRHR).
States should take positive steps to secure an enabling regulatory and policy environment that will ensure the universal availability, accessibility, acceptability and quality (AAAQ) of abortion and post-abortion care.
Abortion should be fully decriminalized. Regulatory, policy and programmatic barriers -as well as barriers in practice -that hinder access to and timely provision of quality abortion care should be removed. These include grounds-based approaches, gestational age limits, mandatory waiting periods, third-party authorization requirements and provider restrictions. States should also protect access to and continuity of abortion care against barriers created by conscientious objection (refer to Recommendations 1,2,3,6,7,21 and 22 in this guidance).
The regulation of abortion should have the objective of respecting, protecting and fulfilling the SRHR of women; achieving positive health outcomes for women; providing good-quality contraceptive information and services; and meeting the particular needs of marginalized persons, including women facing financial hardship, adolescents, women with disabilities, survivors of sexual and gender-based violence, transgender and non-binary persons, women from ethnic, religious and racial minorities, migrant and displaced women, and women living with HIV, among others. The regulation of abortion should be grounded on and should promote equality and nondiscrimination.
Source: Refer to Box 1.2 for references.

# Chapter 2. Abortion regulation including relevant recommendations

# Common approaches to abortion regulation
Almost all countries where abortion is lawfully available regulate abortion differently to other forms of health care (116). Unlike other essential health services, abortion is commonly regulated to varying degrees through the criminal law in addition to regulation under health-care law. Even where abortion is available on certain grounds or until specified gestational ages (often linked to particular grounds), it is usually designated in those cases as a criminal offence if it occurs outside of those specific permitted situations. As a result, people can experience significant barriers in accessing abortion and post-abortion care in such contexts. These barriers persist even though abortion is a safe, effective and non-complex part of sexual and reproductive health (SRH) care, in spite of significant advancements in international human rights law, and notwithstanding the growing frequency with which self-management of abortion occurs safely with little or no contact with the formal health system.
Typical barriers to access to quality abortion care, which may or may not be codified in law, include lack of access to accurate information, the provision of biased information or counselling, the imposition of mandatory waiting periods, third-party authorization requirements, restrictions on the type of facilities or settings where abortion services can lawfully be provided, restrictions on the type of health workers that can lawfully provide services, lack of affordable services, breaches of confidentiality and privacy, failure to safeguard access to and continuity of care where health workers refuse care on the basis of conscientious objection, failure to license or make available essential medicines, and failure to recognize women as individuals who can manage their own abortions.
Restrictive laws, policies and practices often have the effect of making health workers, health-care facilities, committees, ethics boards, police, courts or others the "gatekeepers" for access to quality abortion care by requiring them to determine whether someone "qualifies" for legal abortion. In many cases, this introduces delay in accessing abortion. Such gatekeepers are not always sufficiently informed about the law or willing to interpret and apply law and policy in a way that respects, protects and fulfils abortion seekers' rights. Criminalization of abortion can also have a "chilling effect" more broadly, as it can result in narrow interpretation of applicable law by health workers, including to avoid possible criminal liability (i.e. suppression of actions due to fear of reprisals or penalties). As a consequence, in many settings women's experiences of seeking, accessing and managing abortion are highly variable, with much depending not only on the law but also on the approach of the gatekeeper with whom they interact. Thus, including information on relevant rights, laws and policies in the training and education of health workers is a crucial part of ensuring an enabling environment for quality abortion care (see also Chapter 1, section 1.4.3).
As described above, clear, accessible and rights-based laws and policies are part of an enabling environment for abortion care (see section 1.3). However, in some countries the law on abortion is incoherent, with seemingly conflicting provisions articulated in constitutions, penal codes, health legislation or policy guidance (117). Furthermore, in some cases domestic laws are inconsistent with international human rights standards and incompatible with current public health evidence. Additionally, in certain cases there is a lack of guidance from government to assist providers in identifying when abortion is lawful. Such incoherence can create uncertainty about the law for both those seeking and providing abortion care. The recommendations in this guideline build on human rights law and public health evidence to outline an approach under which abortion is regulated similarly to other health-care interventions, that is, by general health-care law and policy, best practice, training and evidence-based guidelines.

# Recommendations relating to regulation of abortion
Three recommendations relating specifically to the regulation of abortion are presented in this section (Recommendations 1-3) and four additional recommendations, also relating to law and policy and abortion, are presented in Chapter 3, section 3.3: Pre-abortion (Recommendations 6,7,21 and 22). These seven recommendations were formulated by the expert panels formed for the development of this guideline, including expert human rights advisers (all contributors are listed in Annex 1 and the roles of the contributing groups are described in Annex 4). 8 The evidence was first systematically reviewed for each prioritized topic and question, and the level of certainty of that evidence was assessed (i.e. based on the quality of the evidence, including the types and sizes of studies conducted and their various limitations).
The direction (in favour or against) and strength of each recommendation was determined by the panel of experts based on the six substantive criteria of the WHO-INTEGRATE framework as applied to each intervention for the specified population -balance of health benefits and harms; human rights and sociocultural acceptability; health equity, non-discrimination and equality; societal implications; financial and economic considerations; feasibility and health system considerations -while also taking into account the meta-criterion: quality of evidence (118).
Recommendations in favour of an intervention are qualified as either strong or weak (with the conditions of use specified for the latter), with the third alternative being a recommendation against the intervention. To clearly indicate the strength and direction of each recommendation, the following wording is used:
- Recommend -a strong recommendation in favour of the intervention
- Suggest -a weak recommendation in favour of the intervention (requiring additional wording to qualify the recommendation, specifying the conditions of use)
- Recommend against -a strong recommendation against the intervention/in favour of the comparison.
For each topic covered, both in this chapter and also in Chapter 3, first brief background information is presented, then the recommendation itself, followed next by a list of remarks (if any) from the expert panel that reviewed the evidence in detail, explaining the conditions and context relevant to the recommendation, and then the rationale, or summary of the evidence base and decision-making process for the recommendation, and finally a box listing any key human rights considerations relevant to the recommendation or broader topic. It should be noted that the 2012 Safe abortion guidance provided a composite recommendation related to law and policy; in this guideline, this has been developed into seven separate recommendations using GRADE methodology, but they are not considered to be "new" (i.e. Recommendations 1,2,3,6,7,21,22). The methods are described in full in Annex 4, including the differences in the methods applied for the seven recommendations relating to law and policy issues compared with the other types of recommendations. A summary table linking the topics covered, the research questions, the systematic reviews conducted and the recommendation numbers is provided in Annex 7. The full Evidenceto-Decision (EtD) frameworks are provided online as supplementary material and hyperlinked cross-references to these are supplied with the rationale for new and updated recommendation presented. 9

# Criminalization of abortion
Unlike other health services, abortion is commonly regulated to varying degrees through the criminal law (i.e. criminalized), in addition to regulation under health-care law.
Abortion remains a criminal offence in most countries, with penalties against those who have abortions and/or those who provide abortion services or assist with accessing or managing abortion, sometimes including those who provide information about abortion. In some countries, all of these actions are criminal offences.
Decriminalization is a necessary step for the legalization of abortion, but ensuring that abortion is available, accessible and of high quality may require further legal or regulatory changes beyond decriminalization, including, as applicable, implementing the other recommendations contained in this guideline.

# LAW & POLICY Recommendation 1: Criminalization
Recommend the full decriminalization of abortion.
- Decriminalization means removing abortion from all penal/criminal laws, not applying other criminal offences (e.g. murder, manslaughter) to abortion, and ensuring there are no criminal penalties for having, assisting with, providing information about, or providing abortion, for all relevant actors.
- Decriminalization would ensure that anyone who has experienced pregnancy loss does not come under suspicion of illegal abortion when they seek care.
- Decriminalization of abortion does not make women, girls or other pregnant persons vulnerable to forced or coerced abortion. Forced or coerced abortion would constitute serious assault as these are nonconsensual interventions.
Note on updating of the recommendation: This and other law and policy recommendations are not new recommendations. WHO's 2012 Safe abortion guidance provided a composite recommendation related to law and policy (19); in this guideline, this has been developed into seven separate recommendations using GRADE methodology.
Numerous human rights bodies and mandate holders, including the CEDAW Committee (38), the CESCR (3), the United Nations Human Rights Committee (36), and the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (37), support the full decriminalization of abortion. They have clarified that States should not criminalize medical procedures needed only by women, including abortion nor criminalize those who have undergone an abortion, or punish or apply criminal sanctions against those who assist women in having abortions. Under international human rights law, States must not require health workers to report cases of women or girls who have had abortions, or whom they suspect of having had abortions, and States must provide post-abortion care in all circumstances and without the risk of criminal sanction. In addition, States must take steps, including revising laws, to reduce maternal morbidity and mortality (including abortion-related morbidity and mortality), and to effectively protect women and girls from the physical and mental risks associated with resorting to unsafe abortion due to the criminalization of abortion (see also Chapter 1, section 1.3.1 on human rights, and Web annex A: Key international human rights standards on abortion, which provides further information as well as references for the above assertions).
In order to identify the impacts of criminalization of abortion on abortion seekers and health workers, a systematic review of studies published between 2010 and 2019 was undertaken, identifying 22 studies conducted in Australia, Brazil, Chile, El Salvador, Ethiopia, Ireland, Mexico, Northern Ireland (United Kingdom), the Philippines, Rwanda, Senegal, the United Republic of Tanzania, Uruguay and Zambia. A summary of the evidence from these studies is presented in Supplementary material 1, EtD framework for Criminalization. The evidence from these studies demonstrated that criminalization delayed access to abortion, including in some cases causing providers to wait until a woman's life was in danger so that abortion could be provided within the legal exceptions to criminal prohibitions. Furthermore, criminalization imposes a range of burdens on women including unnecessary travel and cost, delayed or no access to post-abortion care, distress and stigma. The evidence indicated that criminalization did not impact the decision to have an abortion, prevent women having abortions, or prevent women from seeking information on and referral to services abroad where they can access abortion. Instead, criminalization limits access to safe and legal abortion, and increases recourse to unlawful and unsafe abortion. When prosecutions take place they may be disproportionately pursued against young, unmarried women and those facing financial hardship and with less access to education. Some countries require health workers to report women and girls when they seek abortion or post-abortion care.
Criminalization can cause health workers to act cautiously, fearing criminal prosecution. As a result, they may be hesitant to provide abortion care even in cases of rape, incest and fatal fetal impairment, when denial of abortion could constitute torture, cruel and inhuman treatment or punishment.
Criminalization contributes to the lower availability of trained abortion providers and a loss of relevant skills in the health workforce. This can have negative effects on health workers who do provide abortion, and can increase bureaucracy within health systems.

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO CRIMINALIZATION OF ABORTION
- Availability, accessibility, acceptability and quality must be central to the regulation of sexual and reproductive health (SRH) services.
- Seeking, having, assisting with, or providing abortion to which the pregnant person has provided free and informed consent should never be criminalized.
- States must not require health workers to report cases of women or girls who have had abortions, or whom they suspect of having had abortions.
- Post-abortion care must always be available without the risk of criminal sanction.
- Seeking or providing accurate, evidence-based and non-biased information on abortion must never be criminalized.
- States must take steps, including revising laws, to reduce maternal morbidity and mortality, and to effectively protect women and girls from the physical and mental risks associated with resorting to unsafe abortion.
- Everyone has a right to non-discrimination and equality in accessing SRH services.
- SRH services must be provided in a way that ensures privacy and confidentiality.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Chapter 2. Abortion regulation including relevant recommendations

