Safe abortion: technical and policy guidance for health systems - Second edition

For more information, please contact:
Department of Reproductive Health and Research
World Health Organization
Avenue Appia 20, CH-1211 Geneva 27, Switzerland
Fax: +41 22 791 4171
E-mail: reproductivehealth@who.int
www.who.int/reproductivehealthISBN 978 92 4 154843 4

Safe abortion:technical and policy guidancefor health systems
Second edition

Safe abortion:technical and policy guidancefor health systems
Second edition

Acknowledgements
WHO is grateful for the technical contributions of the external experts who participated in the initial online
consultation, the technical consultation and the review of this guideline.
(Details of participants and additional external reviewers are provided in Annex 4.)

Funding source
The development of these guidelines was supported by the UNDP/UNFPA/WHO/World Bank Special
Programme of Research, Development and Research Training in Human Reproduction (HRP).

WHO Library Cataloguing-in-Publication Data
Safe abortion: technical and policy guidance for health systems – 2nd ed.
1.Abortion, Induced - methods 2.Abortion, Induced - standards. 3.Prenatal
care - organization and administration 4.Prenatal care - standards
5.Maternal welfare 6.Health policy 7.Guidelines. I.World Health Organization.
ISBN 978 92 4 154843 4			

(NLM classification: WQ 440)

© World Health Organization 2012.
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Printed inii

Safe abortion: technical and policy guidance for health systems

Abbreviations
D&C

dilatation and (sharp) curettage

D&E

dilatation and evacuation

EVA

electric vacuum aspiration

GMP

good manufacturing practice

GRADE Grading of Recommendations Assessment, Development and Evaluation
hCG

human chorionic gonadotrophinHIVhuman immunodeficiency virus

HLDhigh-level disinfection

ICPD

International Conference on Population and Development

IUD

intrauterine deviceIV

intravenous

KClpotassium chloride

LMP

last menstrual period

MVA

manual vacuum aspirationNGO

nongovernmental organization

PG

prostaglandinRh

Rhesus (blood group)

RTI

reproductive tract infection

STI

sexually transmitted infection

UN

United Nations

UNFPA United Nations Population Fund
UNPD

United Nations Population Division

USA

United States of America

WHO

World Health Organization

Safe abortion: technical and policy guidance for health systemsiii

Definitions used in this document
yy Duration or gestational age of pregnancy (gestation): the number of days or weeks since the firstday of the woman’s last normal menstrual period(LMP) in women with regular cycles (for womenwith irregular cycles, the gestational age mayneed to be determined by physical or ultrasoundexamination). The first trimester is generally
considered to consist of the first 12 or the first 14
weeks of pregnancy (see Table 1).

Table 1. Equivalent gestational ages in weeks
and days during the first trimester
Weeks of gestation

Days of gestation

<1

0–6

1

7–13

2

14–20

3

21–27

4

28–34

5

35–41

6

42–48

7

49–55

8

56–62

9

63–69

10

70–76

11

77–83

12

84–90

13

91–97

14

98–104Adapted from: International statistical classification of diseases
and health related problems, 10th revision – ICD-10, Vol. 2,
2008 Edition. Geneva, World Health Organization, 2009.

iv

Safe abortion: technical and policy guidance for health systems

yy Medical methods of abortion (medical abortion):use of pharmacological drugs to terminate pregnancy. Sometimes the terms “non-surgical abortion” or “medication abortion” are also used.
yy Menstrual regulation: uterine evacuation withoutlaboratory or ultrasound confirmation of pregnancy for women who report recent delayed
menses.
yy Osmotic dilators: short, thin rods made of seaweed (laminaria) or synthetic material. After placement in the cervical os, the dilators absorb moisture and expand, gradually dilating the cervix.
yy Routes of misoprostol administration:–– oral – pills are swallowed immediately;–– buccal – pills are placed between the cheekand gums and swallowed after 30 minutes;–– sublingual – pills are placed under the tongue
and swallowed after 30 minutes;–– vaginal – pills are placed in the vaginal fornices (deepest portions of the vagina) andthe woman is instructed to lie down for
30 minutes.
yy Surgical methods of abortion (surgical abortion):use of transcervical procedures for terminating pregnancy, including vacuum aspiration anddilatation and evacuation (D&E). (See Chapter 2,
Section 2.2.4 for a more detailed description of
methods of surgical abortion.)
Human Rights terminology
yy International human rights treaty: also sometimes
called a Covenant or a Convention, is adopted by
the international community of States, normallyat the United Nations General Assembly. Eachtreaty sets out a range of human rights, and corresponding obligations which are legally bindingon States that have ratified the treaty. Annex 7
includes a list of these treaties.

yy Treaty monitoring body: each of the international
human rights treaties is monitored by a designated treaty monitoring body (see Annex 7). The
treaty monitoring bodies are committees composed of independent experts. Their main function is to monitor the States’ compliance with thetreaty in question, including through the examination of State reports.
yy General comments/recommendations: a treaty
monitoring body’s interpretation of the content
of human rights provisions on thematic issues
or its methods of work. General comments seek
to clarify the reporting duties of State parties
with respect to certain provisions and suggest
approaches to implementing treaty provisions.
yy Concluding observations: following submissionof a State report and a constructive dialogue with
the State party to the particular convention, treaty
monitoring bodies issue concluding observations to the reporting State, which are compiled
in an annual report and sent to the United Nations
General Assembly.
yy Regional human rights treaties: States adopted
human rights treaties in Africa, the Americas,
Europe and the Middle East. Regional humanrights bodies, such as the African Union, theOrganization of American States, the Council ofEurope, the European Union, and the League ofArab States monitor States’ compliance with thetreaties. To date, there are no regional humanrights treaties in South-East Asia or the Western
Pacific. Annex 7 includes a list of regional humanrights treaties.
yy Human rights standards: the meaning and scopeof human rights as interpreted and applied by thehuman rights bodies tasked with this work, e.g.
international, regional and national courts, andhuman rights committees.

Safe abortion: technical and policy guidance for health systemsvvi

Safe abortion: technical and policy guidance for health systems

CONTENTS
Executive summary

1

Process of guideline development

10

Background10

Methods

10

Decision-making during the technical consultation

12

Document preparation and peer review

12

Dissemination of the guidance document

12

Updating the guidelines

13

Chapter 1

16

Safe abortion care: the public health and human rights rationale

17

1.1 Background17

1.2 Public health and human rights

18

1.3 Pregnancies and abortions

19

1.4 Health consequences of unsafe abortion

19

1.5 Contraceptive use, accidental pregnancies and unmet need for family planning22

1.6 Regulatory and policy context

23

1.7 Economic costs of unsafe abortion

26

Chapter 2

30

Clinical care for women undergoing abortion

31

2.1 Pre-abortion care32

2.2 Methods of abortion

37

2.3 Post-abortion care and follow-up

52

Chapter 3

62Planning and managing safe abortion care63

3.1 Introduction

64

3.2 Constellation of services

64

3.3 Evidence-based standards and guidelines

65

3.4 Equipping facilities and training health-care providers

69

3.5 Monitoring, evaluation and quality improvement72

3.6 Financing

79

3.7 The process of planning and managing safe abortion care

80

Safe abortion: technical and policy guidance for health systemsvii

Chapter 4

86

Legal and policy considerations

87

4.1 Women’s health and human rights

87

4.2 Laws and their implementation within the context of human rights

90

4.3. Creating an enabling environment

98

Annex 1
Research gaps identified at the technical consultation

105

Annex 2
Final GRADE questions and outcomes

106

Annex 3Standard GRADE criteria for grading of evidence

109

Annex 4
Participants in the technical consultation

110

Annex 5
Recommendations from the technical consultation for the second edition of
Safe abortion: technical and policy guidance for health systems

113

Annex 6
Post-abortion medical eligibility for contraceptive use

120

Annex 7
Core international and regional human rights treaties

viii

Safe abortion: technical and policy guidance for health systems

122

Executive summary

Over the past two decades, the health evidence,technologies and human rights rationale for providing
safe, comprehensive abortion care have evolved
greatly. Despite these advances, an estimated
22 million abortions continue to be performed
unsafely each year, resulting in the death of an
estimated 47 000 women and disabilities for an
additional 5 million women (1). Almost every oneof these deaths and disabilities could have been
prevented through sexuality education, familyplanning, and the provision of safe, legal induced
abortion and care for complications of abortion.
In nearly all developed countries, safe abortions arelegally available upon request or under broad socialand economic grounds, and services are generally
easily accessible and available. In countries where
induced abortion is legally highly restricted and/or
unavailable, safe abortion has frequently become
the privilege of the rich, while poor women have little
choice but to resort to unsafe providers, causing
deaths and morbidities that become the social andfinancial responsibility of the public health system.

Safe abortion: technical and policy guidance forhealth systems (2). In this process, the WHO standards for guideline development have been followed,
including: identification of priority questions andoutcomes; retrieval, assessment and synthesis ofevidence; formulation of recommendations; and planning for dissemination, implementation, impact evaluation and updating. For the clinical recommendations
presented in Chapter 2, evidence profiles related
to the prioritized questions were prepared, based
upon recent systematic reviews, most of which areincluded in the Cochrane Database of Systematic
Reviews. In addition, Chapters 1, 3 and 4 of the original 2003 publication were reviewed and updated toreflect the latest estimates on unsafe abortion worldwide, new literature on the topic of service delivery,
and new developments in international, regional andnational human rights law. A guideline developmentgroup, comprising members of an international panelof experts, reviewed and revised the draft recommendations based on the evidence profiles, througha participatory, consensus-driven process.

In view of the need for evidence-based best practices for providing safe abortion care in order toprotect the health of women, the World HealthOrganization (WHO) has updated its 2003 publication

The target audience for this guidance is policy-makers, programme managers and providers of abortion
care. The use of the clinical recommendations should
be individualized to each woman, with emphasis on

Safe abortion: technical and policy guidance for health systems

1her clinical status and the specific method of abortion to be used, while considering each woman’spreferences for care.
While legal, regulatory, policy and service-delivery
contexts may vary from country to country, therecommendations and best practices describedin this document aim to enable evidence-based
decision-making with respect to safe abortion
care. Details of their development and applicationof the quality of evidence grading are found under
the Methods section, page 10. Box 1 presents therecommendations related to specific methods of surgical abortion, while Box 2 summarizes the recommendations for medical abortion. Box 3 addresses
recommendations for the surgical or medical methods preferred beyond 12 weeks of gestation. Box 4summarizes the recommendations related to clinicalcare prior to induced abortion, including consideration of cervical preparation, use of diagnostic ultrasonography, use of antibiotics and pain-management
options. Box 5 summarizes the recommendations

related to post-abortion care, including initiation ofcontraception, treatment of incomplete abortion andwhether there is a medical need for routine followup visits after induced abortion. Box 6 summarizes
the main recommendations from Chapter 3 related
to application of the clinical guidance in establishing and strengthening abortion services, including
development of national standards and guidelines;
training and equipping of service providers; assessing, prioritizing and financing of health-system needs;
introducing and scaling-up of interventions; andmonitoring and evaluation. Finally, Box 7 summarizes
the main recommendations from Chapter 4 concerning legal, policy and human rights dimensions.
Members of the guideline development group
noted important knowledge gaps that need to beaddressed through primary research. Overall, thegroup placed a high value on research to demedicalize abortion care. Observations regarding the needfor future research are presented in Annex 1.

BOX 1

Recommended methods for surgical abortion
Vacuum aspiration is the recommended technique of surgical abortion for pregnancies of up to
12 to 14 weeks of gestation. The procedure should not be routinely completed by sharp curettage.
Dilatation and sharp curettage (D&C), if still practised, should be replaced by vacuum aspiration.
(Strength of recommendation: strong.
Quality of evidence based on randomized controlled trials: low to moderate.)
See also: Annex 5, Recommendation 1, page 113.

2

Safe abortion: technical and policy guidance for health systems

BOX 2

Recommended methods for medical abortion
The recommended method for medical abortion is mifepristone followed by misoprostol.

For pregnancies of gestational age up to 9 weeks (63 days)
The recommended method for medical abortion is mifepristone followed 1 to 2 days later by misoprostol.
[See notes below for dosages, and routes of administration.](Strength(S
trength of recommendation: strong.
Quality of evidence based on randomized
randomized controlled trials: moderate.)
Dosages and routes of administration for mifepristone followed by misoprostol
Mifepristone should always be administered orally. The recommended dose is 200 mg.
Administration of misoprostol is recommended 1 to 2 days (24 to 48 hours) following ingestion of
mifepristone.
yy For vaginal, buccal or sublingual routes, the recommended dose of misoprostol is 800 μg.
yy For oral administration, the recommended dose of misoprostol is 400 μg.
yy With gestations up to 7 weeks (49 days) misoprostol may be administered by vaginal, buccal, sublingual or oral routes. After 7 weeks of gestation, oral administration of misoprostol should not be used.
yy With gestations up to 9 weeks (63 days) misoprostol can be administered by vaginal, buccal or sublingual routes.
See also: Annex 5, Recommendation 2, page 113.

For pregnancies of gestational age between 9 and 12 weeks (63–84 days)
The recommended method for medical abortion is 200 mg mifepristone administered orally followed
36 to 48 hours later by 800 μg misoprostol administered vaginally. Subsequent misoprostol doses
should be 400 μg, administered either vaginally or sublingually, every 3 hours up to four further doses,
until expulsion of the products of conception.
(Strength of recommendation: weak.
Quality of evidence based on one randomized controlled trial and one observational study: low.)
See also: Annex 5, Recommendation 3, page 114.

For pregnancies of gestational age over 12 weeks (84 days)
The recommended method for medical abortion is 200 mg mifepristone administered orally followed
36 to 48 hours later by repeated doses of misoprostol.
[See notes below for dosages, and routes of administration of misoprostol.](Strength of recommendation: strong.
Quality of evidence based on randomized controlledcontrolled trials: low to moderate.)yy With gestations between 12 and 24 weeks, the initial misoprostol dose following oral mifepristone administration may be either 800 μg administered vaginally or 400 μg administered orally.
Subsequent misoprostol doses should be 400 μg, administered either vaginally or sublingually, every
3 hours up to four further doses.
yy For pregnancies beyond 24 weeks, the dose of misoprostol should be reduced, due to the greater
sensitivity of the uterus to prostaglandins, but the lack of clinical studies precludes specific dosing
recommendations.
See also: Annex 5, Recommendation 6, page 115.

Safe abortion: technical and policy guidance for health systems

3

box 2 continued

Recommended methods for medical abortion
Where mifepristone is not available

For pregnancies of gestational age up to 12 weeks (84 days)
The recommended method of medical abortion is 800 μg of misoprostol administered by vaginal or sublingual routes. Up to three repeat doses of 800 μg can be administered at intervals of at least 3 hours,
but for no longer than 12 hours.
(Strength of recommendation: strong.
Quality of evidence based on one randomized controlled trial: high.)
See also: Annex 5, Recommendation 4, page 115.

For pregnancies of gestational age over 12 weeks (84 days)
The recommended method of medical abortion is 400 μg of misoprostol administered vaginally or sublingually, repeated every 3 hours for up to five doses.
(Strength of recommendation: strong.
Quality of evidence based on one randomized controlled trial: low to moderate.)
yy For pregnancies beyond 24 weeks, the dose of misoprostol should be reduced, due to the greater
sensitivity of the uterus to prostaglandins, but the lack of clinical studies precludes specific dosing
recommendations.
See also: Annex 5, Recommendation 6, pages 115 and 116.

BOX 3

Recommended methods of abortion for pregnancies of gestational age over
12 to 14 weeks
Dilatation and evacuation (D&E) and medical methods (mifepristone and misoprostol; misoprostol alone)
are both recommended methods for abortion for gestation over 12 to 14 weeks. Facilities should offer at
least one, and preferably both methods, if possible, depending on provider experience and the availability of training.
(Strength of recommendation: strong.
Quality of evidence based on randomized controlled trials: low.)
See also: Annex 5, Recommendation 5 page 115.

4

Safe abortion: technical and policy guidance for health systems

BOX 4

Recommendations for care preceding induced abortion
Cervical preparation
Prior to surgical abortion, cervical preparation is recommended for all women with a pregnancy over
12 to 14 weeks of gestation. Its use may be considered for women with a pregnancy of any gestationalage.
(Strength of recommendation: strong.
Quality of evidence based on randomized controlled trials: low.)yy Any one of these methods of cervical preparation before surgical abortion in the first trimester isrecommended:–– oral mifepristone 200 mg (24 to 48 hours in advance); or–– misoprostol 400 μg administered sublingually, 2 to 3 hours prior to the procedure; or–– misoprostol 400 μg administered vaginally 3 hours prior to the procedure; or–– laminaria placed intracervically 6 to 24 hours prior to the procedure.
(Strength of recommendation: strong.
Quality of evidence based on randomized controlled trials: low to moderate.)
See also: Annex 5, Recommendation 7, page 116.

All women undergoing dilatation and evacuation (D&E) with a pregnancy over 14 weeks of gestation
should receive cervical preparation prior to the procedure.
(Strength of recommendation: strong.
Quality of the evidence based on randomized controlled trials: low to moderate.)yy The recommended methods of cervical preparation prior to dilatation and evacuation (D&E) after
14 weeks of gestation are osmotic dilators or misoprostol.
(Strength of recommendation: strong.
Quality of evidence based on randomized controlled trials: moderate.)
See also: Annex 5, Recommendation 8, page 117.

Safe abortion: technical and policy guidance for health systems

5

box 4 continued

Recommendations for care preceding induced abortion
Ultrasound scanning
Use of routine pre-abortion ultrasound scanning is not necessary.
(Strength of recommendation: strong.
Quality of evidence based on a randomized controlled trial and observational studies: very low.)
See also: Annex 5, Recommendation 12, page 118.

Prophylactic antibiotics
All women having surgical abortion, regardless of their risk of pelvic inflammatory infection, should
receive appropriate prophylactic antibiotics pre- or peri-operatively.
(Strength of recommendation: strong.
Quality of evidence based on randomized controlled trials: moderate.)
See also: Annex 5, Recommendation 11, page 118.

For women having medical abortion, routine use of prophylactic antibiotics is not recommended.
(Strength of recommendation: strong.
Quality of evidence based on one observational trial: very low.)
See also: Annex 5, Recommendation 11, page 118.

Pain management
All women should be routinely offered pain medication (e.g. non-steroidal anti-inflammatory drugs) during both
medical and surgical abortions.
General anaesthesia is not recommended routinely for vacuum aspiration abortion or dilatation and evacuation(D&E).
(Strength of recommendation: strong.
Quality of evidence based on randomized controlled trials: low.)
Remarks: Medication for pain management for both medical and surgical abortions should always be offered,and provided without delay to women who desire it. In most cases, analgesics, local anaesthesia and/or conscious sedation supplemented by verbal reassurance are sufficient, although the need for pain management
increases with gestational age.
See also: Annex 5, Recommendation 14, page 118.

6

Safe abortion: technical and policy guidance for health systems

BOX 5

Recommendations for care post-abortion
Contraception
Women may start hormonal contraception at the time of surgical abortion, or as early as the time ofadministration of the first pill of a medical abortion regimen. Following medical abortion, an intrauterine
device (IUD) may be inserted when it is reasonably certain that the woman is no longer pregnant.
(Strength of recommendation: strong.
Quality of evidence based on randomized controlled trials: very low.)
See also: Annex 5, Recommendation 13, page 118.

Follow-up
There is no medical need for a routine follow-up visit following uncomplicated surgical abortion or
medical abortion using mifepristone followed by misoprostol. However, women should be advised that
additional services are available to them if needed or desired.
(Strength of recommendation: strong.
Quality of the evidence based on observational studies and indirect evidence: low.)
See also: Annex 5, Recommendation 9, page 117.

Incomplete abortion
If uterine size at the time of treatment is equivalent to a pregnancy of gestational age 13 weeks or less,either vacuum aspiration or treatment with misoprostol is recommended for women with incomplete
abortion. The recommended regimen of misoprostol is a single dose given either sublingually (400 μg) ororally (600 μg).
(Strength of recommendation: strong.
Quality of evidence based on randomized controlled trials: low.)
See also: Annex 5, Recommendation 10, page 117.

Safe abortion: technical and policy guidance for health systems

7

BOX 6

Recommendations for health systems
To the full extent of the law, safe abortion services should be readily available and affordable to all
women. This means services should be available at primary-care level, with referral systems in place forall required higher-level care.
Actions to strengthen policies and services related to abortion should be based on the health needs andhuman rights of women and a thorough understanding of the service-delivery system and the broadersocial, cultural, political and economic context.
National standards and guidelines for safe abortion care should be evidence based and periodically
updated, and should provide the necessary guidance to achieve equitable access to good-qualitycare. New policy and programme interventions should reflect evidence-based best practices. Complex
service-delivery interventions require local evidence of feasibility and effectiveness through pilot-testing
on a small scale prior to investing resources in scaling-up.
Training of abortion providers must ensure that they have the competencies to provide good-quality
care in accordance with national standards and guidelines. Ensuring good-quality abortion care requires
ongoing supervision, quality assurance, monitoring and evaluation.
Financing of abortion services should take into account costs to the health system while ensuring that
services are affordable and readily available to all women who need them. Costs of adding safe abortion
care to existing health services are likely to be low, relative to the costs to the health system of treatingcomplications of unsafe abortion.
Successful scaling-up requires systematic planning, management, guidance and support for theprocess by which pilot interventions are both expanded and institutionalized. It also requires sufficienthuman and financial resources to support the process.
See Chapter 3 for further details.