# Grounds-based approaches to controlling access to abortion
National laws in most countries permit some abortions, even in settings where abortion is criminalized. Usually abortions will still be permitted under prescribed "grounds", or specific circumstances. The circumstances under which abortion is permitted vary widely across different countries. Some of these circumstances reflect clinical indications (e.g. risk to the health of the pregnant woman or fetal impairment), some relate to the circumstances of conception (e.g. rape), and some relate to socioeconomic circumstances (e.g. economic hardship). Groundsbased approaches are commonly accompanied by gestational age limits, often varying depending on the specific condition under which abortion is permitted. In some countries, abortion is available on request up to a specified gestational age and then limited to specific grounds thereafter.
LAW & POLICY Recommendation 2: Grounds-based approaches a. Recommend against laws and other regulations that restrict abortion by grounds.
b. Recommend that abortion be available on the request of the woman, girl or other pregnant person.
- Grounds-based approaches to restricting access to abortion should be revised in favour of making abortion available on the request of the woman, girl or other pregnant person.
- Until they are replaced with abortion on request, any existing grounds should be formulated and applied in a manner consistent with international human rights law. This means that the content, interpretation and application of grounds-based law and policy should be revised to ensure human rights compliance. This requires that:
i. existing grounds are defined, interpreted and applied in a human rights-compliant way;
ii. abortion is available when carrying a pregnancy to term would cause the woman, girl or other pregnant person substantial pain or suffering, including but not limited to situations where the pregnancy is the result of rape or incest or the pregnancy is not viable;
iii. abortion is available where the life and health of the woman, girl or other pregnant person is at risk; iv. health grounds reflect WHO's definitions of health and mental health (see Glossary); and v. there are no procedural requirements to "prove" or "establish" satisfaction of grounds, such as requiring judicial orders or police reports in cases of rape or sexual assault (for sources to support this information, refer to Web annex A: Key international human rights standards on abortion).
Note on updating of the recommendation: This and other law and policy recommendations are not new recommendations. WHO's 2012 Safe abortion guidance provided a composite recommendation related to law and policy (19); in this guideline, this has been developed into seven separate recommendations using GRADE methodology.
International human rights law requires that abortion be available where carrying a pregnancy to term would cause a woman substantial pain or suffering, or where her life or health is at risk. States may not regulate abortion in a manner that forces women to resort to unsafe abortion and must take steps, including revising laws, to reduce maternal morbidity and mortality, and to effectively protect women and girls from the physical and mental risks associated with unsafe abortion (for further information, please refer to Chapter 1, section 1.3.1 and Web annex A: Key international human rights standards on abortion). Grounds-based approaches are often (i) too narrowly defined or (ii) too conservatively applied to ensure abortion is available in these circumstances. The aim to reduce maternal morbidity and mortality, and protect women and girls from the risks associated with unsafe abortion, can be effectively achieved by making abortion available on the request of the pregnant woman or girl.
In order to identify the impacts of grounds-based approaches on abortion seekers and health workers, a systematic review of studies published between 2010 and 2021 was undertaken, identifying 21 studies conducted in Argentina, Australia, Brazil, Chile, Colombia, Ethiopia, Ghana, the Islamic Republic of Iran, Ireland, Israel, Mexico, Rwanda, Thailand, the United Republic of Tanzania, the United Kingdom of Great Britain and Northern Ireland, Uruguay and Zambia. A summary of the evidence from these studies is presented in Supplementary material 1, EtD framework for Grounds-based approaches. The reviewed evidence showed that grounds-based laws contributed to delayed abortion, with delays occurring because of inconsistencies in interpretation or application of health grounds, women waiting for determination of their eligibility for abortion or having their claim that pregnancy resulted from rape questioned or disbelieved, overly restrictive interpretation of grounds, or disagreement within a medical team about whether a woman satisfies a legal ground. Misinterpretation of the law can also result in denial of abortion. In some cases, health workers waited for a health condition to deteriorate sufficiently to ensure that a woman satisfied a "risk to life" ground, clearly endangering the right to life and potentially violating the right to be free from torture, cruel, inhuman and degrading treatment.
Interpretation of grounds, and thus eligibility for lawful abortion, varies between providers, and providers are not always certain about the law or how it should be applied; interpretation is often narrow and incompatible with human rights law and/or with WHO's definitions of health and mental health, leading to denial of abortion. Women reported significant challenges in accessing care in circumstances where they could not obtain legal support and advice on the permitted grounds. Grounds-based approaches were found to have a particularly negative impact on women facing financial hardship and women with lower educational attainment.
The evidence reviewed for this guidance showed that grounds-based approaches have a disproportionate negative impact on women who seek abortion following rape. These women were often subjected to questioning, protracted delay and bureaucratic processes due to requirements such as reporting the crime to the police or need for a court order, even though it is not human rights compliant to make such reporting or processes a prerequisite for accessing abortion. Even where the law provides that a woman's claim of rape is sufficient to satisfy the legal requirement, providers may require a document or authorization (e.g. court order or police report). In reality this means that obtaining an abortion following rape is laborious and time-consuming. In some cases, delays are so long that women give birth before legal eligibility is determined; in others, women choose instead to resort to unsafe abortion. Thus, "rape grounds" do not satisfy the requirement from international human rights law that abortion be available and accessible in situations of rape. These restrictions also subject the individual to unnecessary trauma, may put them at increased risk from the perpetrator, and may cause women to resort to unsafe abortion.
The evidence also showed that grounds-based approaches that require fetal impairments to be fatal for abortion to be lawful frustrate providers who wish to support patients and leave women no choice but to continue with pregnancy. Being required to continue with a pregnancy that causes significant distress violates numerous human rights. States are obligated to revise these laws to make them compatible with international human rights law.
Under international human rights law, States are required to ensure that women do not have to resort to unsafe abortion. The evidence from the studies described above suggests that grounds-based laws may contribute to an increase in the incidence of unsafe abortion, with people who do not satisfy a ground resorting to unlawful abortion, including unlawful self-management of abortion, some of which may be unsafe. The evidence from the studies also indirectly suggests that grounds-based laws contribute to maternal mortality, because when States shift from a grounds-based approach to permitting abortion on request in the first trimester there is a reduction in maternal mortality (especially for adolescents) as well as a reduction in fertility (birth rates). This suggests a connection between the international obligation to take steps to reduce maternal mortality and morbidity and a shift away from groundsbased approaches.

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO GROUNDS-BASED APPROACHES
- Availability, accessibility, acceptability and quality must be central to the regulation of sexual and reproductive health (SRH) services.
- Abortion must be available where carrying a pregnancy to full term would cause a woman substantial pain or suffering, where pregnancy is a result of rape or incest, or where her life or health is at risk.
- States may not regulate abortion in a manner that forces women to resort to unsafe abortion.
- States must take steps, including revising laws, to reduce maternal morbidity and mortality, and to effectively protect women and girls from the physical and mental risks associated with resorting to unsafe abortion.
- Everyone has a right to non-discrimination and equality in accessing SRH services.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Chapter 2. Abortion regulation including relevant recommendations

# Gestational age limits
Gestational age limits are commonly specified in both liberal and restrictive abortion laws and policies. Imposed through formal law, institutional policy or personal practice by individual health workers, these limits restrict when lawful abortion may be accessed by reference to the gestational age of a pregnancy. In many countries gestational age limits are linked to grounds-based approaches, with gestational age limits varying according to the grounds or circumstances under which abortion is permitted. While methods of abortion may vary by gestational age (see Chapter 3, section 3.4), pregnancy can safely be ended regardless of gestational age. Gestational age limits are not evidence-based; they restrict when lawful abortion may be provided by any method.
International human rights law requires that quality of care be central to the provision and regulation of SRH, and thus that regulation of abortion is evidence-based, scientifically and medically appropriate, and up to date (3, para. 21). Under international human rights law, States may not regulate pregnancy or abortion in a manner that is contrary to their duty to ensure that women and girls do not have to resort to unsafe abortion, and are required to revise their laws accordingly (see Web annex A: Key international human rights standards on abortion).

# LAW & POLICY Recommendation 3: Gestational age limits
Recommend against laws and other regulations that prohibit abortion based on gestational age limits.
Note on updating of the recommendation: This and other law and policy recommendations are not new recommendations. WHO's 2012 Safe abortion guidance provided a composite recommendation related to law and policy (19); in this guideline, this has been developed into seven separate recommendations using GRADE methodology.
In order to identify the impacts of gestational age limits on abortion seekers and health workers, a systematic review of studies published between 2010 and 2020 was undertaken, identifying 21 studies conducted in Australia, Belgium, Mexico, Nepal, South Africa, the United Kingdom and the United States of America (USA). A summary of the evidence from these studies is presented in Supplementary material 1, EtD framework for Gestational age limits. The reviewed evidence demonstrated that -alone or in combination with other regulatory requirements, including grounds-based approaches -gestational age limits delayed access to abortion, especially among women seeking abortions at later gestational ages, women close to the gestational age limit and those living in areas with limited access to clinics. Gestational age limits have been found to be associated with increased rates of maternal mortality and poor health outcomes. International human rights law requires States to reform law in order to prevent unsafe abortion and reduce maternal mortality and morbidity.
The studies also showed that where women requested an abortion and were denied care due to gestational age this could result in the unwanted continuation of pregnancy, especially among women with cognitive impairments or those who presented at 20 weeks' gestation or later. This outcome can be viewed as incompatible with the requirement in international human rights law to make abortion available when carrying a pregnancy to term would cause the woman substantial pain or suffering, regardless of pregnancy viability.
The evidence from these studies showed that women with cognitive impairments, adolescents, younger women, women living further from clinics, women who need to travel for abortion, women with lower educational attainment, women facing financial hardship and unemployed women were disproportionately impacted by gestational age limits. This points to the disproportionate impact of gestational age limits on certain groups of women, with implications for States' obligation to ensure non-discrimination and equality in provision of SRH services.

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO GESTATIONAL AGE LIMITS
- Availability, accessibility, acceptability and quality must be central to the regulation of sexual and reproductive health (SRH) services.
- States may not regulate abortion in a manner that forces women to resort to unsafe abortion.
- States must take steps, including revising laws, to reduce maternal morbidity and mortality, and to effectively protect women and girls from the physical and mental risks associated with resorting to unsafe abortion.
- Everyone has a right to non-discrimination and equality in accessing SRH services.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Chapter 2. Abortion regulation including relevant recommendations
Recommendations and best practice statements across the continuum of abortion care
As a standard approach to human rights-based health care, all norms, standards and clinical practice related to abortion should promote and protect:
- individuals' health and human rights
- informed and voluntary decision-making
- autonomy in decision-making
- non-discrimination (including intersectional discrimination) and equality
- confidentiality and privacy
- adequate referral mechanisms
- the continuum of care.
New and updated recommendations presented in this guideline were formulated by the expert panels formed for the development of this guideline, including expert human rights advisers (all contributors are listed in Annex 1, and the roles of the groups of contributors are described in Annex 4). 10 The evidence was first systematically reviewed for each prioritized topic and question, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology (24,119), and the level of certainty of that evidence was assessed (i.e. based on the quality of the evidence, including the types and sizes of studies conducted and their various limitations).
The direction (in favour or against) and strength of each recommendation was determined by the panel of experts based on the six substantive criteria of the WHO-INTEGRATE framework as applied to each intervention for the specified population -balance of health benefits and harms; human rights and sociocultural acceptability; health equity, non-discrimination and equality; societal implications; financial and economic considerations; and feasibility and health system considerations -while also taking into account the meta-criterion: quality of evidence (118). The methods are described in full in Annex 4, including the differences in the methods applied for the recommendations relating to law and policy issues (Recommendations 1,2,3,6,7,21,22) compared with the other types of recommendations. The full Evidence-to-Decision (EtD) frameworks are provided online as supplementary materials, and hyperlinked cross-references to these are supplied with the rationale for each new and updated recommendation presented. 11 Recommendations in favour of an intervention are qualified as either strong or weak (with the conditions of use specified for the latter), with the third alternative being a recommendation against the intervention. To clearly indicate the strength and direction of each recommendation, the following wording is used:
- Recommend -a strong recommendation in favour of the intervention
- Suggest -a weak recommendation in favour of the intervention (requiring additional wording to qualify the recommendation, specifying the conditions of use)
- Recommend against -a strong recommendation against the intervention/in favour of the comparison.
New and updated recommendations resulted from the review of the PICO questions (i.e. population, intervention, comparator, outcomes) that had been identified during the scoping meetings for this guideline. While 10 recommendations in this guideline are completely "new" (as labelled in the Executive summary table and in this chapter), updated recommendations are those that had been published in prior WHO guidance but had undergone an updated process of scoping, search and review of relevant evidence, application of the GRADE methodology and reconsideration of the WHO-INTEGRATE criteria for the purposes of this guideline, which may or may not have resulted in any substantive change to the strength, direction or substance of the recommendation (19,23,120). Finally, there are some existing recommendations that are carried forward unchanged from previous WHO guidance; 12 in these cases, the topic had not been scoped prior to the development of this guideline and thus no new search or review was conducted or, in some cases, an updated literature search was conducted to review the current evidence base but did not lead to any change in the existing recommendation. In particular it should be noted that the 2012 Safe abortion guidance provided a composite recommendation related to law and policy; in this guideline, this has been developed into seven separate recommendations using GRADE methodology, but they are not considered to be "new" (i.e. Recommendations 1,2,3,6,7,21,22). A summary table linking the topics covered, the research/PICO questions, the systematic reviews conducted and the recommendation numbers is provided in Annex 7.

# Structure of information in this chapter
The information and recommendations in this chapter are presented in sections that reflect the continuum of abortion care and modes of service delivery: (i) services applicable across the continuum of care, (ii) pre-abortion, (iii) abortion, (iv) post-abortion, (v) service-delivery options and self-management approaches. In each section, the following aspects are covered as appropriate: "what" (specific clinical interventions), "who" (which type of health worker can provide the intervention, or self-management), "where" (facility-based versus off-site/ remote service-delivery models/no requirement for on-site versus off-site location), and "how" (service-delivery models, implementation considerations). It should be noted that four recommendations relating to law and policy considerations are presented in the pre-abortion section (section 3.3), while three were presented in Chapter 2, section 2.2.
For each topic covered in this chapter, brief background information is first supplied, followed by the recommendation boxes or tables, providing information on the "what" and the "who" for the intervention in question. Each recommendation is immediately followed by a list of related remarks (if any) from the expert panel that reviewed the evidence in detail, explaining the conditions and context in which the recommendation applies. When appropriate, there is also a section indicating where the intervention can be carried out -in particular whether the intervention must be undertaken at a particular level of health-care facility, or whether there is no such requirement and an "off-site" location (e.g. at home, or other location) would be appropriate if preferred by the individual or if that is the only option available (the "where" is often closely tied to the "who", e.g. tasks provided by pharmacists would be provided in a pharmacy). The remarks for existing unchanged recommendations are repeated from the original cited guidance where still relevant, including revisions as appropriate, based on the results of any relevant updated evidence reviews conducted.
For each of the new/updated recommendations, additional information is presented in the following order after the box presenting the recommendation(s) and remarks:
i. Rationale: This includes a brief summary of the type and extent of the evidence included in the review(s) that form the evidence base, and an explanation of the rationale for the direction (for or against) and strength of the recommendation (strong or weak), with reference to the key judgements on effects of the intervention (benefits and risks), the level of certainty of the evidence and any relevant information on the other criteria of the WHO-INTEGRATE framework. Any additional evidence of potential harms or unintended consequences is highlighted. Such considerations may have been derived from studies and additional evidence that may not directly address the PICO question but provide pertinent information in the absence of direct evidence. This may be extracted from single studies, systematic reviews or other relevant sources.
ii. Implementation considerations: Points to bear in mind regarding implementation, including those relating to "how".
Finally, in each topic section, a box is presented listing any key human rights considerations relevant to the recommendation or broader topic, as well as a box providing cross-references and hyperlinks to related topics within this guideline.
Full details for all related PICO questions can be found in Annexes 8, 9 and 10, and the summaries of the evidence (i.e. from the systematic reviews; listed in Annex 7) and the EtD frameworks relevant to each new or updated recommendation are made available online as supplementary material.