8

Safe abortion: technical and policy guidance for health systems

BOX 7

Recommendations related to regulatory, policy andhuman rights considerations
Laws and policies on abortion should protect women’s health and their human rights.
Regulatory, policy and programmatic barriers that hinder access to and timely provision of safe abortion
care should be removed.
An enabling regulatory and policy environment is needed to ensure that every woman who is legallyeligible has ready access to safe abortion care. Policies should be geared to respecting, protecting
and fulfilling the human rights of women, to achieving positive health outcomes for women, to providing good-quality contraceptive information and services, and to meeting the particular needs of poor
women, adolescents, rape survivors and women living with HIV.
See Chapter 4 for further details.

Safe abortion: technical and policy guidance for health systems

9

Process of guideline development
Background
Safe abortion: technical and policy guidance forhealth systems was published by the World HealthOrganization (WHO) in 2003 (2) as the first global
guidance for abortion-related care and policy issues.
Since that time, the guidance has been translated
into French, Russian, Spanish and various non-official
United Nations (UN) languages and has been widelyused by governments, nongovernmental organizations (NGOs), providers of women’s health services,and women’s health and human rights advocates.
Since publication of the guidance in 2003, a considerable amount of new data have been produced
and published, relating to epidemiological, clinical,
service delivery, legal and human rights aspects ofproviding safe abortion care. Therefore, preparation
for this revision of the guidance included extensive
literature review and updating of recommendations
related to service delivery, legal and policy issues,and the conduct of new systematic reviews andupdates of outdated systematic reviews to provide
the evidence for recommendations related to clinical questions prioritized by an international panelof experts. The substantial revisions in this updatereflect changes in methods of abortion and relatedcare, service delivery as it applies to the availability
and use of new methods, and application of humanrights for policy-making and legislation related toabortion, among other topics. Recommendationsin the 2003 guidance for which there was no newevidence remain unchanged.
Additionally, in parallel with the revision of the guidance, a companion document entitled Clinical practicehandbook for safe abortion care has been developed
for providers of abortion services, with additional
information on the details of implementing the clinicalcare recommendations of the guidance document.

10

Safe abortion: technical and policy guidance for health systems

Methods
This document was prepared according to the WHO
standards and requirements for guideline development. In summary, this process included: identification of priority questions and outcomes; evidence
retrieval, assessment and synthesis; formulation ofrecommendations; and planning for dissemination,
implementation, impact evaluation and updating.
The identification of priority questions for recommendations was initiated by professional staff fromthe WHO Department of Reproductive Health andResearch (WHO Secretariat), who drafted a list ofquestions and outcomes related to provision of safe
abortion care in light of new data since the initialpublication of the guidance in 2003 (2), as well as inresponse to solicited feedback from its users.
A global panel of international stakeholders, including health-service providers, health programmemanagers, researchers, methodologists, humanrights lawyers, and women’s health and human rights
advocates, was established to review and prioritize
the draft questions and outcomes, which included
clinical, technical and programmatic topics. Thisinitial consultation was conducted electronically,
and all responses were reviewed by members of the
WHO Secretariat. Questions and outcomes rated
as critical were included in the scope of this document, for evidence grading using the Grading ofRecommendations Assessment, Development and
Evaluation (GRADE) approach, and the developmentof recommendations. The list of final questions considered for GRADE tables and outcomes is presented
in Annex 2.
Cochrane systematic reviews of randomized clinical trials were the primary source of evidence forthe recommendations. Based on the list of priority
questions, identified as described above, the relevant
Cochrane systematic reviews (3–14) were identified and conducted or updated using their specific,

standard search strategies. Additionally, three systematic reviews were conducted outside of the
Cochrane Database of Systematic Reviews and were
published in peer-reviewed journals (15–17). The
search strategies and the specific criteria for including and excluding trials identified by the search areprovided in the corresponding systematic reviews.
The available evidence was appraised and gradedfollowing the GRADE approach (18–22), reflecting thepriority comparisons and outcomes; comparisonsand outcomes not relevant to the recommendation were excluded. As a result, evidence profiles(GRADE tables) were prepared (available fromhttp://apps.who.int/iris/bitstream/10665/75840/1/
WHO_RHR_12.10_eng.pdf) - date accessed 14
February 2013. Standardized criteria for grading theevidence using GRADE are presented in Annex 3.
For each selected comparison, data for available
priority outcomes have been assessed and presented
in the evidence profiles (if data for priority outcomes
were not available in specific comparisons, they wereomitted in the GRADE tables). Based on the evidence
profiles, recommendations were drafted by the WHO
Secretariat.
For Chapter 3 on establishing and strengthening safe
abortion services, two issues were identified (indicators of safe abortion and competencies for providing safe abortion) for which recent WHO guidance
was already available. Therefore, the steps taken toaddress the topics in Chapter 3 were to adopt andreference recent WHO guidance, and to conduct anextensive literature review of the issues presented forthe existing recommendations from the first edition of
the document, while updating the references.

to the existing content, based on international andregional human rights treaty provisions and the workof international and regional human rights bodies.
Staff at the programme also produced a series ofresearch briefs providing human rights and legal
research and analysis on selected issues of particularconcern (for example, elaboration of the health indication for safe abortion, conscientious objection, andlegal and regulatory barriers).
In order to review the draft recommendations andthe supporting evidence, a technical consultation
was organized at WHO headquarters in Geneva,
Switzerland. The members of a guidelines development group – a subset of the international panel thatparticipated in the initial online consultation and otherexperts – were invited to participate in this consultation (see Annex 4 for a list of participants and theiraffiliations). Draft recommendations, revised chaptersand supporting documents were shared with the participants before the consultation for their review.
Declarations of interest were obtained from theparticipants in the technical consultation using astandard WHO form prior to their participation in themeeting. These declarations were reviewed by the
WHO Secretariat and, when necessary, by the WHO
Office of the Legal Counsel before the consultation.
Two consultation participants (Dr Laura Castleman
and Dr Helena von Hertzen) declared that they were
employed by organizations that have or might appear
to have commercial conflicts of interest. For recommendations that were directly relevant to their organizations’ work, they left the room during final recommendation making. No other participants declared
any conflicts or potential conflicts of interest.

For Chapter 4 on legal and policy considerations,
WHO contracted the Programme on International
Reproductive and Sexual Health Law in the Facultyof Law at the University of Toronto, Toronto, Canada,
to assist the revision, including proposing changes

Safe abortion: technical and policy guidance for health systems

11

Decision-making during the technicalconsultation
For each recommendation, the participants in thetechnical consultation discussed the draft text
prepared by the WHO Secretariat, with the aim ofreaching consensus. Consensus was defined asagreement by the majority of participants, with noone strongly disagreeing. No strong disagreements
occurred during the consultation and, therefore, analternative system, such as voting, was not necessary. In addition to the scientific evidence and its
quality, applicability issues, costs and other expert
opinions were considered while formulating the final
recommendations.
The strength of the recommendations was determined through the assessment of each intervention
on the basis of: (i) desirable and undesirable effects;(ii) the quality of available evidence; (iii) values andpreferences related to interventions in different settings; (iv) the cost of options available to health-care
workers in different settings; and (v) the perceived
likelihood of changing the recommendation due tofurther research. In general, a strong recommendation with moderate- or high-quality evidence indicates that further research should not be considereda priority. The full text of the recommendations fromthe technical consultation is found in Annex 5.
Topics not identified as the subject of a new systematic review for which WHO recommendations alreadyexisted were presented at the technical consultation, for group discussion. Those recommendations
found by the group to be relevant and current wereendorsed and adopted. These topics included:
indicators of safe abortion; contraceptive use following abortion; and the recommendations surrounding
establishing and strengthening abortion services,
including competencies for providing abortion care,found in Chapter 3.

12

Safe abortion: technical and policy guidance for health systems

Document preparation and peer review
A preliminary document, containing the draft recommendations, was prepared and made available to theparticipants in the technical consultation three weeks
before the meeting. The draft recommendations
were amended during the meeting, based on thediscussions. After the meeting, the draft document
was revised by the WHO Secretariat. The revised
version was sent electronically to all participants, fortheir approval and comments. Primary reviewers foreach chapter were identified based on their fields ofexpertise. Finally, the whole document was sent forexternal critical appraisal and peer review. During
this process of review, important suggestions wereincorporated into the document; however, the WHO
Secretariat refrained from making major changes inthe scoping (e.g. further expansion of the guidancescoping) or in the recommendations agreed upon
during the consultation.

Dissemination of the guidance document
As with the first edition of the guidance document,
dissemination will be undertaken through distribution of the print version, and a series of regional
workshops will be organized on applying the WHOStrategic Approach to strengthening sexual andreproductive health policies and programmes (23) tothe issue of unsafe abortion. The aim of the workshops will be to develop proposals based on theguidance that can strengthen safe abortion carewithin sexual and reproductive health programmes.
The workshops will include preselected country
teams with representatives from ministries/departments of health, including a variety of health-service
providers and programme managers, and representatives from NGOs, professional associations and UN
organizations.

Assessing the impact of published guidelines is achallenging task. In an attempt to do so, we plan
to monitor the number of requests from countries
for assistance in implementation of the guidelines,
direct follow-up in countries applying the Strategic
Approach, and the number of countries that modify
their national abortion programme monitoring toreflect the indicators for safe abortion provided inTable 3.2 (page 75) of this document. Additionally, we
will continue to monitor the number of downloads ofthe document, as well as the number of hard copiesof the guidance requested and distributed.

Updating the guidelines
The WHO Secretariat anticipates that these guidelines will be reviewed again four years following their
publication, to assess whether revision is necessary,
based upon newly available evidence and feedback
from users.

Safe abortion: technical and policy guidance for health systems

13

References
1.

Unsafe abortion: global and regional estimates of
the incidence of unsafe abortion and associatedmortality in 2008, 3rd ed. Geneva, World HealthOrganization, 2011.

2.

Safe abortion: technical and policy guidance forhealth systems. Geneva, World Health Organization,
2003.

3.

Kulier R et al. Medical methods for first trimester abortion. Cochrane Database of Systematic
Reviews, 2004, (1):CD002855, updated 2010.

4.

Kulier R et al. Surgical methods for first trimester
termination of pregnancy. Cochrane Database of
Systematic Reviews, 2001, (4):CD002900.

5.

Say L et al. Medical versus surgical methods
for first trimester termination of pregnancy.
Cochrane Database of Systematic Reviews, 2005,(1):CD003037, updated 2010.

6.

7.

8.

9.

Lohr PA, Hayes JL, Gemzell-Danielsson K. Surgicalversus medical methods for second trimester
induced abortion. Cochrane Database of Systematic
Reviews, 2008, (1):CD006714.
Wildschut H et al. Medical methods for mid-trimester termination of pregnancy. Cochrane Database of
Systematic Reviews, 2011, (1):CD005216.
Kapp N et al. Cervical preparation for first trimester
surgical abortion. Cochrane Database of Systematic
Reviews, 2010, (2):CD007207.
Promsonthi P, Preechapornprasert D, Chanrachakul
B. Nitric oxide donors for cervical ripening in firsttrimester surgical abortion. Cochrane Database of
Systematic Reviews, 2009, (4):CD007444.

10. Newmann SJ et al. Cervical preparation forsecond trimester dilation and evacuation.
Cochrane Database of Systematic Reviews, 2010,(8):CD007310.
11. Neilson JP et al. Medical treatments for incomplete miscarriage (less than 24 weeks). Cochrane
Database of Systematic Reviews, 2010,(1):CD007223.

14

Safe abortion: technical and policy guidance for health systems

12. Tunçalp O, Gülmezoglu AM, Souza JP. Surgicalprocedures for evacuating incomplete miscarriage.
Cochrane Database of Systematic Reviews, 2010,(9):CD001993.
13. Mueller M et al. Antibiotic prophylaxis for medical and surgical first trimester induced abortion.
Cochrane Database of Systematic Reviews, 2012,2012, (3):CD005217.
14. Renner RM et al. Pain control in first trimester surgical abortion. Cochrane Database of Systematic
Reviews, 2009, (2):CD006712.
15. Kulier R, Kapp N. Comprehensive analysis of the useof pre-procedure ultrasound for first- and secondtrimester abortion. Contraception, 2011, 83:30–33.
16. Grossman D, Grindlay K. Alternatives to ultrasoundfor follow-up after medication abortion: a systematic
review. Contraception, 2011, 83(6):504–510.
17. Jackson E, Kapp N. Pain control in first-trimesterand second-trimester medical termination of pregnancy: a systematic review. Contraception, 2011,
83:116–126.
18. Guyatt GH et al. Incorporating considerations ofresources use into grading recommendations.
British Medical Journal, 2008, 336:1170–1173.
19. Guyatt GH et al. GRADE: an emerging consensus
on rating quality of evidence and strength of recommendations. British Medical Journal, 336:924–926.
20. Guyatt GH et al. What is “quality of evidence” andwhy is it important to clinicians? British Medical
Journal, 2008, 336:995–998.
21. Guyatt GH et al. Going from evidence to recommendations. British Medical Journal, 2008,
336:1049–1051.
22. Schünemann HJ et al. Grading quality of evidence
and strength of recommendations for diagnostic
tests and strategies. British Medical Journal, 2008,
336:1106–1110.
23. The WHO Strategic Approach to strengthening
sexual and reproductive health policies and programmes. Geneva, World Health Organization, 2007.

Safe abortion: technical and policy guidance for health systems

15

Chapter 1

Safe
Safecare:abortion:the publictechnical
healthandandpolicyhuman
guidancerightsfor
rationale
health systems
16abortion

Safe abortion care: the public health and human rights rationale

Chapter 1
Safe abortion care: the public health and human rights rationale
Summary
yy Each year, 22 million unsafe abortions are estimated to take place. Nearly all unsafe abortions(98%) occur in developing countries. The total
number of unsafe abortions has increased fromabout 20 million in 2003 to 22 million in 2008,
although the global rate of unsafe abortion has
remained unchanged since 2000.
yy Approximately 47 000 pregnancy-related deaths
are due to complications of unsafe abortion. In
addition, 5 million women are estimated to suffer
disability as a result of complications due tounsafe abortion.
yy Impressive gains in contraceptive use haveresulted in reducing the number of unintended
pregnancies, but have not eliminated the need foraccess to safe abortion. An estimated 33 million
contraceptive users worldwide are expected toexperience accidental pregnancy annually while
using contraception. Some of the accidental pregnancies are terminated by induced abortions, andsome end up as unplanned births.
yy Whether abortion is legally more restricted oravailable on request, a woman’s likelihood of
having an unintended pregnancy and seeking
induced abortion is about the same. However,legal restrictions, together with other barriers,
mean many women induce abortion themselves or seek abortion from unskilled providers.
The legal status of abortion has no effect on a

Safe abortion care: the public health and human rights rationale

woman’s need for an abortion, but it dramaticallyaffects her access to safe abortion.
yy Where legislation allows abortion under broad
indications, the incidence of and complications
from unsafe abortion are generally lower thanwhere abortion is legally more restricted.
yy In almost all countries, the law permits abortion tosave the woman’s life, and in the majority of countries abortion is allowed to preserve the physicaland/or mental health of the woman. Therefore,
safe abortion services, as provided by law, need
to be available.
yy Unsafe abortion and associated morbidity andmortality in women are avoidable. Safe abortion
services therefore should be available and accessible for all women, to the full extent of the law.

1.1 Background
Induced abortion has been documented throughout
recorded history (1). In earlier times, abortions were
unsafe and exerted a heavy toll on women’s lives.
Advances in medical practice in general, and theadvent of safe and effective technologies and skills toperform induced abortion in particular, could eliminate unsafe abortions and related deaths entirely,
providing universal access to these services is available. Yet, an estimated 22 million abortions continue
to be unsafe each year, resulting in the death of an
estimated 47 000 women (2).

Safe abortion: technical and policy guidance for health systems

17

Unsafe abortion is defined by the World HealthOrganization (WHO) as a procedure for terminating anunintended pregnancy, carried out either by persons
lacking the necessary skills or in an environment that
does not conform to minimal medical standards, orboth.
In nearly all developed countries (as classified by theUnited Nations Population Division) safe abortions
are legally available upon request or under broadsocial and economic grounds, and services are generally accessible to most women. With the exceptionof a few countries, access to safe abortion in developing countries is limited to a restricted number ofnarrow conditions (3). In countries where abortion islegally highly restricted, unequal access to safe abortion may result. In such contexts, abortions that meet
safety requirements can become the privilege of therich, while poor women have little choice but to resort
to unsafe providers, which may cause disability anddeath (4).
This chapter provides an overview of the health,demographic, legal and policy context of induced
abortion with updated data since the publication of
the document Safe abortion: technical and policy
guidance for health systems by WHO in 2003 (5).

1.2 Public health and human rights
A consensus on the public health impact of unsafe
abortion has existed for a long time. As early as
1967, the World Health Assembly identified unsafe
abortion as a serious public health problem in many
countries (6). WHO’s Reproductive Health Strategy toaccelerate progress towards the attainment of international development goals and targets, adopted by
the World Health Assembly in 2004, noted:“As a preventable cause of maternal mortality andmorbidity, unsafe abortion must be dealt with as part

18

Safe abortion: technical and policy guidance for health systemsof the Millennium Development Goal on improving
maternal health and other international development
goals and targets” (7).
The number of declarations and resolutions signedby countries over the past two decades (see forexample, references 8–11) indicates a growing consensus that unsafe abortion is an important cause ofmaternal death that can, and should, be prevented
through the promotion of sexuality education, familyplanning, safe abortion services to the full extent
of the law, and post-abortion care in all cases. The
consensus also exists that post-abortion care should
always be provided, and that expanding access tomodern contraception is critical to the prevention of
unplanned pregnancy and unsafe abortion. Thus, thepublic health rationale for preventing unsafe abortionis clear and unambiguous.
Discussions that grew out of the 1968 International
Conference on Human Rights in Tehran, Islamic
Republic of Iran, culminated in the new concept ofreproductive rights, which was subsequently definedand accepted at the 1994 International Conference
on Population and Development (ICPD) in Cairo,
Egypt (8). Eliminating unsafe abortion is one of the
key components of the WHO Global reproductive
health strategy (12). The strategy is grounded ininternational human rights treaties and global consensus declarations that call for the respect, protection and fulfilment of human rights, including the rightof all persons to the highest attainable standard ofhealth; the basic right of all couples and individuals
to decide freely and responsibly the number, spacing
and timing of their children and to have the information and means to do so; the right of women to havecontrol over, and decide freely and responsibly on,
matters related to their sexuality, including sexual andreproductive health – free of coercion, discriminationand violence; the right of men and women to choose

Safe abortion care: the public health and human rights rationalea spouse and to enter into marriage only with their
free and full consent; the right of access to relevant
health information; and the right of every person
to enjoy the benefits of scientific progress and its
applications (12). To realize these rights, and tosave women’s lives, programmatic, legal and policy
aspects of the provision of safe abortion need to beadequately addressed, as elaborated further in thefollowing chapters.

1.3 Pregnancies and abortions
Among the 208 million women estimated to become
pregnant each year worldwide, 59% (or 123 million) experience a planned (or intended) pregnancy
leading to a birth or miscarriage or a stillbirth (4).
The remaining 41% (or 85 million) of pregnancies areunintended.
Because of increased contraceptive use, the pregnancy rate worldwide has fallen from 160 pregnancies per 1000 women aged 15–44 years in1995 to 134 per 1000 women in 2008 (4). Rates ofintended and unintended pregnancies have fallen
from, respectively, 91 and 69 per 1000 women aged
15–44 years in 1995 to 79 and 55 per 1000 women
aged 15–44 years in 2008. More significantly, the rateof induced abortion has declined from 35 per 1000
women aged 15–44 years in 1995 to 26 per 1000
women aged 15–44 years in 2008. This decline has
been largely due to a fall in the rate of safe abortion, while the rate of unsafe abortion has remained
relatively constant since 2000 at around 14 per 1000
women aged 15–44 years (13). The absolute numberof unsafe abortions was estimated at about 20 million
in 2003 and 22 million in 2008. The proportion of allabortions that are unsafe has increased from 44% in
1995 and 47% in 2003 to 49% in 2008 (13). Almost
all unsafe abortions occur in developing countries,

Safe abortion care: the public health and human rights rationale

where maternal mortality rates are high and accessto safe abortion is limited.