# Underlying principles and assumptions relating to recommendations on health worker roles
Health workers are all people engaged in actions whose primary intent is to enhance health (100). This includes all categories of health workers listed and described in Annex 5, from community health workers all the way through to specialist medical practitioners (e.g. obstetricians and gynaecologists), and including traditional and complementary medicine professionals (i.e. non-allopathic physicians). Abortions can be done safely using tablets (medical abortion) or a simple outpatient procedure, such that most no longer require a specialist or even a general practice doctor. The recommendations presented in this guideline provide guidance on how to involve a wider range of health workers and pregnant individuals themselves in the provision or self-management of abortion care, to encourage optimization of the available health workforce, address health system shortages of specialized health-care professionals, reduce costs and improve affordability, improve equity and equality in access to health care and increase the acceptability of health services for those who need them.
The following principles and assumptions apply to all health workers:
- The recommendations are appropriate for and intended for all resource settings, i.e. high-, middle-and low-resource settings.
- The recommendations refer to a range of types of health workers who can safely, effectively and satisfactorily perform some or all of the specific abortion-related tasks mentioned. The options for who can perform the same task are intended to be inclusive and do not imply either a preference for or an exclusion of any particular type of health worker. The choice of health worker for a specific task will depend upon the needs, preferences and conditions of the individual, and the local context.
- Training of health workers must ensure that they have the competencies to provide good-quality, gendersensitive care in accordance with national standards and guidelines and human rights. Ensuring quality abortion care requires ongoing supervision, quality assurance, monitoring and evaluation, as well as access to the necessary equipment and commodities.
- It is assumed that any health worker discussed in this guideline has the basic training required of that type of health worker (and in the case of individuals acting as their own provider -i.e. self-management -that they have the appropriate information and understanding). In addition, the recommendations all assume that health workers who are in a category that is recommended or suggested to perform specific tasks will have received the appropriate task-specific training and information prior to performing that task. This section covers information, counselling and linkage to additional care or services, any or all of which may be needed or desired before, during and/or after the abortion procedure or process.
The provision of scientifically accurate and easy-to-understand information to all women undergoing an abortion, and non-directive voluntary counselling to anyone who requests it, is a core element of good-quality, human rights-compliant abortion services (see Chapter 1, section 1.3.2). The provision of information and counselling (where desired), as well as access or referrals to other related services, starts pre-abortion but should continue across the continuum of care. In addition, everyone should be provided with all the necessary information to make an informed decision regarding the use of contraception.

# Providing information
Abortion-related information for individuals considering or seeking abortion or in the post-abortion period should include:
- the available options for abortion methods and pain management;
- information related to free and informed consent;
- what will occur before, during and after the abortion procedure or process, including any tests and/or pain relief that may be needed and any aspects of the care that could be self-managed if desired, with or without remote support;
- what the individual is likely to experience during and after the abortion procedure or process, and how long the procedure/process and the recovery are likely to take;
- when normal activities can be resumed, including sexual intercourse;
- how to recognize potential side-effects and symptoms of ongoing pregnancy (which may persist temporarily even when abortion has been successful, or which may indicate failure of the abortion), and other medical reasons to return for follow-up care, including complications such as prolonged heavy bleeding or fever; and
- when, where and how to access follow-up care or additional services that may be desired such as counselling (section 3.2.2), contraception (see section 3.5.4) and other services (section 3.2.3).

# SERVICE DELIVERY Recommendation 4: Provision of information on abortion care
Type of health worker Recommendation Rationale a

# Community health workers (CHWs) Recommend
Provision of health promotion interventions by CHWs is generally well accepted and feasible in many contexts where there is a strong CHW programme (moderate-certainty evidence). The potential to expand equitable access to information and quality abortion care by equipping CHWs to provide essential information on abortion is high.

# Pharmacy workers Suggest
Condition: In contexts where the pharmacy worker is under the direct supervision of a pharmacist and there is access or referral to appropriate health services.
Insufficient direct evidence was found for the safety, effectiveness and acceptability of this option. However, in many contexts, pharmacy workers are often consulted by women seeking advice on how to deal with delayed menstruation (moderate-certainty evidence). Although the effectiveness of training interventions with pharmacy workers is uncertain, the potential benefits of equipping them to provide essential information outweighs the potential harms of them not providing information or providing incorrect information.

# Pharmacists Recommend
Pharmacists are qualified to provide information about the medicines they dispense. Evidence was found for the effectiveness of provision of education and counselling on chronic illnesses by pharmacists (low to moderate certainty). In many contexts, pharmacists are often consulted by women seeking advice on how to deal with delayed menstruation (moderate-certainty evidence).

# Traditional and complementary medicine professionals
Within their typical scope of practice, b therefore no assessment of the evidence was conducted.

# Source: Recommendation from WHO (2015) (23).
Note on updating of the recommendation: This was an existing recommendation for which evidence relating to pharmacy workers was reviewed using GRADE methodology, since that was the only category of health worker that didn't already have a strong recommendation ("recommend") for this task. After review, no change was made to the existing weak recommendation ("suggest"). A summary of the evidence is presented in Supplementary material 3, EtD framework on Information provision by pharmacy workers.
a For this and all health worker recommendations, given the limited evidence for many of the health worker-task combinations, the discussions of the expert panel focused on the competency framework in WHO's 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women's values and preferences.
b For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.

# Services applicable across the continuum of care
There is no requirement for location (on-site vs off-site), but privacy and confidentiality should be ensured during the provision of information, with particular attention needed to this requirement in the off-site (out-of-facility) settings, such as pharmacies and community-based sites, where infrastructure and procedures may make this more challenging.

# Implementation considerations
- Different modalities exist for the provision of information on abortion, e.g. remote access via hotlines and telemedicine, and through approaches such as harm reduction and community-based outreach (see section 3.6) as well as in-person interactions with health workers.
- Information should be accessible and understandable, including formats catering to low-literacy and differently abled populations.

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO THE PROVISION OF INFORMATION
- Informed consent requires the provision of complete and accurate, evidence-based information.
- Accurate information on abortion must be available to individuals in a way that respects privacy and confidentiality.
- The right to refuse such information when offered must be respected.
- Abortion information should be available to all persons without the consent or authorization of a third party. This includes abortion information being available to adolescents without the consent or authorization of a parent, guardian or other authority.
- Information must be non-discriminatory and non-biased and presented in a respectful manner. It should not fuel stigma or discrimination.
- Dissemination of misinformation, withholding of information and censorship should be prohibited.
- Information should be acceptable to the person receiving it and of high quality; it should be presented in a way that can be understood and it must be accurate and evidence based.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Offering and providing counselling
Some individuals may wish to receive counselling before or after an abortion. Counselling is more than information provision. It is a focused, interactive process through which a person voluntarily receives support, information and non-directive guidance from a trained person (122), in an environment that is conducive to openly sharing thoughts, feelings, perceptions and personal experiences. In addition to the specific knowledge about abortion services and care required for both information provision and counselling, the latter also requires specialized counselling training. Counselling is a core element of provision of abortion and post-abortion care.
When offering and providing counselling, it is essential to apply the following guiding principles:
- ensure that the individual is requesting the counselling and make it clear that counselling is not required;
- ensure privacy and confidentiality;
- ask the individual what they want or need, what their concerns are, given them the time they need, and actively listen to their expressed needs and preferences;
- highlight relevant information during the counselling session (such as the information provided in section 3.2.1);
- communicate information respectfully and non-judgementally, and in a manner understandable to/tailored to the individual;
- support the individual and check to ensure they receive adequate responses to their questions and that they understand the information provided;
- present all suitable options tailored to individual's needs, while avoiding imposing one's personal values and beliefs onto them; and
- make it clear that the individual will need to decide what services to receive.

# Links to related topics/recommendations

# Community health workers (CHWs) Recommend
Insufficient direct evidence was found for the safety, effectiveness or acceptability of this option, but indirect evidence did show that health promotion interventions by CHWs are generally well accepted, effective and feasible in many contexts, and that CHWs are often intermediaries between the health system and women seeking abortion-related care (moderatecertainty evidence). The expert panel affirmed the feasibility of this option and its ability to expand equitable access to quality abortion care.

# Pharmacy workers Suggest
Condition: Balanced counselling is provided (i.e. about both medical and surgical methods) and there is access or referral to appropriate health services should the woman choose a surgical method.
Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a The expert panel affirmed the feasibility of this option and its ability to expand equitable access to quality abortion care.
Condition: Balanced counselling is provided (i.e. about both medical and surgical methods) and there is access or referral to appropriate health services should the woman choose a surgical method.
Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a Pharmacists are qualified to provide information about the medicines they dispense. There is evidence for the effectiveness of provision of counselling on the management of chronic illnesses by pharmacists (low certainty evidence). In many contexts, pharmacists are often consulted by women seeking advice on how to deal with delayed menstruation (moderate-certainty evidence). Pharmacists have been recommended to provide medical abortion at < 12 weeks across all three subtasks (Recommendation 28). Therefore, the expert panel affirmed that it is feasible for pharmacists to provide balanced counselling on abortion, including surgical options.

# Traditional and complementary medicine professionals
Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a
There is no requirement for location (on-site vs off-site), but privacy and confidentiality should be ensured during counselling, with particular attention needed to this requirement in the off-site (out-of-facility) settings, such as the pharmacies and community-based sites, where infrastructure and procedures may make this more challenging.

# Implementation considerations
- Counselling can be provided to those seeking abortion services but also jointly to their partners, family members or other individuals, should the woman wish them to be present.
- While counselling should be made available and accessible, it should always be voluntary for women to choose whether or not they want to receive it.
- Counselling should be person-centred and may need to be tailored according to the needs of the individual; young people, survivors of sexual and gender-based violence or members of marginalized groups may have different information or counselling requirements.
- The content of and approach to counselling will need to be adjusted depending on the reason for seeking abortion services (e.g. induced abortion, intrauterine fetal demise fetal anomaly). Therefore, it is important for the counsellor to be aware of and sensitive to the individual's situation and needs.
- Different service-delivery models exist for pre-and post-abortion counselling, e.g. remote access via hotlines and telemedicine and through approaches such as harm reduction counselling and communitybased outreach.

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO COUNSELLING
- Counselling must be entered into freely and voluntarily, i.e. it should not be mandatory. The right to refuse counselling when offered must be respected.
- Where provided, counselling must be available to individuals in a way that respects privacy and confidentiality.
- Counselling must be acceptable and of good quality, i.e. it must be provided in a way that can be understood by the recipient and it must be accurate and evidence based.
- Counselling must be non-discriminatory and non-biased.
- Dissemination of misinformation, withholding of information, and censorship should be prohibited.
- Counselling should be available to all persons without the consent or authorization of a third party. This includes counselling being available to adolescents without the consent or authorization of a parent, guardian or other authority.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Services applicable across the continuum of care
Information provision (section 3.2.1)
Recommendations 41, 42 and 43 on post-abortion contraception

# Links to additional services
Individuals seeking abortion may require additional services (122). As needed, provide management or referral to other service providers for other health conditions or urgent needs. This includes facilitating linkages (access or referrals) to counselling and testing for sexually transmitted infections including HIV, contraception where desired, and support services for survivors of gender-based violence. This section includes information and recommendations first on the issues of mandatory waiting periods and third-party authorization, followed by recommendations on Rh isoimmunization, antibiotic prophylaxis, determination of gestational age of pregnancy, pain management, and cervical priming prior to surgical abortion, and finally also recommendations on the issues of restrictions on health workers who can provide abortions and conscientious objection.

# Links to related topics/recommendations

# Mandatory waiting periods imposed by States, health-care facilities or health workers
In a number of countries, health-care facilities or health workers require women to wait a specified amount of time between requesting and receiving an abortion. These imposed delays are known as mandatory waiting periods.
In some cases, women must also receive (sometimes biased) counselling or advice (see sections 3.2.1 and 3.2.2), attend the facility at the start and end of the waiting period, and/or undergo mandated ultrasound during these waiting periods (see section 3.3.5, Recommendation 10 on pre-abortion ultrasound).