1.4 Health consequences of unsafe
abortion
The health consequences of unsafe abortion dependon the facilities where abortion is performed; theskills of the abortion provider; the method of abortion
used; the health of the woman; and the gestationalage of her pregnancy. Unsafe abortion procedures
may involve insertion of an object or substance (root,
twig or catheter or traditional concoction) into theuterus; dilatation and curettage performed incorrectly
by an unskilled provider; ingestion of harmful substances; and application of external force. In somesettings, traditional practitioners vigorously pummel
the woman’s lower abdomen to disrupt the pregnancy, which can cause the uterus to rupture, killingthe woman (14). The consequences of using certain
medicines, such as the prostaglandin analogue misoprostol, in incorrect dosages for inducing abortion
are mixed, though there is some evidence that evenan incorrect dosage can still result in lowering thenumber of severe complications and maternal deaths(15–17).
Deaths and disability related to unsafe abortion are
difficult to measure. Given that these deaths or complications occur following a clandestine or illegal procedure, stigma and fear of punishment deter reliable
reporting of the incident. It is especially difficult to getreliable data on deaths from unsafe second-trimester
abortions (18). Moreover, women may not relate theircondition to a complication of an earlier abortion (19).
Therefore, maternal deaths resulting from unsafe
abortions are grossly underreported. Complicationsof unsafe abortion include haemorrhage, sepsis,
peritonitis, and trauma to the cervix, vagina, uterus

Safe abortion: technical and policy guidance for health systems

19and abdominal organs (20). About 20–30% of unsafe
abortions cause reproductive tract infections and
20–40% of these result in infection of the upper genital tract (21). One in four women who undergo unsafe
abortion is likely to develop temporary or lifelong disability requiring medical care (22). For every woman
seeking post-abortion care at a hospital, there areseveral who have had an unsafe abortion but who
do not seek medical care, because they consider thecomplication as not serious, or because they may
not have the required financial means, or because
they fear abuse, ill-treatment or legal reprisal (23–30).
Evidence shows that major physiological, financial
and emotional costs are incurred by women who
undergo unsafe abortion.

The burdens of unsafe abortion and of maternal
deaths due to unsafe abortion are disproportionately
higher for women in Africa than in any other developing region (31). For example, while Africa accounts
for 27% of global births annually and for only 14% of
the women aged 15–49 years in the world, its share of
global unsafe abortions was 29% and, more seriously,
62% of all deaths related to unsafe abortion occurredin Africa in 2008 (see Figure 1.1). The risk of death due
to unsafe abortion varies among developing regions.
The case–fatality rate for unsafe abortion is 460 per
100 000 unsafe abortion procedures in Africa and520 per 100 000 in sub-Saharan Africa, compared with
30 per 100 000 in Latin America and the Caribbean
and 160 per 100 000 in Asia (2).

Figure 1.1 The percentage distribution of women, births, unsafe abortions and related deaths, by developing
region, 2008
Africa70

62

Latin America & Caribbean
62

60% of total for each indicator

Asia

56
50

50
36

40
29

27

30

20
20
10
0

14
9

8
2

Women (15–49) years

BirthsUnsafe abortions

Unsafe abortion deaths

Reproduced from reference 31.

20

Safe abortion: technical and policy guidance for health systems

Safe abortion care: the public health and human rights rationale

When performed by skilled providers using correct
medical techniques and drugs, and under hygienic
conditions, induced abortion is a very safe medical
procedure. In the United States of America (USA),for example, the case–fatality rate is 0.7 per 100 000

legal abortions (32). Late second-trimester legal abortion has a case–fatality rate (33) that is much lower
than the lowest rate of unsafe abortion procedures(see Figures 1.2 and 1.3).

Figure 1.2 Case–fatality rates of legal induced abortions, spontaneous abortions or term
Reproduced, with permission, from reference 32.
deliveries, per 100 000 procedures, USA
10Term delivery

8.9

Surgical >20 weeks

3.4

Surgical 16–20 weeks

1.7

Surgical 13–15 weeks
1st trimester
spontaneous

1

Surgical 11–12 weeks

0.4

Surgical 9–10 weeks

0.2

Surgical <9 weeks

0.1
0Case–fatality rate forlegal abortion=0.7/100 000

2

4
6
8
Deaths (per 100 000 cases)

10

12Figure 1.3 Case–fatality rates per 100 000 unsafe abortion procedures, by region, 2008
Reproduced from reference 2.

220

All developing regions

520

Sub-Saharan Africa

460

Africa160

Asia
Eastern Europe

30

Latin America &Caribbean

30
0

100

200
300
400
500
Deaths (per 100 000 unsafe abortions)

Safe abortion care: the public health and human rights rationale

600

Safe abortion: technical and policy guidance for health systems

21

1.5 Contraceptive use, accidental
pregnancies and unmet need forfamily planning
The prevalence of contraception of any method was
63% globally in 2007 among women of reproductive age (15–49 years) who were married or in a
cohabiting union (34). The use of a modern method
was about seven percentage points lower, at 56%.
Contraceptive prevalence rose globally and in all
regions, though it remains low in Africa, at 28%
for all methods and 22% for modern methods (seeFigure 1.4). The prevalence is even lower in subSaharan Africa, where, in 2007, the use of any contraceptive method was 21%, while the use of modern
methods was 15%. In contrast, contraceptive prevalence of any method was over 66% in Europe, North
America, Asia, and Latin America and the Caribbean.
The use of modern contraception has resulted in alowering of the incidence and prevalence of induced

abortion even where abortion is available on request.
The decline in abortion prevalence with the increasein the level of contraceptive prevalence has been
examined by several authors (35, 36). Recent datafrom 12 countries in eastern Europe and central Asia,
where induced abortion used to be the main method
for regulating fertility, and from the USA, show that
where the use of modern contraceptive methods ishigh, the incidence of induced abortion is low (37).
Rates of induced abortion are the lowest in western
Europe, where modern contraceptive use is highand abortion is generally legally available on request.
Meeting the unmet need for family planning is, therefore, an effective intervention to reduce unintended
pregnancy and induced abortion.
Contraception alone, however, cannot entirely eliminate women’s need for access to safe abortion services. Contraception plays no role in cases of forced
sexual intercourse, which can lead to an unintended
pregnancy. Also, no method is 100% effective in

Figure 1.4 Percentage of women who are married or in cohabiting union, using any method or modern
method of contraception, 2007
56.1

World

58.6

Developed regions

55.7

Developing regions

21.9

AfricaModern method
Any method

62.9
69.7

61.7

28
61.1

Asia

67
64.3

Latin America & Caribbean

56.3

EuropeNorth America
0

10

20

30

40
%

50

60

71.7

70.5
68.5
72.9
70

80

Reproduced from reference 34.

22

Safe abortion: technical and policy guidance for health systems

Safe abortion care: the public health and human rights rationale

preventing pregnancy. Using 2007 data on contraceptive prevalence (34) and the typical failure rates
of contraceptive methods (51), it is estimated thatapproximately 33 million women worldwide annually may experience an accidental pregnancy while
using a method of contraception (see Table 1.1). In
the absence of safe abortion services, some may
resort to unskilled providers and the others may
end up having unwanted births. The implications of
unwanted births are not well studied, but the effects
can be harmful and long-lasting for women and for
those who are born unwanted (38).
Unmet need for family planning, broadly defined as
the number of women who want to avoid or postpone a pregnancy but are not using any method ofcontraception, continues to persist, despite having
declined somewhat (39). Overall, 11% of women indeveloping countries report an unmet need for familyplanning. In sub-Saharan Africa and among the least
developed countries, unmet need for family planningis reported by one in four women in the reproductive
age group of 15–49 years (39). Women will continue
to face unintended pregnancies as long as theirfamily planning needs are not met.
Unlike unmet need for family planning, the lack ofaccess to safe abortion care is less well documented,
except for the stark reality of an estimated 22 million women undergoing unsafe abortion each year(2), with 47 000 of them dying from the complications. Even a “low-risk” unsafe abortion in a legally
restricted context exposes women to an undue risk
should an emergency develop in the process. In suchcases, because of legal restrictions and stigma linked
to having an abortion, women may be reluctant toseek timely medical care if post-abortion complications occur.

Safe abortion care: the public health and human rights rationale

1.6 Regulatory and policy context
Where laws and policies allow abortion under broad
indications, the incidence of, and mortality from,unsafe abortion are reduced to a minimum (2).
Abortion is permitted for social or economic reasons
in only 16% of developing countries as comparedwith 80% of developed countries (see Table 1.2).
Three out of four induced abortions in developing
countries (excluding the People’s Republic of China)
are carried out in unsafe conditions (13). In thesecountries, few women meet the legal conditions, or
know their right, to receive the safe abortion services
to which they are legally entitled. Also, providers may
not be aware of the legal provisions or may be unwilling to provide legal abortion services. Furthermore, insome countries, laws are not applied (40).
Whether abortion is legally restricted or not, the likelihood that a woman will have an abortion for an unintended pregnancy is about the same (13). The legal
restrictions lead many women to seek services in othercountries, or from unskilled providers or under unhygienic conditions, exposing them to a significant riskof death or disability. The maternal mortality ratio per
100 000 live births due to unsafe abortion is generally
higher in countries with major restrictions and lower
in countries where abortion is available on request
or under broad conditions (41, 42). The accumulated
evidence shows that the removal of restrictions on
abortion results in reduction of maternal mortality due
to unsafe abortion and, thus, a reduction in the overalllevel of maternal mortality (43, 44, 45, 46).
In a small number of countries, where maternal mortality is low despite restrictive abortion laws, many
women have access to safe or relatively safe abortion through seeking care from neighbouring countries, through provision of safe, but illegal abortion
care domestically, or through self-use of misoprostol(47–49).

Safe abortion: technical and policy guidance for health systems

23

In addition to the legal restrictions, other barriers tosafe abortion include inability to pay, lack of social
support, delays in seeking health-care, providers’negative attitudes, and poor quality of services.
Young women are especially vulnerable where
effective contraceptive methods are available only
to married women or where the incidence of nonconsensual sexual intercourse is high. Nearly 14%of all unsafe abortions in developing countries areamong women aged under 20 years. In Africa, young
women below the age of 25 years account for nearly
two thirds of all unsafe abortions in that region (50). A
higher percentage of young women, compared withadult women, tend to have second-trimester abortions, which are more risky.

Table 1.1 Estimated number of women using a contraceptive method and thoseexperiencing an unintended pregnancy during the first year of contraceptive use, by typeof contraceptive method, global data, 2007
Contraceptive method

Estimated failure rate (typicaluse), %a

Number of users,
thousandsb

Number of women withaccidental pregnancy(typical use), thousandsc

Female sterilization

0.5

232 564

1163

Male sterilization

0.15

32 07848

Injectables

0.3

42 389127

Intrauterine device
(IUD)

0.8

162 680

1301

Pill

5.0

100 8165041

Male condom

14

69 884

9784

Vaginal barrier

20

2291

458

Periodic abstinence25

37 8069452

Withdrawal

19

32 078

6095

Total

4.7

712 586

33 469Trussell (51) estimates are based on USA data. Estimated failure rates in typical use cover method failure and user failurein using a contraceptive method in typical conditions.

aBased on the estimated number of women aged 15–49 years, married or in union in 2007 and the percentage using a
specific contraceptive method (34).
b

c

24

Column (4) = Column(3) × (Column(2)/100)

Safe abortion: technical and policy guidance for health systems

Safe abortion care: the public health and human rights rationale

Table 1.2 Grounds on which abortion is permitted (% of countries) by region and subregion, 2009
Country orarea

To save the To preserve To preserve Rape or
woman’s
physicalmentalincestlife
healthhealthFetal
EconomicOn
Number of
impairment or social request countries
reasons

All countries

97

67

63

49

47

34

29

195

Developed
countries

96

88

86

84

84

80

69

49

Developing
countries

97

60

55

37

34

19

16

146

Africa

100

60

55

32

32

8

6

53

Eastern Africa

100

71

65

18

24

6

0

17

Middle Africa

100

33

22

11

11

0

0

9

Northern Africa

100

50

50

33

17

17

17

6

Southern
Africa

100

80

80

60

80

20

20

5

Western Africa

100

63

56

50

44

6

6

16

100

63

61

50

54

39

37

46

Eastern Asia

100

100

100

100

100

75

75

4

South-central
Asia

100

64

64

57

50

50

43

14

South-eastern
Asia

100

55

45

36

36

27

27

11

Western Asia

100

59

59

41

59

29

29

17

Latin America
and theCaribbean

88

58

52

36

21

18

9

33

Caribbean

92

69

69

38

23

23

8

13

CentralAmerica

75

50

38

25

25

25

13

8

South America

92

50

42

42

17

8

8

12

Oceania

100

50

50

14

7

0

0

14

Asia

a

a

a

Japan, Australia and New Zealand have been excluded from the regional count, but are included in the total for developed countries.

Adapted from reference 3.

Safe abortion care: the public health and human rights rationale

Safe abortion: technical and policy guidance for health systems

25

1.7 Economic costs of unsafe abortion
Safe abortion is cost saving. The cost to healthsystems of treating the complications of unsafe abortion is overwhelming, especially in poor countries.
The overall average cost per case that governments
incur is estimated (in 2006 US dollars) at US$ 114
for Africa and US$ 130 for Latin America (52). The
economic costs of unsafe abortion to a country’s
health system, however, go beyond the direct costsof providing post-abortion services. A recent study(52) estimated an annual cost of US$ 23 million fortreating minor complications from unsafe abortion at
the primary health-care level; US$ 6 billion for treating post-abortion infertility; and US$ 200 million eachyear for the out-of-pocket expenses of individuals
and households in sub-Saharan Africa for the treatment of post-abortion complications. In addition,
US$ 930 million is the estimated annual expenditure

26

Safe abortion: technical and policy guidance for health systems

by individuals and their societies for lost income fromdeath or long-term disability due to chronic healthconsequences of unsafe abortion (52).
Unsafe abortion was estimated to cost the Mexico
City health system US$ 2.6 million in 2005, before
the legalization of abortion (53). With access tosafe abortion, the system could potentially save
US$ 1.7 million annually. A large amount of money
can thus be conserved and redirected to meetingother urgent needs, including the provision of quality
services using up-to-date standards and guidelines,
trained providers and appropriate technologies, if
unintended pregnancies are prevented by effective contraception, and safe abortion is accessible.
Economic grounds further strengthen the publichealth and human-rights rationale for the provision ofsafe abortion.

Safe abortion care: the public health and human rights rationaleReferences1.

Joffe C. Abortion and medicine: a sociopolitical
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Unsafe abortion: global and regional estimates of
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Geneva, 23 May 1967. Geneva, World HealthOrganization, 1967 (WHA20/1967/REC/1).
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African Union Commission, 2006 (http://www.unfpa.
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Documents/AdoptedText/ta08/ERES1607.htm,
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towards the attainment of international development goals and targets. Geneva, World HealthOrganization, 2004.
13. Sedgh G, et al. Induced abortion: incidence andtrends worldwide from 1995 to 2008. Lancet, 2012,
379:625–632.
14. Ugboma HA, Akani CI. Abdominal massage: anothercause of maternal mortality. Nigerian Journal of
Medicine, 2004, 13:259–262.
15. Harper CC et al. Reducing maternal mortality due
to elective abortion: potential impact of misoprostol
in low-resource settings. International Journal of
Gynecology and Obstetrics, 2007, 98:66–69.
16. Miller S et al. Misoprostol and declining abortionrelated morbidity in Santo Domingo, Dominican
Republic: a temporal association. British Journal of
Obstetrics and Gynaecology, 2005, 112:1291–1296.
17. Sherris J et al. Misoprostol use in developing countries: results from a multicountry study. International
Journal of Obstetrics and Gynecology, 2005,
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18. Walker D et al. Deaths from complications of unsafe
abortion: misclassified second trimester deaths.
Reproductive Health Matters, 2004, 12:27–38.
19. Benson J. Evaluating abortion-care programs:
old challenges, new directions. Studies in Family
Planning, 2005, 36:189–202.
20. Grimes D et al. Unsafe abortion: the preventablepandemic. Lancet, 2006, 368:1908–1919.

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21. Unsafe abortion: global and regional estimatesof incidence of unsafe abortion and associatedmortality in 2000, 4th ed. Geneva, World HealthOrganization, 2004.
22. Singh S. Hospital admissions resulting from unsafe
abortion: estimates from 13 developing countries.
Lancet, 2006, 368:1887–1892.
23. Singh S, Wulf D. Estimated levels of induced abortion in six Latin American countries. International
Family Planning Perspectives, 1994, 20:4–13.
24. Singh S, Wulf D, Jones H. Health professionals’ perceptions about induced abortion in South Central
and Southeast Asia. International Family Planning
Perspectives, 1997, 23:59–67 and 72.
25. Singh S et al. Estimating the level of abortion in thePhilippines and Bangladesh. International Family
Planning Perspectives, 1997, 23:100–107 and 144.
26. Juarez F et al. Incidence of induced abortions in thePhilippines: current level and trends. International
Family Planning Perspectives, 2005, 31:140–149.
27. Singh S et al. The incidence of induced abortion in
Uganda. International Family Planning Perspectives,
2005, 31:183–191.
28. Huntington D. Abortion in Egypt: official constraints
and popular practices. In: Makhlouf ObermeyerC, ed. Cross-cultural perspectives on reproductive health. New York, Oxford University Press,
2001:175–192.
29. Ferrando D. El aborto inducido en el Peru, hechos ycifras. [Clandestine abortion in Peru, facts and figures.] Lima, Centro de la Mujer Peruana Flora Tristán
and Pathfinder International, 2002.
30. Unwanted pregnancy and postabortion complications in Pakistan. Findings from a national study.
Islamabad, The Population Council, 2002.

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33. Lichtenberg E, Grimes D. Surgical complications:prevention and management. In Paul M et al., eds.
Management of unintended and abnormal pregnancy: comprehensive abortion care. Oxford, WileyBlackwell, 2009:224–251.
34. United Nations, Department for Economic andSocial Affairs, Population Division. World contraceptive use (wallchart). New York, United Nations, 2009
(ST/ESA/SER.A/285).
35. Bongaarts J, Westoff C. The potential role of contraception in reducing abortion. Studies in Family
Planning, 2000, 31:193–202.
36. Marston C, Cleland J. Relationships between contraception and abortion: a review of the evidence.
International Family Planning Perspectives, 2003,
29:6–13.
37. Westoff CF. Recent trends in abortion and contraception in 12 countries. Washington, DC, ORC
Macro, 2005, No. 8.
38. David HP. Born unwanted, 35 years later: thePrague study. Reproductive Health Matters, 2006,
14:181–190.
39. The Millennium Development Goals report 2010: statistical annexes. New York, United Nations, 2010.
40. Schuster S. Women’s experiences of the abortion law in Cameroon: “What really matters”.
Reproductive Health Matters, 2010, 18:137–144.
41. World Health Report 2008 – primary healthcare: now more than ever. Geneva, World HealthOrganization, 2008.
42. Women and health: today’s evidence, tomorrow’s
agenda. Geneva, World Health Organization, 2009.
43. David HP. Abortion in Europe, 1920–91 – a publichealth perspective. Studies in Family Planning, 1992,
23:1–22.

31. Shah I, Ahman E. Unsafe abortion: global andregional incidence, trends, consequences andchallenges. Journal of Obstetrics and Gynaecology
Canada, 2009, 1149–1158.

44. Jewkes R et al. Prevalence of morbidity associatedwith abortion before and after legalisation in South
Africa. British Medical Journal, 2002, 324:1252–1253.

32. Bartlett LA et al. Risk factors for legal induced
abortion-related mortality in the United States.
Obstetrics and Gynecology, 2004, 103:729–737.

45. Jewkes R and Rees H, Dramatic decline in abortion mortality due to the Choice on Terminationof Pregnancy Act. South African Medical Journal,
2005, 95[4]:250.

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Safe abortion care: the public health and human rights rationale46. Pradhan A et al., Nepal Maternal Mortality andMorbidity Study 2008/2009: Summary of Preliminary
Findings, Kathmandu, Nepal: Family Health Division,
Department of Health Services, Ministry of Health,2009.
47. Kulczycki A. Abortion in Latin America: changes
in practice, growing conflict, and recent policy
developments. Studies in Family Planning, 2011,
42(3):199–220.
48. Briozzo L et al. A risk reduction strategy to prevent
maternal deaths associated with unsafe abortion.
International Journal of Gynecology and Obstetrics,
2006, 95(2):221–226.
49. Payne D. More British abortions for Irish women.
British Medical Journal, 1999, 318(7176):77.
50. Unsafe abortion: global and regional estimates of
the incidence of unsafe abortion and associatedmortality in 2003, 5th ed. Geneva, World HealthOrganization, 2007.
51. Trussell J. Contraceptive efficacy. In: Hatcher RA, et
al. eds. Contraceptive technology, 17th revised ed.
New York, Ardent Media, 1998:779–884. Levin C etal. Exploring the costs and economic consequencesof unsafe abortion in Mexico City before legalisation.
Reproductive Health Matters, 2009, 17:120–132.
52. Vlassoff M et al. Economic impact of unsafe
abortion-related morbidity and mortality: evidence
and estimation challenges. Brighton, Institute ofDevelopment Studies, 2008 (IDS Research Reports
59).
53. Levin C et al. Exploring the costs and economic
consequences of unsafe abortion in Mexico City
before legalisation. Reproductive Health Matters,
2009, 17:120–132.