# LAW & POLICY Recommendation 6: Mandatory waiting periods
Recommend against mandatory waiting periods for abortion.
Note on updating of the recommendation: This and other law and policy recommendations are not new recommendations. WHO's 2012 Safe abortion guidance provided a composite recommendation related to law and policy (19); in this guideline, this has been developed into seven separate recommendations using GRADE methodology.
In order to identify the impacts of mandatory waiting periods on abortion seekers and health workers, a systematic review of studies published between 2010 and 2020 was undertaken, identifying 33 studies all conducted in the USA. A summary of the evidence from these studies is presented in Supplementary material 1, EtD framework on Mandatory waiting periods. The evidence reviewed showed that mandatory waiting periods delayed access to abortion, sometimes to the extent that women's access to abortion or choice of abortion method was restricted in that setting.
The evidence also indicates that mandatory waiting periods increase the cost of abortion and they may make abortion unattainable, resulting in the continuation of pregnancy against the wishes of the abortion seeker, especially among women with fewer resources, adolescents, younger women, those from racial or ethnic minorities and those who need to travel further for an abortion.
Among those seeking an abortion, the studies showed that mandatory waiting periods were experienced negatively, as a restriction on their access to abortion. For some women, the logistical and economic challenges of completing a mandatory waiting period, such as the need for time off work or education, extra travel and/ or childcare, meant that they were forced to disclose their pregnancy to others even though international human rights law requires States to ensure that SRH services are provided in a way that ensures privacy and confidentiality. The evidence did not establish any benefits of mandatory waiting periods for women.
For health-care facilities, mandatory waiting periods increase staffing costs and logistical difficulties, by mandating additional visits or interventions outside of standard clinical practice (e.g. unnecessary ultrasound, specific counselling that is not evidence-based).

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO MANDATORY WAITING PERIODS
- Availability, accessibility, acceptability and quality must be central to the regulation of sexual and reproductive health (SRH) services.
- States may not regulate abortion in a manner that forces women to resort to unsafe abortion.
- Everyone has a right to non-discrimination and equality in accessing SRH services.
- SRH services must be provided in a way that ensures privacy and confidentiality.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Third-party authorization for abortion
Third-party authorization requirements exist where there is a requirement imposed by law or policy, or in practice, that a party other than the pregnant woman must authorize an abortion, even though other applicable legal requirements for lawful abortion have been met (e.g. grounds or gestational age limits, see sections 2.2.2 and 2.2.3). Common third parties required to provide authorization include a parent, guardian, spouse, partner, health worker, health authority or judicial authority. Third-party authorization requirements operate without regard to whether the person who seeks to end a pregnancy has capacity to consent to medical treatment.
Regardless of whether third-party authorization requirements apply, informed consent of the person availing of abortion is a prerequisite for the provision of abortion (refer to Chapter 1, section 1.3. 1 for information on free and informed consent, and also Web annex A: Key international human rights standards on abortion).

# LAW & POLICY Recommendation 7: Third-party authorization
Recommend that abortion be available on the request of the woman, girl or other pregnant person without the authorization of any other individual, body or institution.
- While parental or partner involvement in abortion decision-making can support and assist women, girls or other pregnant persons, this must be based on the values and preferences of the person availing of abortion and not imposed by third-party authorization requirements.
Note on updating of the recommendation: This and other law and policy recommendations are not new recommendations. WHO's 2012 Safe abortion guidance provided a composite recommendation related to law and policy (19); in this guideline, this has been developed into seven separate recommendations using GRADE methodology.
In order to identify the impacts of third-party authorization requirements on abortion seekers and health workers, systematic reviews of studies published between 2010 and 2019 were undertaken. A total of 32 studies were included, conducted in Hong Kong Special Administrative Region (China), Turkey and the USA. A summary of the evidence from these studies is presented in Supplementary material 1, EtD framework for Third-party authorization. The reviewed evidence showed that third-party authorization requirements were associated with delays to abortion. For minors, these delays were sometimes, although not always, reduced when judicial authorization was used to bypass parental authorization requirements. However, bypass can be burdensome and time-consuming, and minors from ethnic minorities or of lower socioeconomic status are significantly more likely to need to use it. The evidence showed that adolescents and women sought to bypass parental/spousal authorization requirements to avoid anticipated violence, reproductive coercion and family disharmony.
A number of studies described "parental notification" or "parental involvement" rather than using the term "parental authorization". As these terms may encompass parental authorization requirements and mandate the disclosure of the fact that a minor is seeking an abortion, thus creating opportunities for parental veto, these studies were included within the evidence base for this topic. These studies reinforced the associations between mandated parental involvement (including authorization) and barriers to accessing abortion (including delay, continuation of pregnancy, anticipated interpersonal violence or exploitation, reproductive coercion, family disharmony and recourse to unsafe abortion).
Third-party authorization requirements are incompatible with international human rights law, which provides that States may not restrict women's access to health services on the ground that they do not have the authorization of husbands, partners, parents or health authorities, because they are unmarried, or because they are women. Therefore, the evidence underlines the importance of the requirements stated in international human rights law that SRH services be provided in a way that respects and maintains women's and girls' privacy and confidentiality, that States protect women and girls seeking abortion, and that States recognize adolescents' evolving capacity (see section 1.3.1, Box 1.2 and Web annex A: Key international human rights standards on abortion).

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO THIRD-PARTY AUTHORIZATION
- States may not restrict women's access to health services on the ground that they do not have the authorization of husbands, partners, parents or health authorities, because they are unmarried, or because they are women.
- Sexual and reproductive health (SRH) services must be provided in a way that ensures privacy and confidentiality.
- States may not regulate abortion in a manner that forces women to resort to unsafe abortion.
- States must take steps, including revising laws, to reduce maternal morbidity and mortality, and to effectively protect women and girls from the physical and mental risks associated with resorting to unsafe abortion.
- Everyone has a right to privacy and confidentiality in accessing SRH services.
- Availability, accessibility, acceptability and quality must be central to the regulation of SRH services.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Rh isoimmunization
Rh isoimmunization is a type of haemolytic disease of the fetus and newborn (HDFN). Specifically, it is the development of antibodies against the Rh antigens on the surface of red blood cells of another individual (i.e. one's own fetus) (123).

# CLINICAL SERVICES Recommendation 8 (NEW):
Rh isoimmunization for abortion at gestational ages < 12 weeks
For both medical and surgical abortion at < 12 weeks: Recommend against anti-D immunoglobulin administration.
- Standard of care applies for anti-D administration at gestational ages  12 weeks.
A systematic review assessed the effect of routine anti-D administration among unsensitized Rh-negative individuals undergoing an abortion. There are few studies examining Rh isoimmunization in unsensitized Rhnegative individuals seeking abortion before 12 weeks of gestation. Only two studies, conducted in Israel and the USA, met the inclusion criteria for the review, both published in 1972 (124,125). A summary of the evidence is presented in Supplementary material 2, EtD framework on Rh isoimmunization.
The evidence on the effectiveness of the intervention may favour the intervention, because fewer women in the intervention group (anti-D administration) had antibody formation after the initial pregnancy compared to the women in the comparison group (no anti-D), and no harms (undesirable effects) of the intervention were noted. However, after consideration of the resources required, cost-effectiveness and feasibility of administering anti-D, as well as the very low certainty of the evidence on effectiveness, the expert panel concluded that overall, the evidence does not favour the intervention and decided to recommend against it for gestational ages < 12 weeks, rather than < 9 weeks, as mentioned in the 2012 guidance (19). The justification for this new recommendation is outlined in the following points: (i) The presence of fetal blood in Rh-negative women at early gestational ages does not necessarily correlate with development of Rh alloimmunization and if we apply the results of an experimental study to this scenario, then theoretically there is zero chance of antibody formation if the Rh-negative woman is exposed to the Rh antigen of the fetal blood cells (126); (ii) A study comparing Rh alloimmunization rates in two countries demonstrated the safety of not treating Rh-negative women with spontaneous abortion under 10 weeks of gestation (127); (iii) WHO only recommends antenatal prophylaxis with anti-D immunoglobulin in nonsensitized Rh-negative pregnant women at 28 and 34 weeks of gestation to prevent RhD alloimmunization in the context of rigorous research (128).

# Implementation considerations
- Routine laboratory testing, including Rh testing, is not a requirement for abortion services at any gestational age.
- Determination of Rh status and the offer of anti-D prophylaxis are not considered prerequisites for early medical abortion at gestational ages before 12 weeks.

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO Rh ISOIMMUNIZATION
- States must ensure access to up-to-date scientific technologies necessary for women.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Antibiotic prophylaxis
The role of antibiotics is pertinent for surgical abortion. The presence of infection in the lower reproductive tract at the time of surgical abortion is a risk factor for post-abortion reproductive tract infections (129). Provision of antibiotics at the time of abortion (prophylaxis) is to prevent such complications after a surgical abortion.
CLINICAL SERVICES Recommendation 9: Antibiotic prophylaxis for surgical and medical abortion a. For surgical abortion, regardless of the individual's risk of pelvic inflammatory infection:
Recommend appropriate prophylactic antibiotics pre-or perioperatively.
b. For medical abortion: Recommend against the use of prophylactic antibiotics.
- Lack of antibiotics should not limit access to abortion services.
Source: Recommendation 11 carried forward from WHO (2012) (19). The wording has been revised to use the word "recommend" to clarify that these are strong recommendations, and the former wording "routine use" (in 9b) has been changed to "use", following discussion among the expert panel.

# Implementation consideration
- Single-dose administration of nitroimidazoles, tetracyclines or penicillins has been shown to be effective when used as prophylactic antibiotics for surgical abortion.
For information regarding which health workers can provide this intervention, refer to Recommendation 24 on vacuum aspiration (< 14 weeks) and Recommendation 26 on dilatation and evacuation (D&E) ( 14 weeks).

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO ANTIBIOTIC PROPHYLAXIS
- States must ensure adequate access to essential medicines in an affordable and non-discriminatory manner.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Determining gestational age of pregnancy
Determining the gestational age of the pregnancy is a preliminary step before selecting the most appropriate abortion method. There are multiple ways to determine gestational age. Pregnancy dating can be done based on last menstrual period (LMP) alone or in combination with the use of a validated tool (i.e. mobile app, checklist or pregnancy wheel), thus enabling the option of self-assessment of gestational age. When LMP is uncertain, gestational age can be determined by way of a clinical/physical examination (i.e. bimanual pelvic and abdominal examination) or by ultrasound, both of which are used to assess the size of the uterus, estimated in weeks, that corresponds to a pregnant uterus of the same gestational age dated by LMP. In general, the least invasive method that is appropriate in the circumstances and available in the setting should be used.
Routine screening for ectopic pregnancy is not necessary prior to medical abortion. The incidence of ectopic pregnancy is lower in abortion seekers then in the general population (130). Even for continuing pregnancies, WHO only recommends one ultrasound scan before 24 weeks of gestation (early pregnancy ultrasound) to estimate gestational age, improve detection of fetal anomalies and multiple pregnancies, reduce induction of labour for post-term pregnancy, and improve a woman's pregnancy experience (128).
CLINICAL SERVICES Recommendation 10: Pre-abortion ultrasound scanning
For both medical and surgical abortion: Recommend against the use of ultrasound scanning as a prerequisite for providing abortion services.
- Legal regulation that limits the availability of abortion by gestational age may require or result in ultrasounds being used to verify gestational age prior to abortion, even though this is not necessary from a clinical perspective. Removing legal gestational age limits on access to abortion (see Recommendation 3) should result in unnecessary pre-abortion ultrasound being avoided, and increase the availability of abortion in settings where ultrasound is difficult to access.
On a case-by-case basis, there may be clinical reasons for using ultrasound scanning prior to abortion.
Source: Recommendation 12 carried forward from WHO (2012) (19). The wording has been revised to use the word "recommend against" to clarify that this is a strong recommendation against the intervention, and the former wording "routine" has been changed to use "prerequisite" for greater clarity, following discussion among the expert panel.

# Links to related topics/recommendations

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO DETERMINING THE GESTATIONAL AGE OF PREGNANCY
- Any information on gestational age should be complete, accurate and evidence based.
It should not be provided with the aim of directing decision-making.
- As a form of health information, information on gestational age should be of high quality, accurate and accessible. It should be presented a respectful manner and acceptable to the person receiving it. It should not fuel stigma and discrimination.
- Where information on gestational age is made available, it must be provided to individuals in a way that respects privacy and confidentiality.
- The right to refuse such information when offered must be respected. This includes the right to refuse to view ultrasound images.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Pain management for abortion
There is generally some degree of pain with abortion. The need for pain management increases with gestational age. The degree of the pain varies with the age, parity, prior vaginal delivery, history of dysmenorrhoea and anxiety/fear level of the woman undergoing the abortion (131)(132)(133)(134). A shorter procedure time has been associated with less pain (131). Neglecting this important element of care needlessly increases anxiety, discomfort and pain, thereby seriously compromising the quality of care and potentially increasing the difficulty of performing the procedure. Pain management should always be available and it should be administered in advance, in anticipation of the onset of pain, or provided to the woman in case it is needed for later use at home. 12. (NEW) For pain management for surgical abortion at < 14 weeks: a. Recommend the use of a paracervical block; and b. Suggest that the option of combination pain management using conscious sedation 13 plus paracervical block should be offered, where conscious sedation is available.
For pain management for cervical priming with osmotic dilators prior to surgical abortion at  14 weeks:
Suggest the use of a paracervical block. (See also section 3.3.7 on cervical priming prior to surgical abortion.)
- For cervical priming (Recommendation 13), additional pain medication can be considered, such as the use of intravaginal gel.
For pain management for surgical abortion at  14 weeks: a. Recommend the use of a paracervical block; and b. Suggest that the option of combination pain management using conscious sedation plus paracervical block should be offered, where conscious sedation is available.
Source: Recommendation 11 updated from WHO (2012) (19). Recommendations 12-14 are new.
Note on updating of the recommendation: Recommendation 11a was previously published as part of Recommendation 14 in WHO (2012) (19), and evidence for it was reviewed using GRADE methodology. After review, in this updated version, we have split the first part of the original recommendation wording to apply to surgical abortion here (11a) and medical abortion in a separate recommendation (15) and revised the wording to mention provision, and we have separated and revised the wording of the second part of the recommendation referring to general anaesthesia (Recommendation 11b).
13 Conscious sedation is also known as intravenous (IV) sedation or moderate sedation. See definition in Glossary.
In a health-care facility.

# Rationale for Recommendations 11b and 12
An update of an existing Cochrane Review 14 served as the evidence base for assessing the pain management regimens for surgical abortions at < 14 weeks of gestation. Thirty studies reporting on pain management for surgical abortion were identified by the search strategy. Of these studies, nine studies -conducted in France, the Islamic Republic of Iran, Norway, Turkey and the USA -are the focus of the evidence base for these recommendations. Six studies compared the paracervical block (PCB) with a placebo. One study compared the PCB with general anaesthesia. Two studies compared conscious sedation 15 plus PCB versus PCB alone. A summary of the evidence is presented in Supplementary material 2, EtD framework for Pain management for surgical abortion < 14 weeks.
Combination pain management using conscious sedation plus PCB: Mean pain scores were lower in the group of women who received conscious sedation and PCB compared with the women who received a PCB alone, based on moderate-certainty evidence. In addition, satisfaction with their pain management was higher among the former group of women, based on high-certainty evidence.

# Paracervical block (PCB):
Both with and without conscious sedation, mean pain scores were lower in the group of women who received a PCB compared with the women who received a placebo, based on moderate-certainty evidence. Fewer women required additional analgesic medication, based on high-certainty evidence, and satisfaction in the former group of women was high, based on moderate-certainty evidence.
General anaesthesia: Pain scores were lower in the group of women who received general anaesthesia compared with PCB alone, based on moderate-certainty evidence. However, discussions on the resources required, cost effectiveness, feasibility and equity related to administering general anaesthesia resulted in a conclusion that did not favour the intervention. In addition, Recommendation 11b aligns with the existing statement that vacuum aspiration does not require an operating theatre (19).

# Rationale for Recommendations 13 and 14
A systematic review assessed the pain management regimens for surgical abortions at gestational ages  14 weeks. Three studies reporting on pain management for D&E were identified by the search strategy, all of which focused on pain management during the cervical priming prior to the surgical procedure. A summary of the evidence is presented in Supplementary material 2, EtD framework for Pain management for surgical abortion  14 weeks.
Mean pain scores were lower in the group of women who received a PCB compared with the women who received a placebo, based on high-certainty evidence. Satisfaction in the former group of women was high, based on moderate-certainty evidence. An intravaginal gel can be used as an alternative method of pain control; more women had a lower pain score after receiving the gel compared with those who had a PCB, based on lowcertainty evidence. Cervical priming was performed with laminaria. Discussions on the values and preferences of women regarding pain management during surgical abortion, and on the resources required and the feasibility of PCB administration resulted in a determination that favoured the intervention.
No studies were identified that focused on pain management for the D&E procedure. Therefore, the expert panel came to a consensus to align the recommendations to those for pain management for surgical abortion at < 14 weeks of gestation (see Recommendation 12).
For information regarding which health workers can provide this intervention, refer to Recommendations 24 and 26 for surgical abortion (vacuum aspiration and D&E).

# Implementation considerations
- Sufficient supplies and stocks of pain medications should be ensured.

# (NEW) For pain management for medical abortion at  12 weeks:
Suggest consideration of other methods to control pain or discomfort due to increased pain with increasing gestational age. Such methods include certain anti-emetics and epidural anaesthesia, where available.
- For medical abortion at gestational ages < 14 weeks, if NSAIDS (e.g. ibuprofen) are not available or not an option, then acetaminophen can be considered for pain control.
Source: Recommendation 15 updated from WHO (2012) (19). Recommendation 16 is new.
Note on updating of the recommendation: Recommendation 15 was previously published as part of Recommendation 14 in WHO (2012) (19), and evidence for it was reviewed using GRADE methodology. After review, in this updated version, we have split the first part of the original recommendation wording to apply to surgical abortion (see Recommendation 11a) and medical abortion (here in Recommendation 15), and revised the wording to mention provision.
No requirement for location (on-site vs off-site).

# Rationale for Recommendation 15 (specifically for gestational ages < 14 weeks)
A Cochrane Review served as the evidence base for this key question. Five studies reporting on pain management for medical abortion at gestational ages < 14 weeks were identified by the search strategy, conducted in Israel, the United Kingdom and the USA. A summary of the evidence is presented in Supplementary material 2, EtD framework for Pain management for medical abortion < 14 weeks.
Of these studies, three were assessed using the following comparisons:
- ibuprofen versus placebo
- prophylactic versus therapeutic NSAIDs
- ibuprofen versus paracetamol.
Women who received NSAIDs had lower mean pain scores and fewer women from that group required additional analgesic medication, based on high-certainty evidence. Discussions on the values and preferences of women with pain management during medical abortion and the resources required, cost-effectiveness and feasibility for NSAID administration resulted in a determination that favoured the intervention.
Rationale for Recommendations 15 (specifically for gestational ages  14 weeks) and 16
A systematic review was undertaken to address this key question. Eleven studies reporting on pain management for medical abortion at gestational ages  14 weeks were identified by the search strategy, conducted in Belgium, Canada, Germany, Israel, Italy, Sweden, Thailand and the USA. A summary of the evidence is presented in Supplementary material 2, EtD framework for Pain management for medical abortion  14 weeks.
Using data from these studies, the following comparisons were made:
- paracervical block (PCB) versus oral pain medication
- NSAIDs versus non-NSAIDs/placebo
- anti-emetics versus placebo
- anti-epileptics versus anxiolytics
- intermittent versus continuous epidural
- patient controlled epidural versus patient-controlled intravenous (IV) fentanyl
- patient controlled fentanyl versus patient-controlled morphine
- patient controlled IV tramadol versus patient-controlled IV fentanyl.

# Comparison of PCB versus oral pain medication:
In the studies that assessed this comparison, fewer women experienced severe pain and there was a lower expulsion time with the use of oral pain medication compared with PCB, based on moderate-certainty evidence.

# Comparison of NSAIDs versus non-NSAIDs/placebo:
In the studies that assessed this comparison, fewer women required supplemental narcotics after the use of NSAIDs, based on high certainty of evidence. In addition, fewer women receiving NSAIDs experienced side-effects, based on moderate-certainty evidence.

# Comparison of anti-emetics versus placebo:
In the studies that assessed this comparison, there was lower use of supplemental narcotics and lower expulsion time with the use of anti-emetics, based on moderate-certainty evidence.

# Comparison of anti-epileptics versus anxiolytics:
In the studies that assessed this comparison, there were lower mean pain scores, lower use of additional analgesics and lower mean expulsion times with the use of antiepileptics, based on moderate-certainty evidence.

# Comparison of intermittent versus continuous epidural:
In the studies that assessed this comparison, there were fewer side-effects with the use of intermittent epidural, based on low-to high-certainty evidence. Satisfaction was higher among women who had intermittent epidural for their pain management, based on highcertainty evidence.

# Comparison of patient-controlled epidural (PCE) versus patient controlled IV fentanyl:
In the studies that assessed this comparison, there were lower mean pain scores and fewer side-effects of vomiting and sedation with the use of PCE, based on moderate-certainty evidence. In addition, satisfaction was higher among women in the PCE group, based on moderate-certainty evidence.

# Comparison of patient-controlled morphine versus patient-controlled IV fentanyl:
In the studies that assessed this comparison, there were lower pain scores and fewer side-effects with the use of patient-controlled fentanyl (50 g), based on moderate-to high-certainty evidence.

# Comparison of patient controlled IV tramadol versus patient controlled IV fentanyl:
In the studies that assessed this comparison, pain control was comparable with the use of patient-controlled tramadol and fentanyl, based on low-to moderate-certainty evidence. Satisfaction ratings were also similar between the two groups, based on high-certainty evidence.
Discussions on the values and preferences of women regarding pain management during medical abortion, and on the resources required, cost-effectiveness and feasibility for NSAID administration resulted in a determination that favoured the intervention.
For information regarding which health workers can provide this intervention, refer to Recommendations 28 and 30 on medical abortion.
Implementation consideration for Recommendations 15 and 16
- Regardless of the service modality, there should be clear communication to the woman on the pain she may experience, which may vary based on pain perceptions and tolerance. In any event, she should be provided with information on pain management, and access to adequate pain medicines should be ensured.

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO PAIN MANAGEMENT
- States must ensure adequate access to essential medicines in an affordable and non-discriminatory manner.
- Denial of pain medication may violate a wide range of human rights, including the right to health and autonomy in decisionmaking.
- Denial of pain medication as punishment for abortion or because it is part of abortion care may violate the right to equality and nondiscrimination.
- Denial of pain medication may violate the right to be free from cruel, inhuman and degrading treatment.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Cervical priming prior to surgical abortion
Prior to surgical abortion, cervical priming (also known as cervical preparation) may be considered for all women with a pregnancy of any gestational age, in particular for women with a pregnancy over 12 weeks of gestation. Cervical priming before surgical abortion is especially beneficial for women with cervical anomalies or previous surgery, adolescents and those with advanced pregnancies, all of whom have a higher risk of cervical injury or uterine perforation that may cause haemorrhage (135,136). It may also facilitate the abortion procedure for inexperienced providers. However, cervical priming has disadvantages, including additional discomfort for the woman, and the extra cost and time required to administer it effectively.
Whether osmotic dilators or medication is used for cervical priming prior to the surgical abortion, this is done in advance of the procedure. As such, cervical priming may be initiated by a health worker other than the provider who will conduct the D&E.

# CLINICAL SERVICES Recommendation 17: Cervical priming prior to surgical abortion at < 12 weeks of gestation
Prior to surgical abortion at < 12 weeks: a. If cervical priming is used: Suggest the following medication regimens:  Mifepristone 200 mg orally 24-48 hours prior to the procedure  Misoprostol 400 g sublingually 1-2 hours prior to the procedure  Misoprostol 400 g vaginally or buccally 2-3 hours prior to the procedure b. Recommend against the use of osmotic dilators for cervical priming.
- The sublingual route is more effective for misoprostol administration.
- Appropriate pain medication should be provided.
Source: Recommendation updated from Recommendation 7.2 in WHO (2012) (19).
Note on updating of the recommendation: This recommendation was reviewed using GRADE methods. The suggested mifepristone regimen is unchanged, but the misoprostol regimens have been updated, in terms of timing and route of administration, and laminaria is no longer a recommended option; these recommendations therefore replace the prior recommendation.
An update of an existing Cochrane Review serves as the evidence base for this key question. The update identified 8 new studies, which makes a total of 61 included studies that assessed cervical priming methods for vacuum aspiration. From this review, approximately half of the included studies were evaluated to contribute towards the development of the Evidence-to-Decision (EtD) framework. The review includes the following cervical priming methods: medication with mifepristone and/or misoprostol and mechanical methods (i.e. natural or synthetic osmotic dilators). A summary of the evidence is presented in Supplementary material 2, EtD framework for Cervical priming prior to surgical abortion < 12. 16 For Recommendation 17a, we suggest the option of misoprostol or mifepristone as a cervical priming agent prior to surgical abortion less than 12-14 weeks. For the studies that compared misoprostol versus mifepristone, time to complete the procedure was less for misoprostol, based on moderate-certainty evidence. However, the pre-procedure cervical dilation was greater with mifepristone use, based on moderate-certainty evidence. The side-effects profile was comparable between the two groups, based on very low-certainty evidence.
Regarding the timing of misoprostol administration, studies that compared the interval timing for administration of misoprostol for cervical priming revealed that the highest efficacy was seen (i.e. greater pre-procedure cervical dilation) with the 3-hour interval. This finding was based on high-certainty evidence. Although the 3-hour interval is considered optimal, the 1-hour interval is also included as a result of the expert panel members' discussions on the feasibility and acceptability of the shorter duration of waiting time prior to a woman's surgical abortion.
For Recommendation 17b, the reasoning is due to the longer time to complete the procedure if osmotic dilators are used compared with when misoprostol is used for cervical priming, based on high-certainty evidence. In addition, satisfaction rates were higher among those who received misoprostol compared with the laminaria group, based on moderate-certainty evidence.
The expert panel added the buccal route (this was added along with the vaginal route due to buccal and misoprostol concentration curves being similar in pharmacokinetics data), and their remark highlights the sublingual route as being the more effective route.