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Safe abortion: technical and policy guidance for health systems

29

Chapter 2

Clinicalforabortion:
women undergoing
abortion
Safe
technical andpolicy guidance for health systems
30 careClinical care for women undergoing abortion

Chapter 2
Clinical care for women undergoing abortion
SummaryThis chapter addresses, in brief, the clinical management of women before, during and after their abortion. Providing clinical care for women undergoing
abortion is described in greater detail in the WHO
document Clinical practice handbook for safe abortion care.
The evidence base for the following recommendations are available as GRADE (Grading ofRecommendations Assessment, Development and
Evaluation) tables and accessible online. Details of the
GRADE methodology are presented in the Methods
section of this document (pages 10–11). GRADE
tables are available from: http://apps.who.int/iris/bitstream/10665/75840/1/WHO_RHR_12.10_eng.pdf)- date accessed 14 February 2013.

Pre-abortion care

expect during and afterwards must be given to
the woman in a format that is accessible to her
and helps with her decision-making and voluntary
consent. Information regarding post-abortion
contraception also needs to be provided.

Methods of abortion
yy The following methods are recommended for firsttrimester abortion:–– manual or electric vacuum aspiration, for pregnancies of gestational age up to 12–14 weeks(GRADE tables 36 and 37);–– medical method of abortion, specifically, oral
mifepristone followed by a single dose of misoprostol, for pregnancies of gestational age up to
9 weeks (63 days) (GRADE tables 30–32);

yy Determining the gestational age is a criticalfactor in selecting the most appropriate abortion
method. Bimanual pelvic examination, abdominal
examination and recognition of symptoms ofpregnancy are usually adequate. Laboratory or
ultrasound testing may also be used, if needed.

–– medical method of abortion for pregnancies ofgestational age over 9 weeks (63 days) – oral
mifepristone followed by repeated doses of misoprostol (GRADE tables 94–121); or

yy Routine use of antibiotics at the time of surgical abortion reduces the post-procedural risk ofinfection. However, abortion should not be denied
when prophylactic antibiotics are not available(GRADE tables 66–70).

yy Dilatation and curettage (D&C) is an obsolete
method of surgical abortion and should be replacedby vacuum aspiration and/or medical methods(GRADE table 35).

yy Complete, accurate and easy-to-understandinformation about the procedure and what toClinical care for women undergoing abortion–– where mifepristone is not available: misoprostol
alone, in repeated doses (GRADE table 113).

yy For pregnancies of gestational age morethan 12–14 weeks, the following methods arerecommended:

Safe abortion: technical and policy guidance for health systems

31

–– dilatation and evacuation (D&E), using vacuum
aspiration and forceps (GRADE tables 33
and 34); or–– mifepristone followed by repeated doses of
misoprostol (GRADE tables 71–92); or–– where mifepristone is not available, misoprostol alone, in repeated doses (GRADE tables
71–92).
yy Cervical preparation before surgical abortion isrecommended for all women with a pregnancy
of gestational age over 12–14 weeks, although
its use may be considered for women at any
gestational age, in particular those at high risk
for cervical injury or uterine perforation (GRADE
tables 1–19).
yy Medication for pain management for both medical
and surgical abortions should always be offered,and provided without delay to women who desire
it (GRADE tables 38–60, 125–132). In most cases,
analgesics, local anaesthesia and/or conscious
sedation supplemented by verbal reassurance
are sufficient. The need for pain management
increases with gestational age.
yy Local anaesthesia, such as lidocaine, can be used
to alleviate women’s discomfort where mechanical cervical dilatation is required for surgical abortion. General anaesthesia is not recommended
for routine abortion procedures, as it has been
associated with higher rates of complications thananalgesia and local anaesthesia (GRADE tables
38–60).
yy Standard precautions for infection control
should be used, as with the care of all patientsat all times, to reduce the risk of transmission ofbloodborne infections (http://www.who.int/csr/
resources/publications/EPR_AM2_E7.pdf).

32

Safe abortion: technical and policy guidance for health systems

After-care and follow-up
yy For surgical abortion, women can leave thehealth-care facility as soon as they feel able andtheir vital signs are normal.
yy Following uncomplicated surgical and medical
abortion using mifepristone with misoprostol, routine follow-up visits are not necessary. For women
who wish to return to the clinic, a follow-up visit
may be scheduled at 7–14 days after the procedure (GRADE table 93).
yy Before leaving the health-care facility following
the surgical abortion procedure or administration of medical abortion pills, all women should
receive contraceptive information and, if desired,the contraceptive method of their choice or referral for such services (http://www.who.int/
reproductivehealth/publications/family_planning/9789241563888/en/index.html).
yy Before leaving the facility women should receive
oral and written instructions about how to care forthemselves after they leave. These instructions
should include: how much bleeding to expect,
how to recognize potential complications, andhow and where to seek help if required. Where
possible, a phone number that women could callto ask questions or express concerns may reduce
the need to return to the clinic.

2.1 Pre-abortion care
The first steps in providing abortion care are toestablish that the woman is indeed pregnant and, if
so, to estimate the duration of the pregnancy andconfirm that the pregnancy is intrauterine. The risks
associated with induced abortion, though small whenabortion is properly performed, increase with theduration of pregnancy (1, 2). Determination of thelength of pregnancy is a critical factor in selecting theClinical care for women undergoing abortionmost appropriate abortion method, and determines
the content of the information and counselling to begiven to women prior to abortion. Every health-service-delivery point should have staff who are trained
and competent to take the woman’s medical history
and perform a bimanual pelvic and an abdominal
examination to accurately assess pregnancy andits duration. Health-care centres that are not staffedand equipped to provide induced abortion must beable to refer women promptly to the nearest services
with minimal delay. Staff should also be competentto offer counselling to help the woman consider her
options if needed (see Section 2.1.8).

2.1.1 Medical history
Most women begin to suspect that they are pregnant when their expected menstrual period does
not occur. The woman should be asked about thefirst day of her last menstrual period (LMP), i.e. thefirst day of bleeding and whether the menstruation
was normal, as well as about her menstrual history,
including the regularity of her cycles. Women may
experience amenorrhoea for reasons other thanpregnancy, however, and some women who are
pregnant may not report having missed a period. For
example, women who are breastfeeding may become
pregnant before their first postpartum menses, andwomen who are amenorrhoeic while using injectable
hormonal contraception may become pregnant after
missing an injection. Some women may experience
non-menstrual bleeding in early pregnancy, and thiscan be a cause of missing or misdating pregnancy.
Other symptoms that women commonly reportin early pregnancy include breast tenderness andengorgement, nausea sometimes accompanied byvomiting, fatigue, changes in appetite, and increased
frequency of urination.
In addition to estimating the duration of pregnancy,
clinical history-taking should serve to identify

Clinical care for women undergoing abortion

contraindications to medical or surgical abortion
methods and to identify risk factors for complications of treatment. History-taking should include:
personal and family history of relevant diseases;
obstetric and gynaecologic history, including previous ectopic pregnancy; any bleeding tendencies ordisorders; history of or presence of sexually transmitted infections (STIs); current use of medications;known allergies; and risk assessment for violence or
coercion. The health-care provider must be alert tothe possibility of violence or coercion in the context
of unintended pregnancy (see Section 2.1.8.1).
From a clinical point of view, the presence of HIV
infection in a woman undergoing abortion requires
the same precautions as for other medical/surgicalinterventions (see Section 2.2.7.1). HIV testing may
be offered but is not required for women to receive
induced abortion services.

2.1.2 Physical examination
Basic routine observations (pulse, blood pressure
and, in some cases, temperature) are useful baseline
measurements. Additionally, health-care providers
must confirm pregnancy and estimate its duration
by a bimanual pelvic and an abdominal examination.
While many health-care workers have been trained
to assess the length of pregnancy in order to provide
prenatal care, many are not experienced in diagnosing very early pregnancy or accurately estimating
the duration of pregnancy during the first trimester.
Hence, additional training in bimanual pelvic examination is often required for staff who intend to provide
abortion services (see Chapter 3).
Signs of pregnancy that are detectable during abimanual pelvic examination as early as 6–8 weeks
of gestation include softening of the cervical isthmus
and softening and enlargement of the uterus. A pregnant woman’s uterus that is smaller than expected

Safe abortion: technical and policy guidance for health systems

33

could be due to a pregnancy that is less advanced
than estimated from the date of the LMP, an ectopic
pregnancy, or a missed abortion; a uterus that islarger than expected may indicate a pregnancy that ismore advanced than calculated from the date of the
LMP, a multiple pregnancy, a full bladder, the presence of uterine fibroids or other pelvic tumours, or amolar pregnancy. A physical examination is generally
more accurate and reliable if the woman empties her
bladder prior to the examination.
During the physical examination, the health-careprovider should also assess whether the uterus isanteverted, retroverted or otherwise positioned in a
way that might affect assessment of the gestationalage or complicate a surgical abortion. Health-careproviders should be trained to recognize signs of
STIs and other reproductive tract infections (RTIs),
as well as health conditions, such as anaemia or
malaria, that may require additional procedures orservices, or referral.

2.1.3 Laboratory testing
In most cases, health-care providers only require theinformation obtained from the woman’s history andfrom a physical examination to confirm the pregnancy and estimate its duration. Laboratory testingfor pregnancy is not needed, unless the typical signsof pregnancy are not clearly present and the provider
is unsure whether the woman is pregnant. Obtaining
such tests should not hinder or delay uterine
evacuation.
Routine laboratory testing is not a prerequisite
for abortion services. Measuring haemoglobin orhaematocrit levels to detect anaemia may be usefulwhen initiating treatment in the rare cases of haemorrhage occurring at the time of or following theabortion procedure. Tests for Rhesus (Rh) bloodgroup typing should be provided when feasible, to34

Safe abortion: technical and policy guidance for health systems

administer Rh-immunoglobulin when indicated (seeSection 2.1.7).

2.1.4 Ultrasound scanning
Ultrasound scanning is not routinely required for theprovision of abortion (3–5) (GRADE tables 122–124).
Where it is available, a scan can help identify an
intrauterine pregnancy and exclude an ectopic
one from 6 weeks of gestation (6). It may also help
determine gestational age and diagnose pathologies
or non-viability of a pregnancy. Some health-careproviders find the technology helpful before or during
D&E. Where ultrasound is used, service-delivery sites
should, if possible, provide separate areas where
women seeking abortion can be scanned, away fromthose receiving prenatal/antenatal care.

2.1.5 Reproductive tract infections
The presence of infection in the lower reproductive
tract at the time of abortion is a risk factor for postsurgical abortion RTIs (7). The routine use of antibiotics at the time of surgical abortion has been reported
to reduce the post-procedural risk of infection by half
(8, 9). However, where antibiotics are not available
for prophylactic use, abortion may still be performed.
In all cases, strict observation of cleaning and disinfection procedures should be followed (see Section
2.2.7.1).
Following medical abortion, the risk of intrauterine
infection is very low and prophylactic antibiotics are
therefore not necessary (10) (GRADE table 70).
If clinical signs indicate infection, the woman shouldbe treated immediately with antibiotics, and abortion
can then be performed. Where laboratory testing for
STIs is routinely performed, and if there are no visible
signs of infection, abortion should not be delayed to
wait for the test results.

Clinical care for women undergoing abortion

2.1.6 Ectopic pregnancy
Ectopic pregnancy is an uncommon, but potentiallylife-threatening event, occurring in 1.5–2% of pregnancies. Signs and symptoms that might indicate
extrauterine pregnancy include uterine size smaller
than expected for the estimated length of pregnancy;
cervical motion tenderness, lower abdominal pain,
especially if accompanied by vaginal bleeding andspotting; dizziness or fainting; pallor; and, in some
women, an adnexal mass. If ectopic pregnancy issuspected, it is essential to confirm the diagnosis
immediately and to initiate treatment or transfer the
woman as soon as possible to a facility that has thecapacity to confirm diagnosis and provide treatment(11). The inspection of aspirated tissue following asurgical abortion procedure can nearly eliminate therisk of an ectopic pregnancy going undetected (seeSection 2.2.4.5).
It should be noted that it is more difficult to diagnose an ectopic pregnancy during and after medical methods of abortion, due to the similarity ofsymptoms (12). Additionally, neither mifepristone nor
misoprostol are treatments for ectopic pregnancy,
which, if present, will continue to grow. Therefore,
health-care staff must be particularly alert to clinicalsigns of ectopic pregnancy, such as a uterus thatfeels smaller than expected according to the date of
the woman’s LMP, cervical motion tenderness, or thepresence of an adnexal mass on pelvic examination(13). Women should be told to seek medical advice
promptly if they experience symptoms that may indicate ectopic pregnancy, such as severe and intensifying abdominal pain, particularly if it is one-sided.
Where clinical features (e.g. history of previous
ectopic pregnancy or pelvic inflammatory disease,
discrepancy between menstrual dates and assessment of gestational age, vaginal bleeding, pregnancy

Clinical care for women undergoing abortionin the presence of an intrauterine device (IUD), or
pelvic pain) raise suspicion of an ectopic pregnancy,
further investigations should be performed (14). Thesemay include pelvic ultrasound and serial human chorionic gonadotrophin (hCG) measurements. If these are
not possible, or if ectopic pregnancy is diagnosed orstrongly suspected, the woman should be transferred
to an appropriate referral centre for treatment.

2.1.7 Rh-isoimmunization
Passive immunization of all Rh-negative women with
Rh-immunoglobulin within 72 hours after abortion wasrecommended in the USA in 1961 (15), yet there is still
no conclusive evidence about the need for this measure after early induced abortion (16). In settings where
the prevalence of Rh-negative status is high, andRh-immunoglobulin is routinely provided in the facility to Rh-negative women, it should be administeredat the time of the abortion procedure. The dose of
Rh-immunoglobulin may be reduced from 300 µg (thedose given after term delivery) to 50 μg in pregnancies of less than 12 weeks’ duration (17). Rh testing
is not a requirement for abortion services where it is
not available or the prevalence of Rh-negative status
is low.
In pregnancies up to 9 weeks’ (63 days’) gestation, however, the theoretical risk of maternal
Rh-sensitization with medical abortion is very low(17). Thus, determination of Rh status and the offer ofanti-D prophylaxis are not considered prerequisites
for early medical abortion (12). If Rh-immunoglobulin
is available, administration of the immunoglobulin
to Rh-negative women having a medical abortion isrecommended at the time of the prostaglandin administration (18). For women using misoprostol at home,
Rh-immunoglobulin may be administered at the time
mifepristone is taken.

Safe abortion: technical and policy guidance for health systems

35

2.1.8 Information and counselling
The provision of information is an essential part ofgood-quality abortion services (19). Every pregnant woman who is contemplating abortion should
receive adequate relevant information and be offeredcounselling from a trained health-care professionalwith comprehensive knowledge and experience ofdifferent methods of abortion. Information must be
provided to each woman, regardless of her age orcircumstances, in a way that she can understand, toallow her to make her own decisions about whether
to have an abortion and, if so, what method tochoose.
Information, counselling and abortion proceduresshould be provided as promptly as possible without undue delay. Chapter 3 presents details about
training and other health-care provider requirements
related to the provision of information and counselling, including ethical standards.

2.1.8.1 Decision-making information andcounselling
Providing information and offering counselling canbe very important in helping the woman consider her
options and ensuring that she can make a decisionthat is free from pressure. Many women have madea decision to have an abortion before seeking care,and this decision should be respected without subjecting a woman to mandatory counselling. Provisionof counselling to women who desire it should bevoluntary, confidential, non-directive and by a trained
person (19, 20).
If the woman chooses an abortion, the health-care
worker should explain any legal requirements for
obtaining it. The woman should be given as muchtime as she needs to make her decision, even if
it means returning to the clinic later. However, theadvantage of abortion at earlier gestational ages in

36

Safe abortion: technical and policy guidance for health systems

terms of their greater safety over abortion at laterages should be explained. Once the decision ismade by the woman, abortion should be provided
as soon as is possible to do so (19). The health-care
worker should also provide information and referral
for antenatal care to women who decide to carry the
pregnancy to term and/or consider adoption.
In some circumstances, the woman may be underpressure from her partner, family members, healthcare providers or others to have an abortion.
Unmarried adolescents, women in abusive relationships and women living with HIV may be particularly
vulnerable to such pressure. If health-care workers
suspect coercion, they should talk with the woman
alone, or refer her for additional counselling. If staff
know or suspect that the woman has been subjected
to sexual violence or other abuse, they should offer
her referrals for other counselling and treatment
services as appropriate. Managers should ensurethat all staff know about the availability of such
resources in the health system and the community(see Chapter 3).

2.1.8.2 Information on abortion procedures
At a minimum, a woman must be given information on:
yy what will be done during and after the procedure;
yy what she is likely to experience (e.g. menstruallike cramps, pain and bleeding);
yy how long the process is likely to take;yy what pain management will be made available toher;yy risks and complications associated with the abortion method;
yy when she will be able to resume her normal activities, including sexual intercourse;
yy any follow-up care.

Clinical care for women undergoing abortion

If a choice of abortion methods is available, healthcare providers should be trained to give women clear
information about which methods are appropriate,based on the duration of pregnancy and the woman’s
medical condition, as well as potential risk factors
and the advantages and disadvantages of each available method. Women are more likely to find a methodof abortion acceptable if they have chosen it themselves (21, 22). Having a choice of methods is seen
as extremely important by the majority of women
undergoing abortion. Several studies suggest, however, that women who choose medical abortion findit more acceptable at earlier gestations when compared with later gestations (21, 23–25).

the health-care provider should discuss whether the
method may have been used incorrectly and how
to use it correctly, or whether it may be appropriate
for her to change to a different method (for further
discussion, see Section 2.3 and Annex 6). The final
selection of a method, however, must be the woman’s alone.
A woman’s acceptance of a contraceptive method
must never be a precondition for providing her anabortion. Some women may prefer to discuss options
for contraception after their abortion is completed.

2.2 Methods of abortion

2.1.8.3 Contraceptive information and services
The goal of contraceptive counselling and provision in the context of abortion care is to begin thechosen method immediately following abortion,
after ensuring that it is the most appropriate andacceptable method for the woman. This will increase
the likelihood that she will continue its correct andconsistent use. Provision of contraceptive information, and offers of counselling, methods and services
is an essential part of abortion care, as it helps thewoman avoid unintended pregnancies in the future.
Ideally, pre-abortion counselling includes discussion about future contraceptive needs. Every woman
should be informed that ovulation can return as earlyas 2 weeks after abortion (26), putting her at risk ofpregnancy unless an effective contraceptive method
is used. She should be given accurate information toassist her in choosing the most appropriate contraceptive method to meet her needs. In helping thewoman choose the most appropriate contraceptive
method for the future, it may be useful to explore thecircumstances in which the unintended pregnancy
occurred. If the woman is seeking an abortion following what she considers to be a contraceptive failure,

Clinical care for women undergoing abortion

Summary
The most appropriate methods of abortion differ by
the duration of pregnancy. The methods summarized
are indicative rather than prescriptive with regard to
the time limits. For example, most trained providers can safely undertake vacuum aspiration up to
12 weeks of pregnancy, while others with sufficientexperience and access to appropriately sized cannulae can use this procedure safely for terminating
pregnancies of less than 15 weeks’ duration (3).
The availability of safe and effective medical methods of inducing abortion has expanded due to theincreased registration and use of mifepristone andmisoprostol (global maps of registration of mifepristone and misoprostol are available at: www.gynuity.
org). The knowledge of and correct use of thesedrugs, including that of misoprostol alone when mifepristone is not available, is important for programme
planners, managers, health-care workers and pharmacists, as these drugs are introduced into healthsystems.

Safe abortion: technical and policy guidance for health systems

37

Methods up to 12–14 weeks since thelast menstrual period
The recommended abortion methods are manualor electric vacuum aspiration, or medical methods
using a combination of mifepristone followed bymisoprostol.
Mifepristone followed by a prostaglandin analogue
has been shown to be safe and effective up to
9 weeks (63 days) of pregnancy (4, 19). Limited evidence also suggests the safety and effectiveness of aregimen with repeated doses of misoprostol between
9 and 12 weeks of gestation (3, 4, 27, 28); however,misoprostol alone is less effective than its use incombination with mifepristone.
The use of medical methods of abortion requires
the back-up of vacuum aspiration, either on-site or
through referral to another health-care facility in caseof failed or incomplete abortion.
Programme managers and policy-makers shouldmake all possible efforts to replace D&C with vacuum
aspiration and medical methods of abortion.

Methods after 12–14 weeks since thelast menstrual period
The recommended surgical method is D&E, using
vacuum aspiration and forceps. The recommended
medical method for abortions after 12 weeks since
the LMP is mifepristone followed by repeated dosesof misoprostol.

Pre-procedure considerations
2.2.1 Cervical preparation
Cervical preparation (or priming) using osmotic dilators, such as laminaria, or pharmacological agents is
commonly used before some first-trimester surgical38

Safe abortion: technical and policy guidance for health systems

abortions because it may make the abortion procedure quicker and easier to perform by reducing
the need for mechanical cervical dilatation (29, 30).
Cervical preparation before surgical abortion isespecially beneficial for women with cervical anomalies or previous surgery, adolescents and those withadvanced pregnancies, all of whom have a higher
risk of cervical injury or uterine perforation that may
cause haemorrhage (31, 32). It may also facilitate
the abortion procedure for inexperienced providers.
However, cervical preparation has disadvantages,
including additional discomfort for the woman, andthe extra cost and time required to administer it
effectively. It is therefore recommended for all womenwith durations of pregnancy over 12–14 weeks(29, 30, 33), although its use may be considered for
women at any gestational age, in particular those athigh risk for cervical injury or uterine perforation.
Cervical preparation using osmotic dilators requires
at least 4 hours to be effective. In first-trimester
surgical abortion, research suggests that administration of 400 µg misoprostol either vaginally 3–4 hours
or sublingually 2–3 hours prior to the procedure iseffective in preparing the cervix (29). Another effective pharmacological regimen is 200 mg mifepristonetaken orally 36 hours before a vacuum aspiration
procedure (29, 34). For cervical priming prior to D&E,
misoprostol is inferior to overnight dilatation withlaminaria. Unlike laminaria, misoprostol used alone
for cervical preparation has not been studied after
20 weeks’ gestation. Misoprostol use in combination with overnight osmotic dilators does not haveany additional benefit in cervical dilatation before
19 weeks of gestation (30).