# CLINICAL SERVICES Recommendation 18 (NEW):
Cervical priming prior to surgical abortion (MVA or D&E) at  12 weeks of gestation
Prior to surgical abortion at later gestational ages: a. For surgical abortion at  12 weeks: Suggest cervical priming prior to the procedure.
b. For surgical abortion between 12 and 19 weeks: Suggest cervical priming with medication alone (a combination of mifepristone plus misoprostol is preferred) or with an osmotic dilator plus medication (mifepristone, misoprostol, or a combination of both).
c. For surgical abortion between 12 and 19 weeks, when using an osmotic dilator for cervical priming: Suggest that the period between osmotic dilator placement and the procedure should not extend beyond two days.
For surgical abortion at  19 weeks: Recommend cervical priming with an osmotic dilator plus medication (mifepristone, misoprostol, or a combination of both).
- There was limited evidence for cervical priming for gestational ages between 12 and 14 weeks and therefore health workers should use clinical judgement to decide on the most convenient method for cervical priming prior to vacuum aspiration for this gestational age range.
Note: These are new recommendations and they replace Recommendations 8.1 and 8.2 in WHO (2012) (19), which were for D&E after 14 weeks; these new recommendations now include information on methods/regimens for cervical priming at different gestational age ranges.
A Cochrane Review provided the evidence base on cervical priming methods for surgical abortion at later gestational ages. From this review, 16 studies were included in the development of the EtD framework relating to the following cervical priming methods: medication with mifepristone and/or misoprostol; mechanical methods with osmotic dilators and synthetic dilators; one-day versus two-day procedures with laminaria. The study settings included Israel, South Africa, Spain, the United Kingdom and the USA. A summary of the evidence is presented in Supplementary material 2, EtD framework for Cervical priming prior to surgical abortion  12 weeks.
The inclusion of all medication options for cervical priming was based on the expert panel's discussion of the feasibility and acceptability of these interventions. The use of mifepristone with misoprostol is favoured over misoprostol alone for cervical priming due to higher pre-procedure cervical dilatation and shorter time to complete the procedure, based on moderate-certainty evidence. The combined use of medication and laminaria is favoured over laminaria alone due to the higher pre-procedure cervical dilatation, decreased need for further dilatation and shorter time to complete the procedure. This is based on high-certainty evidence. Sub-analyses of the included studies showed that the combined use of medication and laminaria appears to be more effective at higher gestational ages.
- The use of medication for cervical priming prior to surgical abortion beyond 12-14 weeks of gestation can be self-managed and can save travel time for the woman and staff time spent on insertion of osmotic dilators.

# SERVICE DELIVERY Recommendation 19:
Cervical priming with medication prior to surgical abortion at any gestational age

# Type of health worker Recommendation Rationale a

# Community health workers (CHWs) Suggest
Condition: Provision of medication for the purpose of cervical priming is part of the surgical abortion process so the health worker needs to ensure continuity of care of the woman obtaining the medicines prior to the abortion procedure
Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a In addition, CHWs have been recommended to provide medical abortion at < 12 weeks (see Recommendation 28), which requires similar skills and knowledge as for this task.

# Pharmacy workers Suggest
Condition: Provision of medication for the purpose of cervical priming is part of the surgical abortion process so the health worker needs to ensure continuity of care of the woman obtaining the medicines prior to the abortion procedure
Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a In addition, pharmacy workers have been recommended to provide medical abortion at < 12 weeks (see Recommendation 28), which requires similar skills and knowledge as for this task.

# Pharmacists Suggest
Condition: Provision of medication for the purpose of cervical priming is part of the surgical abortion process so the health worker needs to ensure continuity of care of the woman obtaining the medicines prior to the abortion procedure
Although no evidence was found on the safety, effectiveness or acceptability of this option, dispensing medicines with a prescription is within the typical scope of practice of pharmacists. The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a In addition, pharmacists have been recommended to provide medical abortion at < 12 weeks (see Recommendation 28), which requires similar skills and knowledge as for this task.

# Traditional and complementary medicine professionals Auxiliary nurses/ANMs Nurses Midwives
Evidence was found for the safety and effectiveness of this option (low-certainty evidence). Cervical priming is part of the training for provision of manual vacuum aspiration. The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a

# Associate/advanced associate clinicians Recommend
Evidence was found for health workers with similar or less comprehensive basic training (e.g. midwives, nurses, ANMs) using such medicines to provide medical abortion (moderatecertainty evidence). Cervical priming is part of the training for provision of manual vacuum aspiration. The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a

# Generalist medical practitioners Specialist medical practitioners
Within their typical scope of practice, b therefore no assessment of the evidence was conducted.

# Source: Recommendation updated from WHO (2015) (23).
Note on updating of the recommendation: This was an existing recommendation for which evidence relating to all types of health workers was reviewed using GRADE methodology, except for specialist and generalist medical practitioners, which were already "recommend". After review, the recommendations were upgraded for all reviewed health workers, from "recommend against" to "suggest" for pharmacists, pharmacy workers and CHWs, and from "suggest" to "recommend" for all other health worker categories. The gestational age for this recommendation was also amended from "beyond 12 weeks" to "at any gestational age" after conferring with the expert panel. A summary of the evidence is presented in Supplementary material 3, EtD framework for Cervical priming using medication and osmotic dilators.
a For this and all health worker recommendations, given the limited evidence for many of the health worker-task combinations, the discussions of the expert panel focused on the competency framework in WHO's 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women's values and preferences.
No requirement for location (on-site vs off-site).

# Implementation consideration
- Given that cervical priming initiates the process and is done prior to a surgical procedure, with an interval of up to 1-2 days, it is important that the health worker ensures the continuity of care for the woman by ensuring that there is a clear plan for the surgical abortion prior to the woman taking the priming agent and she has access to the existing health system should she desire or need additional support during that interval.

# SERVICE DELIVERY Recommendation 20: Cervical priming with osmotic dilators prior to D&E at gestational ages  12 weeks
Type of health worker Recommendation Rationale a

# Traditional and complementary medicine professionals Suggest
Condition: Health worker ensures continuity of care from the time of cervical priming to the D&E Although insufficient direct evidence was found for the safety and effectiveness of this option, these health workers have been suggested to do other transcervical procedures (e.g. inserting an IUD and vacuum aspiration; see Recommendations 43 and 24). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a The expert panel affirmed that this option has the potential to increase equitable access to quality abortion care in regions where these professionals constitute a significant proportion of the health workforce.

# Auxiliary nurses/ANMs Recommend
Although insufficient direct evidence was found for the safety and effectiveness of this option, ANMs have been recommended to do other transcervical procedures (e.g. inserting an IUD; see Recommendation 43), and auxiliary nurses have been recommended in certain contexts to do other transcervical procedures (e.g. inserting an IUD; see Recommendation 43). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a The expert panel affirmed that this option may help optimize workflow within a facility and decrease waiting times for women.

# Nurses Recommend
Although insufficient direct evidence was found for the safety or effectiveness of this option, nurses have been recommended to do other transcervical procedures (e.g. inserting an IUD; see Recommendation 43), and there is evidence that provision of manual vacuum aspiration by nurses is safe and effective (moderate-certainty evidence). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a The expert panel affirmed that this option may help optimize workflow within a facility and decrease waiting times for women.

# Midwives Recommend
Although insufficient direct evidence was found for the safety or effectiveness of this option, midwives have been recommended to do other transcervical procedures (e.g. inserting an IUD; see Recommendation 43), and there is evidence that provision of manual vacuum aspiration by midwives is safe and effective (moderate-certainty evidence). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a The expert panel affirmed that this option may help optimize workflow within a facility and decrease waiting times for women.

# Table Continues

# Type of health worker Recommendation Rationale a

# Associate/advanced associate clinicians Recommend
Indirect evidence was found for the safety and effectiveness of these clinicians providing vacuum aspiration (moderatecertainty evidence), which includes cervical priming with osmotic dilators for select cases. The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a The expert panel affirmed that this option may help optimize workflow within a facility and decrease waiting times for women.

# Generalist medical practitioners Specialist medical practitioners
Within their typical scope of practice, b therefore no assessment of the evidence was conducted.
Source: Recommendation updated from WHO (2015) (23).
Note on updating of the recommendation: This was an existing recommendation for which evidence relating to all types of health workers was reviewed using GRADE methodology, except for specialist and generalist medical practitioners, which were already "recommend". After review, the recommendations were upgraded for associate/advanced associate clinicians, midwives and nurses from "suggest" to "recommend", for auxiliary nurses and ANMs from "recommend against" to "recommend", and for traditional and complementary medicine professionals from "recommend against" to "suggest". For pharmacists, pharmacy workers and community health workers, the recommendations remain "recommend against" (not listed). The gestational age for this recommendation was also amended from "beyond 12 weeks" to "12 weeks and above" ( 12 weeks) to align this recommendation with Recommendation 18. A summary of the evidence is presented in Supplementary material 3, EtD framework for Cervical priming using medication and osmotic dilators.
a For this and all health worker recommendations, given the limited evidence for many of the health worker-task combinations, the discussions of the expert panel focused on the competency framework in WHO's 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women's values and preferences.
b For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.
In a health-care facility.

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO CERVICAL PRIMING
- Denial of cervical priming as punishment for abortion or because it is part of abortion care may violate the right to non-discrimination and equality.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Links to related topics/recommendations

# Services across the continuum of care

# Preabortion Postabortion

# Servicedelivery models and selfmanagement

# Restrictions (in law or policy) on health workers who may lawfully provide abortion care
In a number of countries, law and policy restrict which type of health workers may lawfully provide abortion care (137), most often limiting this to gynaecologists. Since the advent of vacuum aspiration and medical abortion, however, abortion can be safely provided by a wide range of health workers in diverse settings, and safely selfmanaged in earlier pregnancy (see Recommendations 24,28,30,33). Provider restrictions are inconsistent with WHO's support for the optimization of the roles of health workers; such restrictions are arbitrary and not evidence based (138). Reflecting States' obligation to respect, protect and fulfil the right to health, health-care facilities, goods and services must be available, accessible, adequate and of good quality (46). This includes facilities, goods and services for SRH care. Thus, States must ensure an adequate number of medical and professional personnel and skilled providers in the health system as well as adequate stocks of essential medicines (46). Furthermore, the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, has stressed that abortion law must be evidence based (37) (see Chapter 1, section 1.3.1, and also Web annex A: Key international human rights standards on abortion).

# LAW & POLICY Recommendation 21: Provider restrictions
Recommend against regulation on who can provide and manage abortion that is inconsistent with WHO guidance.
- Where law or policy regulate who may provide or manage abortion, that regulation should be consistent with WHO guidance, which is presented throughout this chapter.
Note on updating of the recommendation: This and other law and policy recommendations are not new recommendations. WHO's 2012 Safe abortion guidance provided a composite recommendation related to law and policy (19); in this guideline, this has been developed into seven separate recommendations using GRADE methodology.
In order to identify the impacts of provider restrictions on abortion seekers and health workers, a systematic review of studies published between 2010 and 2019 was undertaken, identifying seven studies conducted in Australia, Ethiopia, Nepal and the USA. A summary of the evidence from these studies is presented in Supplementary material 1, EtD framework for Provider restrictions. The reviewed evidence showed that restrictions on who can provide and manage abortion resulted in delays to and burdens in accessing abortion. By contrast, expanding the range of health workers who can provide abortion care improved timely access to early medical and surgical abortion; reduced costs, travel and waiting time; shifted components of care away from physicians; made abortion more available including in rural areas and at primary health care level; prevented unsafe selfmanagement of abortion; and reduced system costs. This evidence indicates that provider restrictions produce inefficiencies, administrative burdens and workload burdens within health systems, and reduce in practice the number of available providers.

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO PROVIDER RESTRICTIONS
- Availability, accessibility, acceptability and quality must be central to the regulation of sexual and reproductive health care.
- Abortion regulation should be based on human rights and evidence.
- States must ensure an adequate number of medical and professional personnel and skilled providers in the health system as well as adequate stocks of essential medicines.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Conscientious objection or refusal by health workers to provide abortion care
Refusal of abortion care on the basis of conscience operates as a barrier to access to safe and timely abortion  144). In some countries conscientious objection is expressly regulated through employment law, employment contracts or the law on abortion. As a matter of international human rights law, States that allow conscientious objection must organize their health system and abortion provision in a way that ensures that conscientious objection does not result in the refusal of legally available abortion care, and regulate the exercise of conscientious objection in a way that reflects best international clinical practice, protects abortion seekers, and ensures that provider refusal does not undermine or hinder access to quality abortion care (145 146. WHO has also advised that "health services should be organized in such a way as to ensure that an effective exercise of the freedom of conscience of health professionals in the professional context does not prevent patients from obtaining access to services to which they are entitled under the applicable legislation" (19).

# LAW & POLICY Recommendation 22: Conscientious objection
Recommend that access to and continuity of comprehensive abortion care be protected against barriers created by conscientious objection.
- In spite of the human rights obligation to ensure conscientious objection does not hinder access to quality abortion care, and previous WHO recommendations aimed at ensuring conscientious objection does not undermine or hinder access to abortion care, conscientious objection continues to operate as a barrier to access to quality abortion care. It is critical that States ensure compliance with regulations and design/ organize health systems to ensure access to and continuity of quality abortion care. If it proves impossible to regulate conscientious objection in a way that respects, protects and fulfils abortion seekers' rights, conscientious objection in abortion provision may become indefensible.
- The evidence reviewed considered the impact of conscientious objection on access to and availability of abortion care and not the effectiveness of regulating conscientious objection in terms of improvements in those outcomes. However, international human rights law provides some guidance as to how States can ensure that human rights of abortion seekers are respected, protected and fulfilled. These include:
 organizing the health system to ensure that sufficient, non-objecting providers are employed and distributed fairly across the country (3);  (19); in this guideline, this has been developed into seven separate recommendations using GRADE methodology.
In order to identify the impacts of conscientious objection on abortion seekers and health workers, a systematic review of studies published between 2010 and 2020 was undertaken, identifying 26 studies conducted in Australia, Brazil, Colombia, Ghana, Italy, Mexico, Nigeria, Norway, Portugal, South Africa, Slovakia, Switzerland, Tunisia, the United Kingdom, the USA and Zambia. A summary of the evidence from these studies is presented in Supplementary material 1, EtD framework for Conscientious objection. The evidence reviewed established that conscientious objection may delay timely access to abortion and abortion care. Delay in care is exacerbated where there is a higher proportion of objecting health workers, and sometimes even in emergency cases where abortion is needed to save a woman's life. Delays are sometimes deliberately imposed by objectors. The evidence also suggests that conscientious objection contributes to increased abortion-related morbidity and mortality, and that some health workers claim conscientious objection and refuse abortion in the public sector, while providing abortion for payment in their private practices.
The studies showed that conscientious objection imposes increased barriers on populations in specific settings: rural areas; settings where abortion law has recently been changed and there is insufficient clarity on who may object to what aspects of abortion care; places where conscientious objection is not effectively regulated; and settings where objecting health workers intentionally refuse referrals or use biased counselling, or inaccurate legal and medical information to try to dissuade and obstruct people from accessing abortion (refer to section 3.2.1: Provision of information).
Refusal of abortion on the basis of conscience has been shown to impose significant burdens on women and girls, especially uncertainty about whether and where they can access abortion. Some objectors decide whether to provide abortion on a case-by-case basis depending on their view of the reason a woman seeks abortion, which means availability is not clear or consistent. Furthermore, objectors' referral practices are highly variable.
The evidence demonstrated that while most objectors were willing to refer, this was not true for all, with some objectors referring on a case-by-case basis. Additionally, referral pathways may be circuitous and burdensome, which imposes additional difficulties and delays.
Conscientious objection has significant workload implications for health workers. Where there are many objectors, non-objecting health workers have an increased workload, abortion provision is often stigmatized, and those who do provide abortion care may experience career limitation or discrimination. Unclear, unenforced or non-existent regulation and legal frameworks for conscientious objection can create burdens on health workers, including in navigating challenges associated with their conscience or ethics, cause workplace conflicts, result in non-clinical staff attempting to claim conscientious objection, and undermine organizational models for the delivery of abortion.