2.2.2 Pain management
Most women report some degree of pain with abortion. The factors associated with pain during surgicalabortion with local anaesthesia have been evaluatedin several observational studies. The degree of theClinical care for women undergoing abortion

pain varies with the age of the woman, parity, historyof dysmenorrhoea and the anxiety level or fearfulness of the woman (35–37). Prior vaginal delivery
and greater experience of the provider have beenfound to be associated with less pain during abortion(35, 38). The relationship between pain and gestational age as well as the amount of cervical dilatation required for the abortion have shown conflicting
results (35, 36, 38), although a shorter procedure time
has been associated with less pain (35).
Providing adequate pain management does not
require a large investment in drugs, equipment or
training. Neglecting this important element needlessly increases women’s anxiety and discomfort,
thereby seriously compromising the quality of careand potentially increasing the difficulty of performing
the procedure.
Counselling and sympathetic treatment may reduce
women’s fears and perceptions of pain, as has beenreported for women treated for incomplete abortion(39). Non-pharmacological relaxation techniques canresult in shorter procedure times and decreased needfor pain medications (40, 41), and listening to music
may decrease procedural pain (37). The person
performing the procedure, and other staff present,
should be friendly and reassuring. Where feasible,
and if the woman wishes, it may also be helpful for a
supportive person, such as the woman’s husband or
partner, a family member or friend, to remain with her
during the procedure. However, non-pharmacologicalapproaches should not be seen as a replacement forpharmacological pain alleviation.

2.2.2.1 Medication for pain
Medication for pain management should always
be offered for both medical and surgical methodsof abortion, and provided without delay to women
who desire it. Three types of drugs, either singly
or in combination, are used to manage pain during

Clinical care for women undergoing abortion

abortion: analgesics, which alleviate the sensation of
pain; tranquillizers, which reduce anxiety; and anaesthetics, which decrease physical sensation during
surgical abortion. In most cases of surgical abortion,
analgesics, local anaesthesia and/or mild sedation
supplemented by verbal reassurance, are sufficient.
Most of these drugs are comparatively inexpensive.
Non-narcotic analgesics included on the WHO Model
list of essential medicines, such as non-steroidal
anti-inflammatory agents like ibuprofen, reduce pain,
including uterine cramping, associated with both
surgical and medical methods of abortion (42, 43).
Paracetamol was found, in randomized controlled
trials, to be ineffective to relieve post-procedural pain
following surgical abortion (44–46) and was similarly
ineffective at reducing pain during medical abortion(47); therefore, the use of paracetamol is not recommended to decrease pain during abortion.
For surgical abortion, preoperative administration of
tranquillizers, such as diazepam, can reduce fear andinduce relaxation, making the procedure easier forboth the woman and the provider. Such drugs cancause amnesia, which some women may want, butthey may also induce drowsiness and delay ambulation (37). Supplemental use of narcotic analgesics
may also be appropriate, though the possibility ofcomplications such as respiratory depression meansthat resuscitation capability and narcotic-reversal
agents must be available.

2.2.2.2 Anaesthesia
Where mechanical cervical dilatation is required for
surgical abortion, a paracervical block using a local
anaesthetic, such as rapidly acting lidocaine, injectedbeneath the cervical mucosa around the cervix, iscommonly used. Advantages of using local rather
than general anaesthesia include a reduction inprocedural risks and complications, a faster recovery
time, and a greater sense of control for the woman,

Safe abortion: technical and policy guidance for health systems

39

who remains conscious and able to communicate
with the provider. Injection of local anaesthetic must
be done skilfully, to avoid intravenous introduction of
the drug. The use of local anaesthesia with vacuum
aspiration is safe; however, the degree to which it
decreases pain has not been well studied, despite its
common use (37).
General anaesthesia is not routinely recommended
for abortion procedures, and increases the clinicalrisks (1, 48–50). It has been associated with higher
rates of haemorrhage than local anaesthesia (1, 2).
Use of general anaesthesia increases costs for boththe health-care facility and the woman, particularly assome hospital policies unnecessarily require women
who receive it to stay overnight. Nevertheless, as itis the most effective method of pain control, some
women prefer general anaesthesia, and its use may
also be preferable from the provider’s perspective
during difficult procedures. Any facility that offers
general anaesthesia must have the specialized equipment and staff to administer it and to handle any
complications.

2.2.3 Induction of pre-procedure fetal
demiseWhen using medical methods of abortion after
20 weeks’ gestation, inducing pre-procedure fetal
demise should be considered. Modern medical methods, such as combination regimens of mifepristone
and misoprostol or misoprostol alone, are not directly
feticidal; the incidence of transient fetal survival after
expulsion is related to increasing gestational age anddecreasing interval to abortion (51, 52). Commonlyused pre-procedure regimens to effect fetal demise
include (53):yy Injection of potassium chloride (KCl) throughthe fetal umbilical cord or into the fetal cardiac
chambers, which is highly effective but requires

40

Safe abortion: technical and policy guidance for health systems

expertise for precise, safe injection and time toobserve cardiac cessation on ultrasound.
yy Intra-amniotic or intrafetal injection of digoxin.
Digoxin has a higher failure rate than KCl to cause
intrauterine fetal demise; however, it is technically easier to use, does not require ultrasound if
administered intra-amniotically, and has demonstrated safety (maternal serum levels remain ator below therapeutic digoxin levels) (51). Digoxin
requires time for fetal absorption; therefore, it iscommonly administered the day before inductionof abortion with misoprostol (33, 54).

2.2.4 Surgical methods of abortion
2.2.4.1 Vacuum aspiration
The recommended surgical technique for abortion
up to gestational age less than 15 weeks is vacuum
aspiration (57). The high efficacy of vacuum aspiration has been well established in several randomized
controlled trials. Complete abortion rates between
95% and 100% are reported (55, 56). Electric andmanual vacuum technologies appear to be equallyeffective; however, the use of manual vacuum aspiration is associated with less pain in pregnancies
under 9 weeks’ gestation and with more procedural
difficulty over 9 weeks’ gestation (57). Vacuum aspiration under 14 weeks’ gestation is more effective
and associated with fewer minor complications than
medical abortion (56, 58).
Vacuum aspiration involves evacuation of the contents of the uterus through a plastic or metal cannula,attached to a vacuum source. Electric vacuum aspiration (EVA) employs an electric vacuum pump. With
manual vacuum aspiration (MVA), the vacuum is created using a hand-held, hand-activated, plastic 60 ml
aspirator (also called a syringe). Available aspirators
accommodate different sizes of plastic cannulae,

Clinical care for women undergoing abortion

ranging from 4 mm to 16 mm in diameter. For eachprocedure, the appropriately sized cannula should bechosen based on the gestational age and the amountof cervical dilatation present; generally, the diameterof the cannula corresponds to the gestational age inweeks. Some cannulae and most aspirators are reusable after being cleaned and high-level disinfected orsterilized. Foot-operated mechanical pumps are alsoavailable.
Depending on the duration of pregnancy, abortion
with vacuum aspiration takes from 3 to 10 minutes
to complete and can be performed on an outpatientbasis, using analgesics and/or local anaesthesia. The
completion of abortion is verified by examination of
the aspirated tissue. In very early pregnancy, the cannula may be inserted without prior dilatation of thecervix. Usually, however, dilatation using mechanicalor osmotic dilators, or pharmacological agents suchas misoprostol or mifepristone, is required before
insertion of the cannula (see Section 2.2.1). Generally,
vacuum-aspiration procedures can be safely completed without intrauterine use of curettes or other
instruments. No data suggest that use of curettage
after vacuum aspiration decreases the risk of retained
products (59).
Most women who have a first-trimester abortion
with local anaesthesia feel well enough to leave
the health-care facility after observation for about
30 minutes in a recovery room. Longer recovery
periods are generally needed for abortions performed
later in pregnancy and when sedation or generalanaesthesia has been used.
Vacuum aspiration is a very safe procedure. A studyof 170 000 first-trimester abortions conducted in New
York City by vacuum aspiration reported that lessthan 0.1% of the women experienced serious complications requiring hospitalization (60). Though rare,complications with vacuum aspiration can include

Clinical care for women undergoing abortion

pelvic infection, excessive bleeding, cervical injury,
incomplete evacuation, uterine perforation, anaesthetic complications and ongoing pregnancy (1, 2).
Abdominal cramping and menstrual-like bleeding
occur with any abortion procedure.

2.2.4.2 Dilatation and curettage
D&C involves dilating the cervix with mechanicaldilators or pharmacological agents and using sharp
metal curettes to scrape the walls of the uterus.
D&C is less safe than vacuum aspiration (61) andconsiderably more painful for women (62). Therefore,vacuum aspiration should replace D&C. The rates
of major complications of D&C are two to threetimes higher than those of vacuum aspiration (3).
Randomized controlled trials comparing D&C withvacuum aspiration found that, for up to 10 weeks
since the LMP, vacuum aspiration is quicker andassociated with less blood loss than D&C (63, 64).
Where it is still practised, all possible efforts should
be made to replace D&C with vacuum aspiration, toimprove the safety and quality of care for women.
Where no abortion services are currently offered,vacuum aspiration should be introduced rather than
D&C. At sites where vacuum aspiration has yet to be
introduced, managers must ensure that proper painmanagement protocols are followed, and that D&C
procedures are performed by well-trained staff underadequate supervision.

2.2.4.3 Dilatation and evacuation
D&E is used after 12–14 weeks of pregnancy. It is thesafest and most effective surgical technique for later
abortion, where skilled, experienced providers areavailable (3). D&E requires preparation of the cervix
using osmotic dilators or pharmacological agents(see Section 2.1) and evacuating the uterus using
EVA with 12–16 mm diameter cannulae and long

Safe abortion: technical and policy guidance for health systems

41

forceps. Depending on the duration of pregnancy,
preparation to achieve adequate cervical dilatation
can require from 2 hours to 2 days. Many providers
find the use of ultrasound helpful during D&E procedures, but its use is not essential (65).
A randomized controlled trial comparing D&E withintra-amniotic instillation of prostaglandin PGF2α
found D&E to be faster, safer and more acceptable, at least up to 18 weeks of pregnancy (66). D&E
has been compared to the use of mifepristone withrepeated doses of misoprostol in one small trial,
where it was found to be associated with less pain
and fewer adverse events (67). Like any medical procedure, providers need the requisite training, equipment and skills to safely perform D&E (68).
A D&E procedure can usually be performed on
an outpatient basis with a paracervical block andnon-steroidal anti-inflammatory analgesics or conscious sedation. General anaesthesia is not requiredand can increase risk (see Section 2.2.2.2). A D&E
procedure usually takes no more than 30 minutes
to perform. Clinic staff and women undergoing theprocedure should expect more postoperative vaginal
bleeding than after a first-trimester abortion. Staff
should also be trained to provide counselling andinformation specific to second-trimester abortion.

2.2.4.4 Other surgical methods of abortion for use
in later pregnancy
Major surgical operations should not be used as primary methods of abortion. Hysterotomy has no rolein contemporary abortion practice, since its morbidity, mortality and cost are markedly higher than thoseof D&E or medical methods of abortion. Similarly,
hysterectomy should not be used except for womenwith conditions that would warrant the operation
independently (19).

42

Safe abortion: technical and policy guidance for health systems

2.2.4.5 Tissue examination following surgicalabortion
After surgical methods of abortion, immediate examination of the products of conception is important
to exclude the possibility of ectopic pregnancy andassess whether the abortion is likely to be complete.
With vacuum aspiration, beginning around 6 weeks
of pregnancy, trained providers can visually identify
the products of conception, specifically chorionic villi
and the gestational sac (59). If the aspirate does notcontain products of conception, ectopic pregnancy
should be suspected and the woman should undergo
further evaluation (see Section 2.1.6). In addition,
providers should be alert to tissue appearances suggestive of molar pregnancy, particularly in countries
where molar pregnancy is common. If the contentsof the aspirate contain less tissue than expected, thepossibility of incomplete abortion and treatment withre-aspiration should be considered. Routine examination of the products of conception by a pathology
laboratory is not necessary when trained providers
perform routine tissue examination.

2.2.5 Medical methods of abortion(see Box 2.1)
Medical methods of abortion have been proved tobe safe and effective (4, 19, 24, 69–71). The mosteffective regimens rely on the antiprogestogen,mifepristone, which binds to progesterone receptors, inhibiting the action of progesterone and henceinterfering with the continuation of pregnancy.
Treatment regimens entail an initial dose of mifepristone followed by administration of a synthetic
prostaglandin analogue, generally misoprostol, which
enhances uterine contractions and aids in expelling the products of conception (72). Gemeprost is
a prostaglandin analogue similar to misoprostol, but
it is more expensive, requires refrigeration, and may
only be administered vaginally (12). Thus, although

Clinical care for women undergoing abortion

BOX 2.1
Dosages and routes of administration for mifepristone followed by misoprostol
For pregnancies of gestational age up to 9 weeks (63 days)
yy 200 mg mifepristone administered orally.
yy Administration of misoprostol is recommended 1 to 2 days (24–48 hours) following ingestion of
mifepristone.
yy For vaginal, buccal or sublingual routes, the recommended dose of misoprostol is 800 μg.
yy For oral administration, the recommended dose of misoprostol is 400 μg.
yy With gestations up to 7 weeks (49 days) misoprostol may be administered by vaginal, buccal, sublingual or oral routes. After 7 weeks of gestation, oral administration of misoprostol should not be used.
yy With gestations up to 9 weeks (63 days) misoprostol can be administered by vaginal, buccal or sublingual routes.

For pregnancies of gestational age 9–12 weeks (63–84 days)
yy 200 mg mifepristone administered orally, followed after 36 to 48 hours by:yy 800 µg vaginal misoprostol, administered in a health-care facility. A maximum of four further dosesof misoprostol 400 µg may be administered at 3-hourly intervals, vaginally or sublingually.

For pregnancies of gestational age over 12 weeks (>84 days)
yy 200 mg mifepristone administered orally, followed after 36 to 48 hours by:yy 400 µg oral or 800 µg vaginal misoprostol followed by 400 µg vaginal or sublingual misoprostol every
3 hours up to a maximum of five doses, administered in a health-care facility. For pregnancies ofgestational age greater than 24 weeks, the dose of misoprostol should be reduced due to the greater
sensitivity of the uterus to prostaglandins, but the lack of clinical studies precludes specific dosing
recommendations.

gemeprost demonstrates similar efficacy as misoprostol, misoprostol is the prostaglandin analogueof choice for abortion-related care (73). A number ofother prostaglandins that were used in the past, suchas sulprostone and prostaglandin F2α, are no longer
used because of their adverse side-effects or relativelack of efficacy (74).
The effects of medical methods of abortion are similar
to those associated with spontaneous abortion andinclude uterine cramping and prolonged menstruallike bleeding. Bleeding occurs for 9 days on average but can last up to 45 days in rare cases (75).

Clinical care for women undergoing abortion

Side-effects include nausea, vomiting and diarrhoea.
Contraindications to the use of mifepristone and a
prostaglandin analogue include chronic or acute adrenal or hepatic failure, inherited porphyria, and allergy
to any of the drugs used. Mifepristone is not aneffective treatment for ectopic pregnancy; suspicionof ectopic pregnancy demands further investigation
and, if confirmed, immediate treatment (11). Caution
and clinical judgement are required for women using
corticosteroids long term, and for those who have
bleeding disorders, severe anaemia, pre-existingheart disease or cardiovascular risk factors (12).

Safe abortion: technical and policy guidance for health systems

43Medical methods of abortion have proved acceptablein many settings, including low-resource settings(76–78). The medications are increasingly available
globally, and the combination of mifepristone andmisoprostol for medical abortion is now included on
the WHO model list of essential medicines (73, 79).
As these medications become increasingly available,
programme managers should be aware of what isrequired to introduce medical methods of abortion
into existing health services (see Chapter 3).

2.2.5.1 Mifepristone and prostaglandin analogue
For pregnancies of gestational age up to 9 weeks(63 days)
Mifepristone with misoprostol has been proven highly
effective, safe and acceptable for abortions occurring up to 9 weeks since the LMP. Efficacy rates up
to 98% are reported (70, 80). Approximately 2–5% of
women treated with the combination of mifepristone
and misoprostol will require surgical intervention toresolve an incomplete abortion, terminate a continuing pregnancy, or control bleeding (81).
The original protocols for the use of mifepristone
recommended an oral dose of 600 mg mifepristone followed by 1 mg of vaginal gemeprost after
36–48 hours. However, several studies have established that 200 mg of mifepristone is the dosageof choice, since it is as effective as 600 mg, andreduces costs when followed by a suitable prostaglandin analogue (4, 81–83). Some studies haveindicated that mifepristone can be given as five orsix divided doses of 25 mg over 3 days, for a total
dose of 125–150 mg (84), a regimen widely used in
the People’s Republic of China. However, for service
delivery and patient convenience, the single dose of
mifepristone is recommended. A 50 mg dose of mifepristone is less effective than 200 mg, when given in
combination with gemeprost (85). One trial reported
that mifepristone, 100 mg, when combined with

44

Safe abortion: technical and policy guidance for health systems

800 µg of misoprostol given vaginally, was as effective as 200 mg; however, efficacy in both arms of thisstudy was lower than expected (86).
Misoprostol is an effective prostaglandin analoguethat is considerably less expensive than gemeprost,and does not require refrigeration. It is therefore theprostaglandin analogue of choice. An oral dose of
200 mg mifepristone followed by 800 µg misoprostol administered vaginally, sublingually or buccallyis an effective medical abortion regimen (4). When
compared to vaginal administration, sublingual misoprostol appears to be associated with higher rates
of gastrointestinal side-effects, and buccal administration appears to be associated with higher rates ofdiarrhoea (4). Vaginal misoprostol is more effective
and better tolerated than misoprostol given orally(87). Misoprostol given orally at a dose of 400 µg
should be restricted to pregnancies up to 7 weeks’(49 days’) gestation, given its higher failure rate when
given orally as pregnancy progresses (12, 81).
Some protocols require that women take both mifepristone and a prostaglandin analogue under clinicalsupervision, involving a second visit to the healthcare facility one or two days after receiving mifepristone, to take the prostaglandin analogue. Home useof misoprostol is a safe option for women (80, 88).
Increasingly, after receiving the mifepristone in theclinic, women receive misoprostol for self-administration at home within 24–48 hours following the
mifepristone. Nevertheless, some women may preferclinic use (89). Women using misoprostol at home
may leave the facility shortly after taking the mifepristone. They must be told what to expect with regard
to vaginal bleeding and expulsion of products ofconception following use of misoprostol, and how torecognize complications and whom to contact if theyshould occur. Explaining that the misoprostol doseshould be taken as planned regardless of whether

Clinical care for women undergoing abortion

bleeding occurs following mifepristone is important
for the few women who experience such bleeding.
Following administration of the misoprostol, up to
90% of women will expel the products of conception
over the following 4–6 hours. Most women are likely
to require medication for cramping pain during thisperiod of time (see Section 2.2.2.1).
In the case of a failed abortion where pregnancy is
ongoing, re-administration of misoprostol or surgical abortion should be offered to the woman (12).
Women with incomplete abortions can generally beobserved unless vaginal bleeding is heavy, or they
may be offered re-administration of misoprostol
or surgical completion of their abortion. Facilities
offering medical methods of abortion must be able
to ensure provision of vacuum aspiration, if needed.
Such provision can be available on-site or throughan arrangement with another facility that performs
vacuum aspiration. In all cases, health-care providers
must ensure that the woman can reach such services
in case of an emergency.
Women are more likely to be satisfied with the procedure if they have realistic expectations about theabortion process (90). Hence, they need complete
information about what is to be expected with, andthe possible side-effects of, medical methods ofabortion. Health-care workers should ensure thatwomen understand the importance of complying
with the protocol, especially for drugs that are selfadministered, and that they know how to recognize,
and what to do in case of, complications.
For pregnancies of gestational age from
9 to 12 weeks (63–84 days)
Limited data suggest that during this period the mosteffective medical regimen is mifepristone 200 mg
orally followed 36–48 hours later by misoprostol
800 µg vaginally, administered in a health-care

Clinical care for women undergoing abortion

facility. A maximum of four further doses of misoprostol 400 µg may be administered at three-hourlyintervals, vaginally or sublingually (27, 28). Regimens
during this period of pregnancy and the setting inwhich they can be administered are the subject ofongoing research.
For pregnancies of gestational age over
12 weeks (>84 days)
A regimen of oral mifepristone, 200 mg, followedby repeated doses of misoprostol is safe and highly
effective when administered in a health-care facility(3, 91). An oral dose of 200 mg mifepristone followed
36–48 hours later by an initial dose of misoprostol,
either 400 µg orally or 800 µg vaginally, with further
doses of 400 µg of vaginal or sublingual misoprostol
every 3 hours, up to four further doses is highly effective (91). For pregnancies beyond 24 weeks’ gestation, the dose of misoprostol should be reduced, due
to the greater sensitivity of the uterus to prostaglandins, but the lack of clinical studies precludes specific dosing recommendations.
A vaginally administered dose of 1 mg gemeprost
used after 200 mg mifepristone, and repeated if
necessary every 6 hours up to four doses can also be
used effectively (92). The treatment with gemeprost
may continue with 1 mg gemeprost every 3 hours forfour additional doses if necessary (93, 94).

2.2.5.2 Misoprostol alone
For pregnancies of gestational age up to
12 weeks (84 days)
Misoprostol alone has also been studied for medical abortion in terms of effectiveness and safety. The
effectiveness of misoprostol alone is lower, the time
to complete abortion is prolonged, and the abortion process is more painful and associated withhigher rates of gastrointestinal side-effects thanwhen misoprostol is combined with mifepristone

Safe abortion: technical and policy guidance for health systems

45

(4, 95). Because of misoprostol’s wide availability
and low cost, and since in some settings its broader
use has been reported to contribute to a decreasein complications from unsafe abortion (96), the useof misoprostol alone appears to be common where
mifepristone is unavailable.
The recommended misoprostol regimens are 800 μg
administered vaginally or sublingually, and repeatedat intervals no less than 3 hours but no more than
12 hours for up to three doses. This regimen is
75–90% effective in completing abortion. Sublingual
administration is less effective than vaginal administration unless it is given every 3 hours, but thisregimen has high rates of gastrointestinal side-effects(4, 96, 97). Oral administration is not recommended
due to its low efficacy.
For pregnancies of gestational age over
12 weeks (84 days)
Misoprostol is effective in inducing abortion after
12 weeks of pregnancy, although the time to complete abortion is not as short as when it is used in
combination with mifepristone. The recommended
regimen is 400 μg of vaginal or sublingual misoprostol every 3 hours for up to five doses (91, 98).
Particularly for nulliparous women, vaginal administration of misoprostol is more effective than sublingual dosing. For pregnancies beyond 24 weeks’gestation, the dose of misoprostol should be reduced
due to the greater sensitivity of the uterus to prostaglandins; however, the lack of clinical studies precludes dosing recommendations.
Vaginal administration of gemeprost alone is registered for termination of second-trimester pregnancy
in several countries. The recommended dose is 1 mg,
which is given every 3 hours up to five times during
the first day and repeated the next day if necessary.
With this treatment, 80% and 95% of women willabort within 24 and 48 hours, respectively (99).

46

Safe abortion: technical and policy guidance for health systems

2.2.5.3 Other medical abortion agents
Methotrexate, which is a cytotoxic drug used to treat
certain types of cancer, rheumatoid arthritis, psoriasis and some other conditions, has been used in
combination with misoprostol as a medical method
for early abortion (pregnancies of gestational age up
to 7 weeks) in some countries where mifepristone
has not been available. When combined with misoprostol, it is effective: a number of studies report an
overall success rate of greater than 90% with 50 mg
of methotrexate orally or intramuscularly, followed
by 800 µg vaginal misoprostol 3–7 days later (4).
However, a WHO toxicology panel recommended
against the use of methotrexate for inducing abortion, based on concerns of teratogenicity if the pregnancy was not successfully aborted (100). Although
the actual risks are as yet unknown, limb defects
and skull and facial abnormalities in pregnancies that
continued after failed attempts to induce abortion
with methotrexate have been reported (101–103). It
is therefore recommended that services wishing to
introduce medical methods of abortion use combination regimens of mifepristone and misoprostol.
Other agents are used to stimulate uterine contractions and induce abortion after 12 weeks, but available data regarding their safety are limited. These
agents include hypertonic saline, or hyperosmolarurea, injected intra-amniotically; ethacridine lactate
administered intra- or extra-amniotically; prostaglandin analogues administered parenterally or
intra- or extra-amniotically; and oxytocin injected
intravenously or intramuscularly (91, 104). Thesemethods and routes of administration, however, areinvasive and likely to be less safe, and the time tocomplete abortion is longer when compared to theuse of methods such as combined mifepristone andmisoprostol.

Clinical care for women undergoing abortion

2.2.6 Managing abortion complications
When abortion is performed by appropriately trained
personnel under modern medical conditions, complications are impressively rare and the risk of deathis negligible (in contrast to unsafe abortion, see
Chapter 1). Nevertheless, every service-delivery
site at each level of the health system should beequipped and have personnel trained to recognize
abortion complications and to provide, or refer
women for, prompt care, 24 hours a day (104). The
facilities and skills required to manage most abortion
complications are similar to those needed to carefor women who have had a spontaneous abortion(miscarriage).

2.2.6.1 Ongoing pregnancy
Failed abortion with ongoing pregnancy can occur in
women who have undergone either surgical or medical methods of abortion, although it is more common
after medical procedures. Women with continuing
symptoms of pregnancy or clinical signs of failed
abortion should be offered a uterine evacuation procedure as expeditiously as possible (19).

2.2.6.2 Incomplete abortion
Incomplete abortion is uncommon following vacuum
aspiration when the abortion is performed by a skilledprovider. It is more common with medical methodsof abortion (56). Common symptoms include vaginal
bleeding and abdominal pain, and signs of infection
may be present. Incomplete abortion should also
be suspected if, upon visual examination, the tissue
aspirated during surgical abortion is not compatible with the estimated duration of pregnancy. Staff
at every health-care facility should be trained andequipped to treat incomplete abortion by emptying the uterus, paying attention to the possibility of
haemorrhage, which might cause anaemia, or infection, which would necessitate antibiotic treatment.

Clinical care for women undergoing abortion

Incomplete abortion may be treated using either
vacuum aspiration or misoprostol. Vacuum aspiration is recommended over D&C for uterine evacuation, as it is associated with less blood loss, lesspain and shorter procedure times (105). Incomplete
abortion may also be treated using misoprostol:no differences were demonstrated in rates of complete abortion or of adverse events between uterine
aspiration or misoprostol for women with incomplete
spontaneous abortion (miscarriage) with uterine size
up to 13 weeks’ gestation, although there were more
unplanned surgical interventions with misoprostol use(106). The recommended misoprostol dose and routeof administration for this indication is either 600 μg
oral or 400 μg sublingual (106, 107). The presenceof bleeding may decrease misoprostol absorption
when the drug is administered vaginally (108); thus,
a non-vaginal route is generally preferable, althoughvaginal administration of 400–800 μg has been usedeffectively (106). Incomplete spontaneous abortions
may also be managed expectantly, for women who
are clinically stable and wish to avoid medical or
surgical treatment, but the process takes more time(106). The decision about management of incomplete
abortion should be based upon the clinical conditionof the woman and her preference for treatment.

2.2.6.3 Haemorrhage
Haemorrhage can result from retained products ofconception, trauma or damage to the cervix, coagulopathy or, rarely, uterine perforation. Depending on
the cause of the haemorrhage, appropriate treatment
may include re-evacuation of the uterus and administration of uterotonic drugs to stop the bleeding,intravenous fluid replacement, and, in severe cases,
blood transfusion, replacement of clotting factors,
laparoscopy or exploratory laparotomy. Because of
the low incidence of haemorrhage using vacuum
aspiration, oxytocic drugs are not routinely needed,

Safe abortion: technical and policy guidance for health systems

47

although they may be indicated with D&E. Prolonged
menstrual-like bleeding is an expected effect of
medical methods of abortion. On average, vaginal
bleeding gradually diminishes over about 2 weeks
after medical abortion but, in individual cases, bleeding and spotting may persist for up to 45 days; such
bleeding is rarely heavy enough to constitute an
emergency. Surgical evacuation may be performedon the woman’s request, or in cases where the bleeding is heavy or prolonged, causes anaemia, or thereis evidence of infection. However, every service-delivery site must be able to stabilize and treat or refer
women with haemorrhage immediately (19).

2.2.6.4 Infection
Infection rarely occurs following properly performed
abortions. The genital tract, however, is more susceptible to ascending infection when the cervix is dilated
after abortion or childbirth. Common signs andsymptoms of infection include fever or chills, foulsmelling vaginal or cervical discharge, abdominal or
pelvic pain, prolonged vaginal bleeding or spotting,uterine tenderness, and/or an elevated white blood
cell count. When infection is diagnosed, health-care
staff should administer antibiotics and, if retained
products of conception are a likely cause of theinfection, re-evacuate the uterus. Women with severe
infections may require hospitalization. As discussed
in Section 2.1.5, prophylactic provision of antibiotics
for women undergoing surgical abortion has beenfound to reduce the risk of post-abortion infection (9)and they should be provided where possible.
There are few data on the incidence of clinicallysignificant pelvic infection after medical abortion,
but it occurs rarely and possibly less frequently thanafter vacuum aspiration. Many of the symptoms ofpelvic infection, such as pain, are rather nonspecificand hence precise diagnosis is difficult. Women

48

Safe abortion: technical and policy guidance for health systems

with pelvic pain, abdominal or adnexal tenderness,vaginal discharge, and fever should be treated withbroad-spectrum antibiotics.
Rare cases of anaerobic infection without fever havebeen reported from Canada and the USA, following
medical abortion (10, 12, 109). No such cases havebeen reported elsewhere. In these cases, women had
little or no fever; variable nausea, vomiting, weakness
and some abdominal pain; rapid deterioration within
hours or days; tachycardia and refractory hypotension; multiple effusions; elevated haematocrit; andelevated leukocyte count and neutrophilia. All women
had Clostridium-related toxic shock. Reported cases
have also occurred outside of abortion care, suchas during the postpartum period following a normaldelivery (110). There is no evidence that prophylactic
antibiotic treatment during medical abortion would
eliminate these rare fatal cases of serious infection; therefore, prophylactic provision of antibiotics for women undergoing medical abortion is notrecommended.

2.2.6.5 Uterine perforation
Uterine perforation usually goes undetected andresolves without the need for intervention. A studyof more than 700 women undergoing concurrent
first-trimester abortion and laparoscopic sterilization
found that 12 out of the 14 uterine perforations wereso small that they would not have been recognized
had laparoscopy not been performed (111). Whenuterine perforation is suspected, observation andantibiotic treatment may be all that is necessary.
When available and necessary, laparoscopy is theinvestigative method of choice. If the laparoscopy
examination and/or the status of the patient giverise to any suspicion of damage to the bowel, bloodvessels or other structures, a laparotomy to repair thedamaged structures may be needed.

Clinical care for women undergoing abortion

2.2.6.6 Anaesthesia-related complications

2.2.6.9 Other complications

Local anaesthesia is safer than general anaesthesia,
both for vacuum aspiration in the first trimester andfor D&E in the second trimester (1, 49, 50). Where
general anaesthesia is used, staff must be skilled inmanagement of seizures and cardiorespiratory resuscitation. Narcotic-reversal agents should always bereadily available in settings where narcotics are used.

Following unsafe abortion, various other complications may occur that result from the manner or
method of provoking the abortion. Examples are poisoning, abdominal trauma, or the presence of foreign
bodies in the genital tract, among others. Women
with these complications should be stabilized andtreated or referred for appropriate treatment, in addition to managing any abortion-related complications(see Sections 2.2.6.1–2.2.6.6) and receiving appropriate post-procedure care (see Section 2.3).

2.2.6.7 Uterine rupture
Uterine rupture is a rare complication. It is associated with later gestational ages and uterine scar, but
has also been reported in women without these risk
factors. In a meta-analysis, the risk of uterine rupture
in women with a prior caesarean delivery having amisoprostol-induced abortion in the second trimester
was found to be 0.28% (112).

2.2.6.8 Long-term sequelae
The vast majority of women who have a properly
performed induced abortion will not suffer any longterm effects on their general or reproductive health(113–115). In modern times, the risk of death from asafe, induced abortion is lower than from an injectionof penicillin (116) or carrying a pregnancy to term (1).
Research shows no association between safely
induced first-trimester abortion and adverse outcomes in subsequent pregnancies (117). Althoughsecond-trimester abortions have not been studied
as extensively, there is no evidence of an increased
risk of adverse outcomes in subsequent pregnancies (114, 118). Sound epidemiological data show noincreased risk of breast cancer for women following
spontaneous or induced abortion (119, 120). Negative
psychological sequelae occur in a very small numberof women and appear to be the continuation of preexisting conditions, rather than being a result of theexperience of induced abortion (121, 122).

Clinical care for women undergoing abortion

2.2.7 Other issues related to abortion
procedures
2.2.7.1 Infection prevention and control
Since abortion procedures and care involve contact
with blood and other body fluids, all clinical and support staff in all facilities that provide these services
should understand and apply standard precautions
for infection prevention and control, for both theirown protection and that of their patients.
Standard precautions are simple infection-control
practices to be used in the care of all patients, at all
times, to reduce the risk of transmission of bloodborne infections. They include: hand-washing withsoap and water before and after all procedures; useof protective barriers such as gloves, gowns, aprons,
masks, and goggles to avoid direct contact withblood and other body fluids; safe disposal of waste
contaminated with blood or other body fluids; proper
handling of soiled linen; careful handling and disposalof “sharps”; and proper disinfection of instruments
and other contaminated equipment (123).
Hand-washing and use of protective barriers
All staff should wash their hands thoroughly before
and after coming into contact with the woman, as

Safe abortion: technical and policy guidance for health systems

49

well as immediately following any contact with blood,
body fluids or mucous membranes (124). High-level
disinfected or sterile gloves should be worn andreplaced between contacts with different patientsand between vaginal (or rectal) examinations of
the same woman. After completing the care of one
woman and removing gloves, the health-care provider should always wash their hands, as gloves may
have undetected holes in them (124). The use of auxiliary supplies, such as sterile booties, does not makea significant difference in infection rates, although it
increases costs.
Cleaning
Detergents and hot water are adequate for theroutine cleaning of floors, beds, toilets, walls, andrubber draw sheets. Following spillage of body fluids,
heavy-duty rubber gloves should be worn and asmuch body fluid as possible removed with an absorbent material. This can then be discarded in a leakproof container and later incinerated or buried in a
deep pit. The area of spillage should be cleaned witha chlorine-based disinfectant and then thoroughly
washed with hot soap and water.
All soiled linen should be handled as little as possible, bagged at the point of collection and not sorted
or rinsed in patient-care areas. If possible, linen withlarge amounts of body fluid should be transported
in leak-proof bags. If leak-proof bags are not available, the linen should be folded with the soiled parts
inside, and handled carefully, wearing gloves.
Safe disposal of waste contaminated withbody fluids
Solid waste that is contaminated with blood, body
fluids, laboratory specimens or body tissue shouldbe treated as clinical waste, and disposed of properly
and in accordance with local regulations (123). Liquid

50

Safe abortion: technical and policy guidance for health systems

waste, such as blood or other body fluids, should
be poured down a drain connected to an adequately
treated sewer or pit latrine.
Safe handling and disposal of “sharps”
The greatest hazard of HIV transmission in healthcare settings is through skin puncture with contaminated needles or “sharps”. This also applies to transmission of hepatitis B and C. Most “sharps” injuries
involving such transmission are through deep injuries
with hollow-bore needles. Such injuries frequently
occur when needles are recapped, cleaned, disposedof, or inappropriately discarded. Although recapping
needles is to be avoided whenever possible (124),
sometimes recapping is necessary. When this is thecase, a single-handed scooping method should be
used. Puncture-resistant disposal containers must
be available and readily accessible for the disposal of“sharps”. These can be burned in a closed incinerator or buried in a deep pit. Added precautions to prevent “sharps” injuries include wearing gloves, having
an adequate light source when treating women,
placing “sharps” containers directly at the point ofuse, never discarding “sharps” in general waste,
and keeping “sharps” out of the reach of children.
Whenever possible, needle holders should be used
when suturing.
Safe cleaning of equipment after use
Immediately after use, all reusable surgical instruments used in abortion should be sent for cleaningand sterilization. Medical equipment and supplies
intended for single use should not be reused (124).
Where central services for instrument processing are
not available, or in resource-poor settings, the following procedures are recommended.
The most important step to ensure proper final
decontamination of instruments is physical cleaning

Clinical care for women undergoing abortion

(123). Instruments should be kept wet until cleaning.
Letting the devices dry may make it difficult to completely remove all contaminants. A disinfectant suchas a 0.5% chlorine solution can be used. Aspirators
must be disassembled before cleaning and further
processing. Detachable adaptors must be removed
from cannulae.

including bacterial endospores such as those thatcause tetanus and gas-gangrene. High-level disinfection (HLD) destroys all microorganisms including
hepatitis and HIV but does not reliably kill bacterial
endospores.

Caution: aspirators, cannulae and adaptors are notsafe to handle with bare hands until cleaned.
After soaking, wash all surfaces thoroughly in runningwater and detergent. Detergent is preferable to soap,
which can leave a residue. All instruments should
then be sterilized (preferred) or disinfected with ahigh-level disinfectant (where sterilization is not possible or feasible). Sterilization kills all microorganisms,

Sterilization is best achieved with pressurized steam(autoclave) or multi-hour (>5 hours) soaks in fresh
glutaraldehyde solution (125). HLD can be achievedby shorter soaks in glutaraldehyde or bleach (sodium
hypochlorite) solutions (125). The use of phenol orantiseptics will not achieve HLD. Instruments thatwere cold-processed (soaked in solutions) must be
thoroughly rinsed after processing. Instruments thatwere subjected to HLD may be rinsed in boiled water;
instruments that were sterilized should be rinsed insterile water (see Table 2.1 for instrument-processing
details).

Table 2.1 Instrument processing
Method

Agent

Time

Notes

Sterilization

Pressurized steam(autoclave)

20 minutes at 121°C and 103.5–140 kPa
pressure

Assumes the areas of equipment
targeted for decontamination areaccessible to steam. Time should
be increased to 30 minutes forwrapped items.

2% glutaraldehyde

5 hours contact at 20–25°C with a 2%
activated alkaline formulation(pH = 7.5–9)

Some sources/manufacturers
suggest 10 hours for sterilization.

Chlorine (sodium
hypochlorite)

5 minutes contact at 20–25°C withbuffered hypochlorite (pH = 7–8) at aconcentration of 5000 ppm available
chlorine (approximately 10% dilution ofhousehold bleach – can be corrosive tometals)Some sources recommend
20 minutes in a 5% dilution if
made with tap water, or 1% dilution if made with boiled water.

2% glutaraldehyde

30 minutes contact at 20–25°C with a
2% activated alkaline formulation(pH = 7.5–9)

Some sources/manufacturers
suggest 20 minutes for HLD.

Boiling

20 minutes at a “rolling boil”

The pot should be covered; items
that float do not need to be fully
immersed.

High-level
disinfection(HLD)

Note: the effectiveness of all sterilization and HLD techniques depends on prior cleaning to remove organic matter or material that is dried andadherent to the equipment (123, 125, 126).
Clinical care for women undergoing abortion

Safe abortion: technical and policy guidance for health systems

51

Some manufacturers produce aspirators and cannulae made of high-grade plastics that are engineered
to be sterilized in an autoclave, while other plastic instruments will crack and melt when exposed
to high heat for sterilization. Health-care workers
should always refer to the instructions for use of all
items being disinfected, to ensure they are using theappropriate form of disinfection. Additionally, themanufacturers’ instructions for all products used in
the disinfection process should be followed.