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO CONSCIENTIOUS OBJECTION
- Availability, accessibility, acceptability and quality must be central to the regulation of sexual and reproductive health (SRH) services.
- States that allow conscientious objection must organize their health system and abortion provision in a way that ensures that conscientious objection does not hinder access to or result in the refusal of legally available abortion care.
- States that allow conscientious objection should regulate the exercise of conscientious objection in a way that reflects best international clinical practice, protects abortion seekers, and ensures that provider refusal does not undermine or hinder access to quality abortion.
- Everyone has the right to accurate information on SRH.
- Everyone has a right to privacy and confidentiality in SRH services.
- Everyone has a right to non-discrimination and equality in accessing SRH services.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.
Ho Abortion management is needed for both induced and spontaneous abortion, including for clinical indications such as missed abortion and intrauterine fetal demise (fetal death).
Recommended management options include medical management, or surgical management using manual or electric vacuum aspiration (MVA or EVA) or dilatation and evacuation (D&E). The method of surgical abortion would depend on gestational age: generally vacuum aspiration at < 14 weeks of gestation and D&E at  14 weeks, but there is flexibility in the use of these methods between 12 and 16 weeks. Medical abortion regimens include sequential use of mifepristone followed by misoprostol or, in settings where mifepristone is not available (or is restricted for certain clinical indications), the use of misoprostol alone. A new alternative medical method, in particular using letrozole in combination with misoprostol, is also available.
For missed abortion and intrauterine fetal demise (see sections 3.4.5 and 3.4.6), in addition to the options of medical and surgical management, expectant management can be offered as an option on the condition that the woman is first informed of the longer time for expulsion of the pregnancy tissue and the increased risk of incomplete emptying of the uterus (the same applies in the case of incomplete abortion, which is addressed in section 3.5.2 on post-abortion care).
Medical abortion care for all indications plays a crucial role in providing wider access to safe, effective and acceptable abortion care. This may increase the availability and accessibility of abortion and realization of the right to SRH. Across all resource settings, the use of medical abortion has contributed to the expansion of health worker roles, more efficient use of resources and reduced maternal mortality and morbidity from unsafe abortions. Moreover, medical abortion -particularly in early pregnancy -can now be provided at the primary-care level and on an outpatient basis, or from a pharmacy, which further increases access to abortion care. Medical abortion care reduces the need for skilled surgical abortion providers and offers a non-invasive and highly acceptable and safe option to pregnant women. As a matter of international human rights law, States must provide essential medicines listed under WHO's Action Programme on Essential Drugs, which include abortion medicines (46, para. 12a).
The recommendations presented below address surgical and medical management of abortion. Implementation of all of the recommendations in this section are conditional upon women's values and preferences, the acceptability of each intervention, and the availability of resources to provide the chosen method safely. It should be noted that a woman's choice of method for abortion management may be limited or not applicable if she has medical contraindications to one of the methods. The recommendations below relate only to the method of abortion, and should not be read as suggesting gestational age limits for the availability of abortion.

# Methods of surgical abortion
The provision of vacuum aspiration includes the assessment of gestational age, cervical priming (if needed), the actual procedure, pain management including the provision of a paracervical block and the assessment of completeness of abortion through the visual inspection of products of conception. Health workers with the skills to perform a bimanual pelvic examination to diagnose and date a pregnancy, and to perform a transcervical procedure such as intrauterine device (IUD) insertion, can be trained to perform vacuum aspiration.
Recommended methods of surgical abortion at later gestational ages are vacuum aspiration and dilatation and evacuation (D&E). Although the recommendations in this section indicate differences before and after 14 weeks of gestation, it should be noted that there is flexibility in the use of one surgical method versus the other between the gestational ages of 12 and 16 weeks.

# CLINICAL SERVICES Recommendation 23: Vacuum aspiration for induced abortion at gestational ages < 14 weeks
For surgical abortion at < 14 weeks:
a. Recommend vacuum aspiration.
b. Recommend against the practice of dilatation and sharp curettage (D&C), including sharp curette checks (i.e. to "complete" the abortion) following vacuum aspiration.
- Observational studies indicate that vacuum aspiration is associated with fewer complications than D&C; however, randomized controlled trials were underpowered to detect a difference in complication rates.
- No evidence supports the use of sharp curette checks following vacuum aspiration.
- The quality of the evidence based on randomized controlled trials is low to moderate.
Source: Recommendation 1 carried forward from WHO (2012) (19). Some of the wording has been revised, and the gestational age range has been changed from "up to 12 to 14 weeks" to "before 14 weeks" (< 14 weeks).

# SERVICE DELIVERY Recommendation 24:
Vacuum aspiration for induced abortion at gestational ages < 14 weeks

# Type of health worker Recommendation Rationale a
Traditional and complementary medicine professionals
Very low-certainty evidence was found for the effectiveness of this option for components of the task (e.g. assessing uterine size with bimanual examination as part of medical abortion provision). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a These professionals perform transcervical procedures (e.g. IUD insertion) in some settings.
The expert panel affirmed that the benefits outweigh possible harms and this option has the potential to increase equitable access to quality abortion care in regions where these professionals constitute a significant proportion of the health workforce.

# Auxiliary nurses/ANMs Suggest
Condition: In contexts where established health system mechanisms involve auxiliary nurses/ANMs in providing basic emergency obstetric care, and where referral and monitoring systems are strong.
Although insufficient direct evidence was found for the safety and effectiveness of this option, the benefits outweigh any possible harms. This option has been shown to be feasible, including at scale in low-resource settings, and has the potential to decrease inequities by extending quality abortion care to rural and underserved populations.

# Nurses Recommend
Evidence was found for the safety and effectiveness (low certainty) and for women's satisfaction (low certainty) with this option. Women often consider care received from nurses as more supportive compared with other health workers (moderate-certainty evidence). This option is feasible and may decrease inequities by extending quality abortion care to underserved populations.

# Midwives Recommend
This task is recognized as a core competency in midwifery. a Evidence was found for the safety and effectiveness (moderate certainty) and for women's satisfaction with the overall abortion experience (low certainty) with this option. Women often consider care received from midwives as more supportive compared with other health workers (moderate-certainty evidence). This option has been shown to be feasible, including in lowresource settings.

# Associate/advanced associate clinicians
Evidence was found for the safety and effectiveness (moderate certainty) and for women's satisfaction with the overall abortion experience (low certainty) with this option. This option is feasible in all resource settings, and may decrease inequities by extending quality abortion care to underserved populations.

# Generalist medical practitioners Specialist medical practitioners
Within their typical scope of practice, b therefore no assessment of the evidence was conducted.
Source: Recommendation updated from WHO (2015) (23).
Note on updating of the recommendation: This was an existing recommendation for which evidence relating to traditional and complementary medicine professionals, auxiliary nurses and auxiliary nurse midwives was reviewed using GRADE methodology. After review, only the recommendation for traditional and complementary medicine professionals was upgraded, from "suggest" to "recommend"; the recommendations for all the other health worker categories remained unchanged. A summary of the evidence is presented in Supplementary material 3, EtD framework for Vacuum aspiration for all indications < 14 weeks.
a For this and all health worker recommendations, given the limited evidence for many of the health worker-task combinations, the discussions of the expert panel focused on the competency framework in WHO's 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women's values and preferences.
b For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.
In a health-care facility. Both types of vacuum aspiration can be performed in a primary care facility and on an outpatient basis.

# Implementation considerations
- While MVA is more commonly used and more likely in primary care settings, the skills required for EVA are similar, thus the recommendations above apply to the provision of either form of vacuum aspiration.
- MVA is used earlier in pregnancy and in the absence of access to a stable source of electricity.
- Dilatation and sharp curettage (D&C) should be replaced with MVA.

# CLINICAL SERVICES Recommendation 25: Methods of surgical abortion at gestational ages  14 weeks
For surgical abortion at  14 weeks: Recommend dilatation and evacuation (D&E).
- Vacuum aspiration can be used during a D&E (i.e. for the purpose of amniotomy or tissue removal at the end of the D&E).
Source: Recommendation 5 carried forward from WHO (2012) (19). The wording has been revised to use the word "recommend" to indicate that this is a strong recommendation, and the gestational age has been changed from "over 12 to 14 weeks" to "14 weeks and above" ( 14 weeks), and medical methods were removed (medical methods at later gestational ages are covered in Recommendation 29 in this guidance).

# SERVICE DELIVERY Recommendation 26: Dilatation and evacuation (D&E) for surgical abortion at gestational ages  14 weeks

# Type of health worker Recommendation Rationale a
Traditional and complementary medicine professionals
Condition: In settings where established health system mechanisms exist to include these health workers in other tasks related to maternal and reproductive health.
Although no direct evidence was found for the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a This type of health worker has been suggested (weak recommendation) to do other transcervical procedures, such as cervical priming with osmotic dilators, vacuum aspiration and inserting an IUD (see Recommendations 20,24 and 43). The expert panel affirmed that this option has the potential to increase equitable access to quality abortion care in regions where these professionals constitute a significant proportion of the health workforce.

# Midwives Suggest
Condition: In settings where established health system mechanisms exist to include these health workers in other tasks related to maternal and reproductive health.
Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a This type of health worker has been recommended to do other transcervical procedures, such as cervical priming with osmotic dilators, vacuum aspiration and inserting an IUD (see Recommendations 20,24 and 43).

# Associate/advanced associate clinicians Suggest
Condition: In settings where established health system mechanisms exist to include these health workers in other tasks related to maternal and reproductive health.
Although no direct evidence was found on the safety or effectiveness of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a The expert panel affirmed that the potential benefits outweigh the possible harms, and this option has the potential to increase equitable access to quality abortion care beyond 14 weeks of gestation.

# Table Continues

# Type of health worker Recommendation Rationale a

# Generalist medical practitioners Recommend
No direct evidence was found on the safety or effectiveness of this option as compared with provision by specialist medical practitioners. However, it appears to be feasible in both high-and low-resource settings where D&E use is common. Such doctors routinely perform other surgical procedures, such as caesarean section, vacuum aspiration and tubal ligation. The potential benefits of this option outweigh the harms. A specialist provider may not always be available on-site and this option may therefore increase equitable access to quality abortion care.

# Specialist medical practitioners Recommend
Within their typical scope of practice, b therefore no assessment of the evidence was conducted.
Source: Recommendation updated from WHO (2015) (23).
Note on updating of the recommendation: This was an existing recommendation for which evidence relating to associate/advanced associate clinicians (previously only suggested in the context of rigorous research), midwives and traditional and complementary medicine professionals (both previously recommended against) was reviewed using GRADE methodology. After review, the recommendations were upgraded for all of them to a weak recommendation ("suggest"). The gestational age range was also amended from "beyond 12 weeks" to "14 weeks and above" ( 14 weeks) to align with Recommendation 25 on this topic. A summary of the evidence is presented in Supplementary material 3, EtD framework for D&E for surgical abortion  14 weeks.
a For this and all health worker recommendations, given the limited evidence for many of the health worker-task combinations, the discussions of the expert panel focused on the competency framework in WHO's 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women's values and preferences.
b For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.
In a health-care facility. The procedure can be provided on an outpatient basis.

# Implementation considerations
- For all providers, skills needed for D&E provision are greater than for a vacuum aspiration done in earlier pregnancy and training needs are higher.
- D&E includes the use of vacuum aspiration and therefore skills and knowledge of vacuum aspiration are relevant for this task.
- Health workers providing abortion or caring for women undergoing abortion at gestational ages  12 weeks may have additional needs for professional and mentoring support.

# KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO SURGICAL ABORTION
- Health-care facilities, commodities and services must be available, accessible, acceptable and of good quality. This means they must be evidence-based and scientifically and medically appropriate and up to date.
- AT < 14 WEEKS OF GESTATION: As dilatation and sharp curettage (D&C) causes pain and suffering to women and is not recommended for use, its use is incompatible with numerous human rights including the right to health.
- AT  14 WEEKS OF GESTATION: States must ensure adequate access to essential medicines in an affordable and non-discriminatory manner.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

# Medical management of induced abortion
Medical management of spontaneous and induced abortion (for both viable and non-viable pregnancies) at early or later gestational ages involves the use of a single-dose regimen or a combination regimen of medicines used in sequence, with specific dosages and routes of administration.
The medicines that have been used for some decades for medical abortion are mifepristone in combination with misoprostol, or misoprostol alone. Similar to mifepristone, letrozole can be used in combination with misoprostol for medical abortion at early gestational ages. Letrozole is a third-generation selective aromatase inhibitor. Its mechanism of action involves suppression of estrogen levels, which modifies the progesterone receptor concentration, subsequently leading to pregnancy loss.
Medical abortion is a process that takes place over a period of up to several days rather than being a discrete procedure. In addition to information provision (including reasons to seek urgent care at any point during the process), medical abortion includes the following components or subtasks:
i. assessing eligibility for medical abortion (diagnosing and dating the pregnancy, ruling out medical contraindications);
ii. administering the abortion medicines with instructions on their appropriate use and managing the common side-effects;
iii. assessing whether the abortion process has had a successful outcome and whether any further intervention is required.
One health worker can provide the whole package of care for medical abortion, but it is equally possible for the subtasks to be carried out by different health workers and at different locations, including remotely. In addition, given the nature of the medical abortion process, it is also possible for women to manage the process by themselves outside of a health-care facility (e.g. at home), with support if and when needed. Such self-assessment and self-management approaches can be empowering for women and help to triage care, leading to a more woman-centred and more optimal use of health resources.

# Routes of administration for misoprostol used for medical abortion:
- Oral -pills are swallowed immediately - Buccal -pills are placed between the cheek and gums and swallowed after 20 to 30 minutes - Sublingual -pills are placed under the tongue and swallowed after 30 minutes - Vaginal -pills are placed in the vagina

# CLINICAL SERVICES Recommendation 27: Medical management of induced abortion at gestational ages < 12 weeks
For medical abortion at < 12 weeks: a. Recommend the use of 200 mg mifepristone administered orally, followed 1-2 days later by 800 g misoprostol administered vaginally, sublingually or buccally. The minimum recommended interval between use of mifepristone and misoprostol is 24 hours. b. When using misoprostol alone: Recommend the use of 800 g misoprostol administered buccally, sublingually or vaginally. c. (NEW) Suggest the use of a combination regimen of letrozole plus misoprostol (letrozole 10 mg orally each day for 3 days followed by misoprostol 800 g sublingually on the fourth day) as a safe and effective option. 
- Evidence from clinical studies demonstrates that the combination regimen (Recommendation 27a) is more effective than misoprostol alone.
- All routes are included as options for misoprostol administration, in consideration of patient and provider preference.
- The suggested combination regimen of letrozole plus misoprostol may be safe and effective up to 14 weeks of gestation.
Repeat doses of misoprostol can be considered when needed to achieve success of the abortion process. In this guideline we do not provide a maximum number of doses of misoprostol.  Further evidence is needed to determine the safety, effectiveness and acceptability of the letrozole plus misoprostol combination regimen at later gestational ages, especially in comparison with that of the mifepristone plus misoprostol combination regimen (the available evidence focused on comparison with the use of misoprostol alone).
Source: Recommendations 27a and 27b carried forward from WHO (2018) where they were Recommendation 3a (120). Recommendation 27c is new.

# Rationale for Recommendation 27c (combination regimen of letrozole plus misoprostol)
A systematic review assessed the efficacy, safety and acceptability of alternative methods of medical abortion to the standard regimens using mifepristone and/or misoprostol. The literature search identified seven studies, all of which reported on the combination of letrozole plus misoprostol (intervention) versus misoprostol alone (comparison) for medical abortion. No studies were identified that compared letrozole plus misoprostol versus mifepristone plus misoprostol. The study settings included China, Egypt and the Islamic Republic of Iran. A summary of the evidence is presented in Supplementary material 2, EtD framework for New medical methods for abortion.
Overall, the evidence favoured the intervention. The use of letrozole in combination with misoprostol showed lower rates of ongoing pregnancy and higher rates of successful abortion, based on low-to very low-certainty evidence. In addition, fewer women experienced side-effects, based on moderate-certainty evidence.
Discussion on the cost-effectiveness, equity, feasibility and acceptability favoured the intervention. Letrozole's typical use for infertility and cancer treatment makes it more readily accessible than mifepristone in certain parts of the world. In addition, the low cost of letrozole is another contributing factor to making this an alternative method for medical abortion.
SERVICE DELIVERY Recommendation 28: Medical management of induced abortion at gestational ages < 12 weeks, in whole or in part (i.e. performing all or some of the subtasks; see list at start of section 3.4.2) using mifepristone plus misoprostol, or misoprostol alone  Type of health worker Recommendation Rationale a

# Community health workers (CHWs) Recommend
Evidence was found for the safety, effectiveness and acceptability of this option, for all three subtasks of medical abortion (moderate certainty). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a Indirect evidence also demonstrated the feasibility and acceptability of CHWs facilitating assessment of eligibility and outcome.

# Pharmacy workers Recommend
Limited evidence was found for the safety, effectiveness, acceptability or feasibility of this option (non-comparative studies). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a Indirect evidence on CHWs was applied to support the feasibility of this option.

# Pharmacists Recommend
Although insufficient evidence was found for the safety, effectiveness and acceptability of pharmacists performing the three subtasks of medical abortion, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a Dispensing medicines on prescription is within their typical scope of practice. The expert panel affirmed that, with the aid of tools for assessment of eligibility and outcome, it would be feasible for pharmacists to provide all three subtasks of medical abortion.

# Traditional and complementary medicine professionals Recommend
Evidence was found for the safety and effectiveness of this option, and for women's satisfaction with this type of provider and services provided by them (very low certainty). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a The expert panel affirmed that the benefits outweigh any possible harms, and the potential to increase equitable access to quality abortion care in regions where these professionals constitute a significant proportion of the health workforce is high.

# Auxiliary nurses/ANMs Recommend
Evidence was found for the safety and effectiveness of this option (moderate certainty). This option is feasible and is already being implemented in some low-resource settings.

# Nurses Recommend
Evidence was found for the safety and effectiveness of this option, and for women's satisfaction with abortion services with this option (moderate certainty).

# Midwives Recommend
Evidence was found for the safety and effectiveness of this option (moderate certainty). More women are satisfied with the provider when midwives provide medical abortion (moderatecertainty evidence). This option is feasible and is already being implemented in several countries.

# Associate/advanced associate clinicians Recommend
Insufficient direct evidence was found for the effectiveness of these clinicians carrying out components of the task, e.g. assessing gestational age as part of provision of manual vacuum aspiration. Evidence was also found that health worker types with similar or less comprehensive basic training (e.g. midwives, nurses, auxiliary nurse midwives) can provide medical abortion safely and effectively (moderate certainty). This option is feasible and the potential to expand access to underserved populations is high.

# Generalist medical practitioners Specialist medical practitioners
Within their typical scope of practice, b therefore no assessment of the evidence was conducted.

# Table Continues

# Type of health worker Recommendation Rationale a

# Pregnant woman, girl or other pregnant person Recommend
Please refer to Recommendation 50 in section 3.6.2 for rationale, remarks and implementation considerations for this recommendation and further information on self-management approaches.
Source: Recommendation updated from WHO (2015) (23).
Note on updating of the recommendation: This was an existing recommendation for which evidence relating to traditional and complementary medicine professionals (previously only recommended in contexts with established health system mechanisms for the participation of these health workers in other tasks related to maternal and reproductive health), pharmacists (previously only suggested in the context of rigorous research), pharmacy workers (previously "recommend against"), community health workers (previously only suggested in the context of rigorous research) and individual/self (selfmanagement; previously "suggest") was reviewed using GRADE methodology. After review, the recommendations were upgraded for all of those health worker categories to "recommend", including all three subtasks of this intervention. A summary of the evidence is presented in Supplementary material 3, EtD framework for Medical abortion at < 12 weeks.
a For this and all health worker recommendations, given the limited evidence for many of the health worker-task combinations, the discussions of the expert panel focused on the competency framework in WHO's 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women's values and preferences.
b For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.
Available evidence for the independent provision of medical abortion by non-physicians is for pregnancy durations up to 10 weeks (70 days).  For this recommendation, the medical abortion regimens covered in the available evidence were mifepristone plus misoprostol, or misoprostol alone (the regimen using letrozole was not included).
No requirement for location (on-site vs off-site).

# Implementation considerations
- It is not essential that the person providing the medical abortion should also be trained and competent in vacuum aspiration provision.
- Restrictions on prescribing and dispensing authority for some categories of health workers may need to be modified within the regulatory framework of the health system or other mechanisms put in place to allow these providers to make the medicines available to abortion seekers.
- Privacy should be ensured in all settings, in particular in places where a private space may be challenging (e.g. pharmacies).
- Support tools can be used to assess eligibility and outcome (e.g. high-sensitivity pregnancy tests, checklists).
- A range of service-delivery models exist to facilitate the medical abortion process, such as telemedicine or community outreach (see section 3.6.1).
- Mechanisms to ensure access to quality medicines need to be set up. Development of tools like point-ofcare tests to assess quality could support both the pharmacy worker and the individual.
- It is important to note that as with all other medicines, pharmacy workers should dispense mifepristone and misoprostol as indicated by prescription.
- The person undergoing medical abortion should have access/referral to emergency care in case this becomes necessary.
- As part of the enabling environment, health workers should recognize self-management as a legitimate pathway to abortion care and to adapt health systems to facilitate and support women in their selfmanagement of abortion, e.g. adapting clinical protocols.
- Mechanisms need to be established to ensure access or referrals to post-abortion contraception services and provision of contraceptives for women who want them. For medical abortion at  12 weeks: a. Suggest the use of 200 mg mifepristone administered orally, followed 1-2 days later by repeat doses of 400 g misoprostol administered buccally, sublingually or vaginally every 3 hours.  The minimum recommended interval between use of mifepristone and misoprostol is 24 hours.
b. When using misoprostol alone: Suggest the use of repeat doses of 400 g misoprostol administered vaginally, sublingually or buccally every 3 hours. 
- The combination regimen (Recommendation 29a) is more effective than use of misoprostol alone.
- Evidence suggests that the vaginal route is the most effective. Consideration for patient and provider preference suggests the inclusion of all routes.
- Pregnancy tissue should be treated in the same way as other biological material unless the individual expresses a desire for it to be managed otherwise.
Misoprostol can be repeated at the noted interval as needed to achieve success of the abortion process. Providers should use caution and clinical judgement to decide the maximum number of doses of misoprostol in pregnant individuals with a prior uterine incision. Uterine rupture is a rare complication; clinical judgement and health system preparedness for emergency management of uterine rupture must be considered with later gestational age.  The dose of misoprostol should be reduced for induced abortion beyond 24 weeks due to limited data. Clinical judgement should be used to determine the appropriate dosage, recognizing the greater sensitivity of the uterus to prostaglandins. Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a In addition, these professionals have been recommended to provide medical abortion at < 12 weeks (Recommendation 28). The potential to increase equitable access to quality abortion care in regions where these professionals form a significant proportion of the health workforce is high.

# Auxiliary nurses/ANMs Suggest
Condition: In contexts where established and easy access to appropriate surgical backup and proper infrastructure is available to address incomplete abortion or other complications.
Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker. a In addition, these health workers have been recommended to provide medical abortion at < 12 weeks (Recommendation 28). This option is feasible and acceptable and has the potential to increase equitable access to quality abortion care. Although insufficient direct evidence was found for the safely and effectiveness of nurses providing this intervention as a whole, these health workers are often responsible for the monitoring and care of women from the time of misoprostol administration to completion of the abortion. Women often find abortion care provided by nurses to be more acceptable (moderate-certainty evidence).

# Midwives Suggest
Condition: In contexts where established and easy access to appropriate surgical backup and proper infrastructure is available to address incomplete abortion or other complications.
Although insufficient direct evidence was found for the safety and effectiveness of midwives providing this intervention as a whole, these health workers are often responsible for the monitoring and care of women from the time of misoprostol administration to completion of the abortion. Women often find abortion care provided by midwives to be more acceptable (moderate-certainty evidence).

# Associate/advanced associate clinicians Suggest
Condition: In contexts where established and easy access to appropriate surgical backup and proper infrastructure is available to address incomplete abortion or other complications.
Although insufficient direct evidence was found for the safety of effectiveness of this option, these clinicians routinely carry out tasks of similar complexity (e.g. vacuum aspiration and manual removal of placenta) (138). These clinicians are often present at higher-level facilities where care during advanced gestation is provided. A trained specialist medical practitioner may not always be present at higher-level facilities and the potential to sustain services for advanced gestational ages is increased with more than one trained provider on site.

# Generalist medical practitioners Recommend
Although insufficient direct evidence was found for the safety and effectiveness of this option, generalist medical practitioners routinely carry out tasks of similar or greater complexity (e.g. conducting deliveries, manual removal of placenta, vacuum aspiration). The potential benefits of this option outweigh the harms and the intervention has proven feasible in several settings. A specialist medical practitioner may not always be available on-site and therefore this option may increase equitable access to quality abortion care.

# Specialist medical practitioners Recommend
Within their typical scope of practice, b therefore no assessment of the evidence was conducted.
Source: Recommendation updated from WHO (2015) (23).