2.3 Post-abortion care and follow-up
Following an induced or spontaneous abortion,
women should receive appropriate post-abortion
care. For those women whose abortions were performed unsafely, post-abortion care is used as a
strategy to attenuate the morbidity and mortality
associated with complications, including uterine aspiration for incomplete abortion (see Section 2.2.6.2);
offer of contraception to prevent future unintended
pregnancies; and linking women with other needed
services in the community. Following safe, induced
abortion, post-abortion care may not require afollow-up visit if the woman has adequate information
about when to seek care for complications and hasreceived any needed supplies or information to meether contraceptive needs.
All women should receive contraceptive information and be offered counselling for and methods ofpost-abortion contraception, including emergency
contraception, before leaving the health-care facility. All methods of contraception, including IUDs andhormonal contraceptives, can be initiated immediately following surgical or medical abortion, as longas attention is paid to each woman’s health profileand the limitations associated with certain methods(see Annex 6). There are a few methods that should

52

Safe abortion: technical and policy guidance for health systems

not be started immediately following an abortion: thecontraceptive diaphragm and cervical cap should not
be used until about 6 weeks after a second-trimester
abortion, and fertility-awareness-based methods
should only be started after the resumption of regularmenses (127). IUDs placed immediately post-abortion offer better protection against unintended pregnancy than postponing insertion (128–130). Although
it is safe, there is a higher risk of expulsion of IUDs
if inserted at the time of a second-trimester abortion(131). For medical abortion, hormonal contraceptives
can be started by the woman after taking the first pillof a medical abortion regimen, but confirmation thatthe abortion is complete should precede insertion of
an IUD or sterilization. Additionally, special attention
should be given when women request sterilization,
to ensure their choice is not unduly influenced by thenature of the moment.
Abortion-service-delivery sites should be able toprovide a woman’s contraceptive method of choice inthe facility. If the contraceptive method chosen by the
woman cannot be provided on-site (e.g. sterilization
is rarely offered at primary-care level), the woman
should be given information about where and how
she can obtain it, and be offered an interim method.
For those methods not available on-site, the abortion facility should develop a direct referral system toensure women are able to obtain their chosen contraceptive method. All women should be informed about
emergency contraception, and consideration should
be given to providing it to them to be kept at home
for future use, particularly for women who choose
condoms as their primary method of contraception
and those who choose not to start using a routine
contraceptive method immediately.
Providers should discuss prevention of STIs, including HIV, and the importance of condom use withwomen who choose methods other than condoms

Clinical care for women undergoing abortion

for contraception (127). Information about infection prevention should be particularly emphasized
for individuals who may be at increased risk, andin areas of known high prevalence of HIV and other
STIs. HIV counselling and testing should be available in the facility, or by referral to other facilities.
Dual protection, or the use of one method such as
condoms, or a combination of methods, to protect against both pregnancy and STIs should bepromoted.
Women undergoing abortion should receive clear,simple, oral and written instructions about how tocare for themselves after leaving the health-care facility, and how to recognize complications that require
medical attention. These instructions should include:
abstaining from sexual intercourse and from placing
anything in the vagina until bleeding stops; the availability of contraception, including emergency contraception, to avoid a pregnancy (fertility may return assoon as 2 weeks following abortion); and the need toreturn to the health-care facility in case of increasing
pelvic pain, heavy bleeding or fever (19). During thetime it takes for a medical abortion to be completed,
women should be able to contact, at any time, a physician or other health-care worker who can answer
questions and provide support.

2.3.1 Surgical methods of abortion
During the observation period following surgicalabortion, staff should offer women comfort and support and monitor their recovery. Health-care workers should take special note of women’s reports ofpain, since pain may be due to uterine perforation(which may require observation or laparotomy fortreatment) or acute haematometra (blood filling theuterus, which can be treated by re-aspiration of theuterine cavity). Thus, particularly with late abortions,
it is important to confirm manually the size of theClinical care for women undergoing abortion

uterus through the abdominal wall. In the absenceof complications, most women can leave the healthcare facility as soon as they feel able and their vital
signs are normal (19). After abortions performed laterin pregnancy, and after heavy sedation or generalanaesthesia, recovery periods may be longer andwomen may require closer observation.
After a surgical abortion, women may experience
light menstrual-like bleeding or spotting for several
weeks. Women should be informed that bleeding
similar to or heavier than a heavy menstrual period
might be expected with medical methods of abortion. Symptoms that warrant clinical attention include
excessive bleeding, fever lasting more than one day,and worsening pelvic pain, or, rarely, signs of ongoing pregnancy. Nausea, sometimes accompanied
by vomiting, generally subsides within 24 hours
after surgical abortion. Staff should advise women
to expect cramping, which they can usually alleviatesufficiently with non-prescription non-steroidal antiinflammatory drugs, such as ibuprofen. Information
on recognizing complications and where and how toseek help for them should be made available in pictorial form for women who cannot read.
After first-trimester abortion, most women can returnto their usual activities and responsibilities within
hours or days (19). Women undergoing surgical abortion may be offered a follow-up visit with a trained
practitioner, within 2 weeks after the procedure. Thisvisit can be an opportunity for providers to talk withwomen about their experiences, if needed. For example, women having an abortion for medical reasons,or following rape, may need to speak about theirsense of loss or ambivalence, or may want additionalcounselling.

Safe abortion: technical and policy guidance for health systems

53

2.3.2 Medical methods of abortion
Due to the high effectiveness of the mifepristone andmisoprostol combination for medical abortion up to
9 weeks (63 days) of gestation, there is no need for
medical follow-up to confirm completed abortion.
Women, however, should be advised to return forfollow-up if they are experiencing signs of ongoing
pregnancy or for other medical reasons, such as
prolonged heavy bleeding or fever. Those who had
a medical abortion using a misoprostol-only regimen should return for follow-up for confirmation ofcomplete abortion 7–14 days following misoprostol
intake.
Treatment protocols for mifepristone followed bymisoprostol used up to 9 weeks of pregnancy that
require women to remain under clinical observation for 4–6 hours after taking the misoprostol
should have confirmation of an abortion during thistime, if possible. Confirmation is generally made byinspecting sanitary pads and bed pans used during
the period of observation, for expelled products ofconception.

an unsuccessful medical abortion are limited andinconclusive; therefore, it is unnecessary to insist on
termination of an exposed pregnancy if the woman
wishes to continue it. Women should, nevertheless,be informed that due to the unknown risk to thefetus of abortifacient drugs, follow-up is important(12, 133).
Women with incomplete abortions can generally beobserved unless vaginal bleeding is heavy, or they
may be offered re-administration of misoprostol orsurgical completion of their abortion. In view of thegreater risk of haemorrhage and of incomplete abortion associated with procedures undertaken after
12 weeks of pregnancy, all women in these situations should remain under clinical observation until
both the fetus and placenta have been expelled.
Additionally, medical abortions after 9 weeks’ gestation should take place in a health-care facility,
although research is ongoing to determine whether
home abortion among a subgroup of this gestational
age range is safe and appropriate.

Complete abortion may be confirmed by pelvic
examination, pelvic ultrasound or a repeat hCG
measurement. If hCG measurements are used, itshould be remembered that in some cases low hCGlevels can be detectable for up to 4 weeks after
successful expulsion. Ultrasound is useful to detect
ongoing pregnancy; measuring endometrial thickness, however, is not useful for diagnosing incomplete abortion and may lead to inappropriate surgicalinterventions (132). Women who continue to havesymptoms of pregnancy or have minimal bleeding are
likely to be still pregnant.
Women with failed abortion (the pregnancy is ongoing) should be offered either vacuum aspiration or
repeat administration of misoprostol. Available data
regarding a potential risk of fetal abnormality after

54

Safe abortion: technical and policy guidance for health systems

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79. Essential medicines: WHO model list, 12th ed.
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88. Ngo TD et al. Comparative effectiveness, safety andacceptability of medical abortion at home and in aclinic: a systematic review. Geneva, World HealthOrganization, 2011 (Report no. 89).

80. Fjerstad M et al. Rates of serious infection after
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89. Hajri S et al. Expanding medical abortion in Tunisia:
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90. Breitbart V. Counseling for medical abortion.
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91. Wildschut H et al. Medical methods for mid-trimester termination of pregnancy. Cochrane Database of
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92. Ho PC, Chan YF, Lau W. Misoprostol is as effective
as gemeprost in termination of second trimester
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93. Gemzell-Danielsson K, Ostlund E. Termination of
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Scandinavica, 2000, 79:702–706.
94. Tang OS, Thong KJ, Baird DT. Second trimester
medical abortion with mifepristone and gemeprost: a review of 956 cases. Contraception, 2001,
64:29–32.
95. Bugalho A et al. Termination of pregnancies of<6 weeks gestation with a single dose of 800 μg ofvaginal misoprostol. Contraception, 2000, 61:47–50.
96. Costa SH, Vessey MP. Misoprostol and illegal
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97. Faundes A et al. Misoprostol for the termination ofpregnancy up to 12 completed weeks of pregnancy.
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98. Ho PC et al. Misoprostol for the termination ofpregnancy with a live fetus at 13 to 26 weeks.
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99. Thong KJ, Robertson AJ, Baird DT. A retrospective study of 932 second trimester terminations
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100. UNDP/UNFPA/WHO/World Bank Special
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101. Powell HR, Ekert H. Methotrexate-induced congenital malformations. Medical Journal of Australia,1971,
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102. Diniz E et al. Efietos sobre o concepto do metotrexato (ametopterina) administrado à mae.
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103. Feldkamp M, Carey JC. Clinical teratology counseling and consultation case-report – low-dose
methotrexate exposure in the early weeks of pregnancy. Teratology, 1993, 47:533–539.
104. Clinical management of abortion complications: apractical guide. Geneva, World Health Organization,
1994.
105. Tuncalp O, Gulmezoglu AM, Souza J. Surgicalprocedures to evacuate incomplete miscarriage.
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106. Neilson JP et al. Medical treatments for incomplete miscarriage (less than 24 weeks). Cochrane
Database of Systematic Reviews, 2010,(1):CD007223.
107. Diop A et al. Two routes of administration for misoprostol in the treatment of incomplete abortion:a randomized clinical trial. Contraception, 2009,
79:456–462.
108. Tang OS et al. Pharmacokinetics of repeateddoses of misoprostol. Human Reproduction, 2009,24:1862–1869.
109. FDA public health advisory; sepsis and medical
abortion. Silver Spring, MD, US Food and Drug
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110. Ho CS et al. Undiagnosed cases of fatal
Clostridium-associated toxic shock in Californian
women of childbearing age. American Journal of
Obstetrics and Gynecology, 2009, 201:459–457.
111. Kaali SG, Szigetvari IA, Bartfai GS. The frequency
and management of uterine perforations during 1sttrimester abortions. American Journal of Obstetrics
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112. Goyal V. Uterine rupture in second-trimester misoprostol-induced abortion after cesarean delivery:a systematic review. Obstetrics and Gynecology,
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Technical Report Series 871. Geneva, World HealthOrganization, 1997.
114. Atrash HK, Hogue CJ. The effect of pregnancy
termination on future reproduction. Baillières ClinicalObstetrics and Gynaecology, 1990, 4:391–405.
115. Virk J, Zhang J, Olsen J. Medical abortion andthe risk of subsequent adverse pregnancy outcomes. New England Journal of Medicine, 2007,
357:648–653.
116. Cates W Jr, Grimes DA, Schulz KF. The public healthimpact of legal abortion: 30 years later. Perspectives
on Sexual and Reproductive Health, 2003, 35:25–28.
117. Rowland Hogue CJ et al. Answering questions
about long-term outcomes. In Paul M et al., eds.
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118. Lurie S et al. The influence of midtrimester termination of pregnancy on subsequent fertility: four to five
years follow-up. Contraception, 1994, 50:239–241.
119. Beral V et al. Breast cancer and abortion: collaborative reanalysis of data from 53 epidemiologicalstudies, including 83 000 women with breast cancerfrom 3.6 countries. Lancet, 2004, 363:1007–1016.
120. Melbye M et al. Induced abortion and the risk ofbreast cancer. New England Journal of Medicine,
1997, 336:81–85.
121. Dagg PKB. The psychological sequelae of therapeutic-abortion – denied and completed. American
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122. Major B et al. Abortion and mental health evaluating the evidence. American Psychologist, 2009,
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123. World Health Organization. Standard precautions inhealth care. WHO Infection Control, October 2007,
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124. WHO guidelines on hand hygiene and health care.
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128. Goodman S et al. A. Impact of immediate postabortal insertion of intrauterine contraception on repeat
abortion. Contraception, 2008, 78:143–148.
129. Reeves MF, Smith KJ, Creinin MD. Contraceptive
effectiveness of immediate compared with delayed
insertion of intrauterine devices after abortion: adecision analysis. Obstetrics and Gynecology, 2007,
109:1286–1294.
130. Roberts H, Silva M, Xu S. Post abortion contraception and its effect on repeat abortions in Auckland,
New Zealand. Contraception, 2010, 82:260–265.
131. Stanwood NL, Grimes DA, Schulz KF. Insertion of
an intrauterine contraceptive device after inducedor spontaneous abortion: a review of the evidence.
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132. Reeves MF et al. Endometrial thickness following
medical abortion is not predictive of subsequent
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133. Sitruk-Ware R, Davey A, Sakiz E. Fetal malformationand failed medical termination of pregnancy. Lancet,
1998, 352:323.

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Clinical care for women undergoing abortion

Safe abortion: technical and policy guidance for health systems

61

Chapter 3

Planning
managing
abortion
Safe
abortion:safe
technical
and carepolicy guidance for health systems
62 andPlanning and managing safe abortion care

Chapter 3
Planning and managing safe abortion care
Summary
Planning and managing safe, legal abortion carerequires consideration of a number of health system
issues. These issues apply whether services are
public, private or not-for-profit. In most cases, minor
modifications of existing facilities, acquisition of minimal additional equipment and medications, and/or
provision of basic training can facilitate service provision where none previously existed, or can improve
the quality, safety, efficiency and capacity of existing
services. Establishing and/or strengthening existing
services should be based on careful planning encompassing the following principles and recommendations, which have been generated from reviews of
the relevant scientific literature and on recent World
Health Organization (WHO) consultative processes(indicated by links to online publications).
yy Establishment of national standards and guidelines facilitating access to and provision ofsafe abortion care to the full extent of the law.
Standards and guidelines should cover: types ofabortion service, where and by whom they can beprovided; essential equipment, instruments, medications, supplies and facility capabilities; referral mechanisms; respect for women’s informed
decision-making, autonomy, confidentiality andprivacy, with attention to the special needs ofadolescents; special provisions for women who
have suffered rape; and conscientious objection
by health-care providers.
yy Ensuring health-care provider skills and performance through: training; supportive andPlanning and managing safe abortion carefacilitative supervision; monitoring, evaluation,and other quality-improvement processes.
Training should be competency based andaddress health-care provider attitudes and ethicalissues related to the provision of safe, induced
abortion (http://whqlibdoc.who.int/publications/2011/9789241501002_eng.pdf). Monitoringand evaluation include the collection of routine
service statistics and safe abortion indicators, theuse of checklists, periodic special studies, andfeedback mechanisms to ensure continuous quality improvement (http://www.who.int/reproductivehealth/publications/monitoring/924156315x/
en/index.html).
yy Financing: health-service budgets should include
the costs of staff, training programmes, equipment, medications, supplies and capital costs.
Consideration also needs to be given to making
services affordable to women who need them.
The costs of adding safe abortion services toexisting health services are likely to be modest,
relative to the costs to the health system of unsafe
abortion and to gains for women’s health (http://
screening.iarc.fr/doc/policybrief1.pdf).
yy A systematic approach to policy and programme
development: this means planning and implementing policies and programmes with the end
result – promoting women’s health and their
human rights – in mind. It involves assessing
the current situation; introducing interventions
and testing their feasibility, acceptability and

Safe abortion: technical and policy guidance for health systems

63effectiveness on a small scale; and then scalingup successful interventions so that the benefits
can have broader impacts on health-system
performance and the health and well-being of
women, their families and communities (http://
www.who.int/reproductivehealth/publications/strategic_approach/9789241500319/en/index.
html).

3.1 Introduction
This chapter sets out considerations for establishing
and/or strengthening safe abortion care. It highlights
the key components of safe abortion care as well as
the process of putting policies, programmes and services in place, including issues such as assessmentof needs and priorities, introducing interventions on asmall scale, and scaling-up successful interventions
for broader impact.
Policy-makers and health-care managers working toprovide reproductive health services should always
ensure that safe abortion care is readily accessible
and available to the full extent of the law. Women in
all countries have induced abortions. Where legal
services are readily accessible and available, thoseabortions are generally safe; where access and availability of legal services are highly restricted, they tend
to be unsafe (1, 2). Abortion laws and services should
protect the health and human rights of all women,
including adolescents. They should not create situations that lead women and adolescents to seek
unsafe abortion. Indeed, most countries have one ormore legal indications for the provision of safe abortion. However, in countries with highly restrictive laws
on induced abortion, services may be largely limited
to the treatment of complications from unsafe abortion. Such treatment is often referred to as “postabortion care”. Emergency treatment of abortion

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Safe abortion: technical and policy guidance for health systems

complications is essential to reduce deaths andinjuries from unsafe abortion but it cannot replace theprotection of women’s health and their human rights
afforded by safe, legal induced abortion.

3.2 Constellation of services
Abortion services should be integrated into the healthsystem, either as public services or through publicly
funded, non-profit services, to acknowledge theirstatus as legitimate health services and to protect
against stigmatization and discrimination of womenand health-care providers.
Constellation of services should always involve, at aminimum:
yy medically accurate information about abortion
in a form the woman can understand and recall,and non-directive counselling if requested by the
woman to facilitate informed decision-making;yy abortion services delivered without delay;
yy timely treatment for abortion complications,
including complications from unsafe abortion;
yy contraceptive information, services and referrals,
to help prevent repeat unintended pregnancy andreduce the need for another abortion.
Access to safe abortion depends not only on theavailability of services, but also on the manner inwhich they are delivered and the treatment of women
within the clinical context. Services should bedelivered in a way that respects a woman’s dignity,
guarantees her right to privacy and is sensitive to herneeds and perspectives. Attention should be given to
the special needs of the poor, adolescents, and othervulnerable and marginalized women.

Planning and managing safe abortion care3.3 Evidence-based standards andguidelines
In many countries, evidence-based standards andguidelines for abortion service delivery, including
treatment of abortion complications, do not exist.
Standards for abortion care refer to the underlying
principles and essential requirements for providing
equitable access to, and adequate quality of, lawfulabortion services. Guidelines for abortion care are
evidence-based recommendations for the delivery ofsafe abortion care. In countries where standards andguidelines already exist, routine review and updates
ensure that they continue to promote women’s physical, mental, and social well-being and reflect new
evidence of best practices. Standards and guidelines
should be developed and updated with the intent ofeliminating barriers to obtaining the highest attainable
standard of sexual and reproductive health.

3.3.1 Types of abortion services, where andby whom they can be provided
The availability of facilities and trained providers
within reach of the entire population is essential toensuring access to safe abortion services. Regulationof providers and facilities should be based on evidence of best practices and be aimed at ensuringsafety, good quality and accessibility of services.
Abortion facilities within both the public and private sectors should be available at all levels of thehealth system, with appropriate referral mechanisms
between facilities.
Abortion care can be safely provided by any properly
trained health-care provider, including midlevel (i.e.
non-physician) providers (3–5, 6). The term “midlevelproviders” in the context of this document refers toa range of non-physician clinicians (e.g. midwives,
nurse practitioners, clinical officers, physician assistants, family welfare visitors, and others) who are

Planning and managing safe abortion caretrained to provide basic clinical procedures related toreproductive health, including bimanual pelvic examination to determine age of pregnancy and positioningof the uterus, uterine sounding and other transcervical procedures, and who can be trained to provide
safe abortion care.
Abortion care provided at the primary-care level andthrough outpatient services in higher-level settings issafe, and minimizes costs while maximizing the convenience and timeliness of care for the woman (7).
Where capacity to provide good-quality abortion services at the primary level does not yet exist, referral
to services at higher levels is essential (see Box 3.1).
Allowing home use of misoprostol following provision of mifepristone at the health-care facility canfurther improve the privacy, convenience and acceptability of services, without compromising on safety(8–10). Inpatient abortion care should be reserved forthe management of medical abortion for pregnancies of gestational age over 9 weeks (63 days) andmanagement of severe abortion complications (seeChapter 2).

3.3.1.1 Community level
Community-based health-care workers can play animportant role in helping women avoid unintended
pregnancy, through providing contraceptive information, counselling and methods, and informing them
about the risks of unsafe abortion (11). They can also
inform women about where to obtain a pregnancy
test and how to obtain safe, legal abortion care, andthey can refer women with complications from unsafe
abortion for emergency care. Chemists/pharmacists,
like community health-care workers, can help women
avoid unintended pregnancy through provision of
accurate contraceptive information and methods.
They can also provide pregnancy tests and referral tosafe abortion services.

Safe abortion: technical and policy guidance for health systems

65

BOX 3.1
Types of service suitable to each level of the health system
Community level:yy public health education/information on reproductive health, including contraception and abortion;
yy community-based distribution of appropriate methods of contraception;yy all health-care workers trained to provide information on, and referral to, pregnancy-detection andsafe, legal abortion services;
yy all health-care workers trained to recognize abortion complications and promptly refer women fortreatment;
yy transportation to services for management of complications of abortion;yy all health-care workers (and other key community professionals such as police or teachers) trained torecognize signs of rape and to provide referral to health-care or other social services.

Primary-care facility level:yy all elements of care mentioned for the community level;yy all health-care workers providing reproductive health services trained to provide counselling on contraception, unintended pregnancy and abortion;
yy a broad range of contraceptive methods, including IUDs, implants, and injectables;
yy vacuum aspiration (manual or electric) for pregnancies of gestational age up to 12–14 weeks (seeChapter 2);
yy medical methods of abortion for pregnancies of gestational age up to 9 weeks, or up to 12 weeks if
the woman can stay in the facility until the abortion is complete (see Chapter 2);
yy clinical stabilization, provision of antibiotics, and uterine evacuation for women with complications ofabortion;yy vacuum aspiration or treatment with misoprostol for incomplete abortion;yy prompt referral for women needing services for abortion or for management of abortion complications that cannot be provided on-site.

Referral hospitals:
yy all elements of abortion care mentioned for the primary-care level;yy provision of sterilization in addition to other contraceptive methods;
yy abortion services for all circumstances and stages of pregnancy, as permitted by law;yy management of all abortion complications;
yy information and outreach programmes covering the full catchment area;
yy training of all relevant cadres of health-care professionals in abortion provision.

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Planning and managing safe abortion care3.3.1.2 Primary-care facility level
Both vacuum aspiration and medical abortion canbe provided at the primary-care level on an outpatient basis and do not require advanced technicalknowledge or skills, expensive equipment such as
ultrasound, or a full complement of hospital staff(e.g. anaesthesiologist) (12). Primary health-care staff
are likely to include nurses, midwives, health-careassistants and, in some contexts, physicians. Healthcare personnel with the skills to perform a bimanual
pelvic examination to diagnose and date a pregnancy, and to perform a transcervical procedure suchas intrauterine device (IUD) insertion, can be trained
to perform vacuum aspiration (5, 6, 13–15). Where
medical methods of abortion are registered and available, midlevel health-care providers can also administer and supervise abortion services (3, 16, 17).
For both vacuum aspiration and medical abortion,
procedures for referral to higher-level care should bein place (12).

3.3.1.3 Referral hospitals
Referral hospitals should have the staff and capacity
to perform abortions in all circumstances permitted
by law and to manage all abortion complications.

3.3.2 Methods of abortion
Respect for a woman’s choice among different safeand effective methods of abortion is an importantvalue in health-service delivery. Although the choiceof methods will reflect health-system capability,
even the most resource-constrained health systems
should be able to provide medical methods andmanual vacuum aspiration. Where a choice of methods cannot be offered, at least one recommended
method should always be available. Vacuum aspiration and medical methods should also be widely
available to treat women with complications fromspontaneous as well as unsafe abortion.

Planning and managing safe abortion care

3.3.3 Certification and licensing of healthcare professionals and facilities
Where certification of abortion providers is required,it should ensure that health-care providers meet thecriteria for provision of abortion care according tonational standards, and it should not create barriers to accessing legal services. The certification andlicensing of abortion-care services should be thesame as for other medical procedures and should not
be a barrier to the availability and provision of abortion care.
Licensing criteria, where required, should not impose
excessive requirements for infrastructure, equipment,
or staff that are not essential to the provision of safe
services. Facility licensing criteria should clearly differentiate between requirements at primary-care levelversus requirements at referral levels, in order to facilitate, rather than restrict, access to care. Licensing
criteria should be the same for both the public andprivate sectors and not-for-profit facilities.

3.3.4 Referral mechanisms
As with all health interventions, well-functioning
referral systems are essential for the provision ofsafe abortion care. Timely referrals to appropriate
facilities reduce delays in seeking care, enhancesafety, and can mitigate the severity of abortion
complications (12).

3.3.5 Respect for women’s informed andvoluntary decision-making, autonomy,
confidentiality and privacy, with attention toadolescents and women with special needs
Within the framework of national abortion laws,
norms and standards should include protections for
informed and voluntary decision-making, autonomy
in decision-making, non-discrimination, and confidentiality and privacy for all women, including

Safe abortion: technical and policy guidance for health systems

67

adolescents (18). These human rights are enshrined
in international and regional human rights treaties, aswell as in national constitutions and laws.

3.3.5.1 Informed and voluntary decision-making
Depending upon the context and her individual situation, a woman trying to resolve the decision about
an unintended pregnancy may feel vulnerable. She
needs to be treated with respect and understanding
and to be provided with information in a way that she
can understand so that she can make a decision freeof inducement, coercion or discrimination. Healthcare providers should be trained to support women’s
informed and voluntary decision-making. They
should also be aware of situations in which a woman
may be coerced into having an abortion against her
will (e.g. based on her health status, such as livingwith HIV). Extra attention is needed in such cases, toensure that the woman is fully informed and makes afree decision.

3.3.5.2 Third-party authorization
A woman seeking an abortion is an autonomous
adult. Autonomy means that mentally competent
adults do not require the authorization of any third
party, such as a husband, partner, parent or guardian, to access a health service. Therefore, health-careproviders should not impose a requirement of thirdparty authorization unless required by law and related
regulations.
Adolescents may be deterred from going to needed
health services if they think they will be required toget permission from their parents or guardians, which
increases the likelihood of them going to clandestine
abortion providers. Health-care providers should
therefore be trained to inform, counsel and treat
adolescents according to their evolving capacities
to understand the treatment and care options being
offered, and not according to an arbitrary age cut-off

68

Safe abortion: technical and policy guidance for health systems(19). Health-care workers should support minors
to identify what is in their best interests, including
consulting parents or other trusted adults about theirpregnancy, without bias, discrimination or coercion.

3.3.5.3 Protection of persons with special needs
Depending upon the context, unmarried women,adolescents, those living in extreme poverty, womenfrom ethnic minorities, refugees and other displaced
persons, women with disabilities, and those facing
violence in the home, may be vulnerable to inequitable access to safe abortion services. Abortion-service
providers should ensure that all women are treated
without discrimination and with respect.
Stigma and discrimination associated with physical and mental disabilities, and health status suchas living with HIV, are widespread and may be used
as a reason to coerce women into having an abortion. Coercion violates women’s rights to informed
consent and dignity, and should not be tolerated(20). Thus, health-care providers have a human rights
obligation to ensure that women are not subject tocoercion and that they receive the necessary psychological, social and health services to support theirchoice.

3.3.5.4 Confidentiality and privacy
The fear that confidentiality will not be maintained
deters many women – particularly adolescents andunmarried women – from seeking safe, legal abortion services, and may drive them to clandestine,
unsafe abortion providers, or to self-induce abortion.
Confidentiality is a key principle of medical ethics
and an aspect of the right to privacy (21) and mustbe guaranteed. Health-care providers therefore havea duty to protect medical information against unauthorized disclosures, and to ensure that women who
do authorize release of their confidential information to others do so freely and on the basis of clear

Planning and managing safe abortion care

information. Adolescents deemed mature enoughto receive counselling without the presence of aparent or other person are entitled to privacy, andmay request confidential services and treatment (seeSection 3.3.5.2).
Health-service managers should ensure that facilities
provide privacy for conversations between womenand providers, as well as for actual services. For
example, procedure rooms should be partitioned
for visual and auditory privacy, and only facility staff
required for the induced abortion should be present.
There should be a private place for undressing, curtained windows, and cloth or paper drapes to cover
the woman during the procedure.

3.3.5.5 Special provisions for women who havesuffered rape
Women who are pregnant as a result of rape have a
special need for sensitive treatment, and all levels of
the health system should be able to offer appropriate care and support. Standards and guidelines forprovision of abortion in such cases should be elaborated, and appropriate training given to health-careproviders and police. Such standards should not
impose unnecessary administrative or judicial procedures such as requiring women to press charges
or to identify the rapist (22). The standards should
ideally be part of comprehensive standards andguidelines for the overall management of survivorsof rape, covering physical and psychological care,emergency contraception, post-exposure prophylaxis
for HIV prevention, treatment for sexually transmitted
infections (STIs) and injuries, collection of forensic
evidence, and counselling and follow-up care (20).

3.3.6 Conscientious objection by health-careproviders
Health-care professionals sometimes exempt
themselves from abortion care on the basis ofPlanning and managing safe abortion careconscientious objection to the procedure, while
not referring the woman to an abortion provider.
Individual health-care providers have a right to conscientious objection to providing abortion, but thatright does not entitle them to impede or deny accessto lawful abortion services because it delays care forwomen, putting their health and life at risk. In suchcases, health-care providers must refer the woman toa willing and trained provider in the same, or anothereasily accessible health-care facility, in accordancewith national law. Where referral is not possible, thehealth-care professional who objects, must provide
safe abortion to save the woman’s life and to prevent
serious injury to her health. Women who present withcomplications from an unsafe or illegal abortion mustbe treated urgently and respectfully, as any otheremergency patient, without punitive, prejudiced orbiased behaviours (see also Chapter 4).

3.4 Equipping facilities and training
health-care providers
The provision of safe abortion care requires properly
equipped facilities and well-trained health-care providers. Public health authorities have a responsibility
to ensure that systems are in place for continuousand timely procurement and distribution of all medical equipment, drugs, contraceptives and supplies
necessary for the safe delivery of services. In addition, health-care providers require appropriate preservice and in-service training, based on routinely
updated guidelines for safe abortion care.

3.4.1 Preparing and equipping facilities
Abortion facilities must be well prepared andequipped to provide safe care. Supportive services,such as commodity procurement, logistics supply
chain functioning, and financing mechanisms, are asimportant as training providers for introducing new

Safe abortion: technical and policy guidance for health systems

69

Table 3.1 Drugs, supplies and equipment for safe abortion care
Procedural step

Drugs and supplies

Equipment

Clinical assessment

yy Clean examination gloves
yy Clean wateryy Detergent or soap
yy Cervical preparation agent (e.g. misoprostol tablets, osmotic dilators,
mifepristone)
yy Pain medications, such as analgesics
and anxiolytics
yy Gloves
yy Gown, face protection
yy Needles (22 gauge spinal for paracervical block and 21 gauge for drug
administration)yy Syringes (5, 10 and 20 ml)
yy Lidocaine for paracervical blockyy Gauze sponges or cotton balls
yy Antiseptic solution (non-alcohol based)
to prepare the cervix
yy Instrument-soaking solution
yy Sterilization or high-level disinfection
solutions and materials
yy Silicone for lubricating syringes

yy Blood pressure equipment
yy Stethoscopeyy Speculum (wide mouth to increase exposureof the cervix and short to avoid pushing thecervix away, or a Sims speculum if an assistant is available)
yy Tenaculum (atraumatic tenaculum)yy Tapered dilators up to 37 mm (up to 51 mm) or
equivalent circumference
yy Electric vacuum aspirator (with 14 or 16 mm
cannulae) or MVA aspirator and cannulae up to
12 mm
yy Bierer uterine evacuation forceps (large andsmall)
yy Sopher uterine evacuation forceps (small)yy Large, postpartum flexible curetteyy Sponge (ring) forceps
yy Stainless steel bowl for prepping solution
yy Instrument tray
yy Clear glass dish for tissue inspection
yy Strainer (metal, glass or gauze)

Medical abortionyy Mifepristoneyy Misoprostol
yy Pain medications

yy Private area with chairs separate from antenatalor labour care, for women who wait in clinic for
expulsionyy Adequate toilet facilities

Recoveryyy Sanitary napkins or cotton wool
yy Analgesics
yy Antibiotics
yy Information on post-procedure self-careyy Post-abortion contraceptive methods
and information, and/or referral

yy Blood pressure equipment
yy Stethoscope

In case ofcomplications

yy Appropriate antagonists to medications
used for pain
yy Uterotonics (oxytocin, misoprostol orergometrine)
yy IV (intravenous) line and fluids (saline,
sodium lactate, glucose)yy Clear referral mechanisms to higherlevel facility, when needed

yy Oxygen and Ambu bagyy On-site access to an ultrasound machine(optional)
yy Long needle-driver and suture
yy Scissors
yy Uterine packing

Surgical abortion procedure (equipment for
dilatation and evacuation (D&E) highlighted
in bold font)70

Safe abortion: technical and policy guidance for health systems

Planning and managing safe abortion care

services. Where services already exist, infrastructural
upgrades can facilitate more efficient patient flow andincrease privacy and user satisfaction, while introducing updated methods, such as vacuum aspirationand medical abortion, can improve safety and reduce
costs (23, 24).

risks to providers and the community. Reusable
equipment saves costs, but rigorous cleaning anddisinfection procedures must be followed (seeChapter 2).

3.4.1.1 Essential equipment, medications andsupplies

Each country has specific regulatory requirements forthe registration and importation of drugs and medical equipment such as MVA instruments. However,the WHO model list of essential medicines, which
has been adapted by many countries as a national
essential drugs list, includes combination mifepristone and misoprostol for medical abortion, misoprostol alone for treatment of incomplete abortion andmiscarriage, non-narcotic analgesics such as nonsteroidal anti-inflammatory agents (e.g. ibuprofen),
tranquillizers (e.g. diazepam) and local anaesthetics(e.g. lidocaine) (25). Inclusion on the national essential drugs list usually means that the drug is registered and available in the country. Where a drug is
not registered, some countries will allow importation
through the WHO Certification Scheme on the Qualityof Pharmaceutical Products Moving in International
Commerce (26).

Most of the equipment, medications, and supplies needed to provide vacuum aspiration (manualand electric) and medical methods of abortion (seeTable 3.1) are the same as those needed for othergynaecological services.
The shift towards using vacuum aspiration withplastic cannulae depends upon official approval andlocal availability of the instruments. In settings wheremanual vacuum aspiration (MVA) instruments are notapproved medical devices, efforts will be needed to
add them to the government’s standard equipment
list.
These instruments and medications should beroutinely included in the planning, budgeting, procurement, distribution and management systems.
Criteria for determining what instruments to use
include: quality, durability, cost, and system capacity to ensure consistent availability and maintenanceover time. As with any other drug, mifepristone andmisoprostol for medical abortion should be sourced
from manufacturers that adhere to good manufacturing practice (GMP).

3.4.1.2 Regulatory requirements for drugs anddevices

The commodities included in Table 3.1 that are
specific to the provision of abortion services should
be included in the national medical supplies logistics
management programme and be available to healthcare providers that provide abortion services.

Instruments for MVA are made for either single ormultiple use. In contexts where instruments will bereused, it is essential to purchase those that canwithstand multiple use, cleaning and high-level disinfection or sterilization, as well as to ensure supplies
for such disinfection/sterilization. Single-use instruments must be carefully disposed of to avoid health

Planning and managing safe abortion care

Safe abortion: technical and policy guidance for health systems

71

3.4.2 Ensuring provider skills andperformance
3.4.2.1 Health-care provider skills and training
Health-care providers who perform vacuum aspiration for treatment of incomplete abortion can learn to
use the technique for induced abortion, with minimal
additional training. All such health-care providers canalso be trained to provide medical abortion.
In addition to skills training, participating in valuesclarification exercises can help providers differentiate their own personal beliefs and attitudes fromthe needs of women seeking abortion services (27).
Values clarification is an exercise in articulating how
personal values influence the way in which providers interact with women seeking abortion. Despite
providers’ attempts at objectivity, negative and predefined beliefs about abortion, and the women who
have them, often influence professional judgement
and the quality of care (28, 29).
In many contexts, making safe, legal abortion services readily available to all eligible women will
require training of midlevel health-care professionals(30–34). Comparative studies have shown no difference in complication rates between women who
had first-trimester abortions with MVA performed by
midlevel health-care providers and those who had
the procedure performed by a physician (6). Skills
and performance expectations set out in standards
and guidelines should serve as the basis of pre-service training for all appropriate cadres, and abortioncare providers should receive periodic in-service
training to ensure they maintain their skills to performtheir jobs according to abortion-care standards.

3.4.2.2 Training programmes
As for any other health intervention, abortion training programmes should be competency based and72

Safe abortion: technical and policy guidance for health systems

conducted in facilities that have sufficient patient
flow to provide all trainees with the requisite practice,including practice in managing abortion complications. In addition, training should address healthcare provider attitudes and beliefs about sexual andreproductive health, including induced abortion,
safeguarding privacy and confidentiality, treating all
women with dignity and respect, and attending thespecial needs of adolescents, women who have been
raped, and those who may be vulnerable for other
health or socioeconomic reasons.
Training health-service providers in new or updated
clinical procedures can be a powerful tool in changing practices. However, training alone is not sufficient. Trained providers need support following
training to put skills into practice, and need to work in
an environment that ensures adequate drugs, equipment, remuneration and professional development tosupport the provision of safe abortion services. They
also need supportive and facilitative supervision andoversight to ensure that standards and guidelines
are followed. Box 3.2 lists the recommended training content for all health-care professionals providing
abortion services.

3.5 Monitoring, evaluation and quality
improvement
As with all health services, ensuring good-quality
abortion care depends upon effective processes formonitoring, evaluation and quality assurance andimprovement. The accurate collection of service
statistics and routine monitoring and evaluation at
the health-care facility level are a key component ofprogramme management, and feedback based on
analysis of these data provides necessary information
for improving access and maintaining and improving
the quality of services delivered.

Planning and managing safe abortion care

BOX 3.2
Recommended training content for abortion-service providers
Background for abortion service delivery:
yy legal, regulatory and policy provisions;
yy health effects of unsafe abortion;yy ethical responsibility to provide abortion (or to refer women when the health-care professional has
conscientious objection to providing abortion) and to treat complications from unsafe abortion;
yy national standards and guidelines for abortion care;yy human rights related to safe abortion.

Counselling and provider–patient interaction:yy clarification of health-care provider attitudes and beliefs regarding abortion;
yy confidentiality and privacy;
yy interpersonal communication and counselling skills;
yy information on abortion and contraception;
yy issues and risks associated with HIV and other STIs;
yy consideration of needs of all women, including adolescents, poor women, women from ethnic minorities, displaced women and refugees, women with disabilities, survivors of rape, women living withHIV or other STIs;
yy recognition of signs that the woman has been subjected to violence, and guidance in helping her
obtain additional counselling and services;
yy informed decision-making.

Clinical skills:
yy anatomy and physiology relevant to pregnancy and abortion;yy pre-procedure assessment (e.g. medical history, examinations, pregnancy dating);yy STI screening;
yy cervical dilatation;yy uterine evacuation;yy infection prevention;yy pain management;
yy recognition and management of complications of abortion;yy management and care following the procedure, including provision of contraceptive information,
counselling and methods;
yy criteria for referral and referral procedures.

Administrative/managerial issues and quality assurance:
yy organization of services to ensure efficient patient flow while maintaining privacy and confidentiality;
yy record-keeping and reporting of service statistics;
yy practices for maintaining privacy and confidentiality;
yy logistics, equipment and inventory management;
yy monitoring, evaluation, and quality improvement/assurance;
yy mechanisms for effective referral and transport;
yy standards for supervision.

Planning and managing safe abortion care

Safe abortion: technical and policy guidance for health systems

73

3.5.1 Monitoring
Monitoring oversees the processes of implementing services, including changes over time. Routine
monitoring can assist managers and supervisors to
identify and manage, or avoid, problems before they
become serious or overwhelming. Good monitoring
includes listening to service providers, who can haveimportant recommendations to improve the quality ofcare. Well-designed monitoring enables facility managers and staff supervisors to give feedback on problems to staff and to engage staff in a participatory
process to implement solutions. At the facility level,mechanisms for monitoring services include analysisof routine service statistics, case reviews, logbook
reviews, observation, checklists, facility assessments,
maternal death and near-miss audits, and obtaining
feedback from service users to improve the qualityof care. Routine abortion-service statistics include:
the age and number of women provided an induced
abortion by method (vacuum aspiration, medical
abortion, D&E) and the gestational age of pregnancy.
Monitoring national indicators of safe abortion isimportant and has been largely neglected (35). The
introduction of abortion-specific indicators and service statistics should be developed within the context
of monitoring the national maternal and reproductive
health programme. Health-facility data on abortion
services can be integrated into existing management
information systems (e.g. forms, logbooks, supply
stock records, checklists, patient records, daily
activity registers) rather than creating separate ones
(36, 37). The WHO indicators for safe abortion care(38) are shown in Table 3.2.

74

Safe abortion: technical and policy guidance for health systems

3.5.2 Quality assurance and quality
improvement
Quality assurance and improvement encompasses
planned and systematic processes for identifying
measureable outcomes based on national standards
and guidelines and the perspectives of health-service
users and care providers, collecting data that reflect
the extent to which the outcomes are achieved, andproviding feedback to programme managers andservice providers. Quality-improvement processes
should attempt to identify and address both individual and organizational barriers to the achievement of good quality of care (39–41). For abortion
care, the goal is to promote change for continuous
improvement as part of maintaining good-quality
services that respond to the needs of health-careproviders, as well as the health-care needs and rights
of women. Quality improvement involves ongoing
monitoring of routine service delivery, provider performance and patient outcomes, as well as periodic
assessments conducted at facility level (42).

3.5.3 Evaluation
Evaluation is the systematic assessment of servicedelivery processes and outcomes. Comprehensive
evaluation requires multiple data sources, including
service statistics, feedback from health-care providers and from women and communities served, andfinancial records. Programme evaluators can focus
their attention on three key areas related to policies,
programmes and services: access; availability; andquality of care. Examples of a range of issues andquestions to consider for periodic assessment andevaluation are highlighted in Box 3.3. Answering
these questions can provide information that will
enable policy-makers and programme managers tobetter understand and overcome existing barriers toaccess and improve the quality of care.

Planning and managing safe abortion care

Table 3.2. Indicators for safe abortion carea
Type ofmeasureType of indicator(coreb, additionalc)

Source of data

Number of facilities offering
safe abortion services per
500 000 population

Rate

Additional

HISd

Health-care providers trained
to provide safe abortion
services to the full extent of
the law

Percentage

Additional

Survey (facility)

Population living within
2 hours travel time from afacility providing safe abortion
services

Percentage

Additional

Survey (population)

Population with correctknowledge of the legal status
of abortion

Percentage

Additional

Survey (population)

Health-care personnel withcorrect knowledge of the legal
status of abortion

Percentage

Additional

Survey (facility)

Service-delivery points that
use WHO-recommended
methods for induced abortion

Percentage

Additional

Survey (facility)

Service-delivery points that
use WHO-recommended
methods for management ofabortion complications

Percentage

Additional

Survey (facility)

Obstetric and gynaecologicaladmissions due to abortion

Percentage

Core

HIS

Hospitalization rate for unsafe
abortion per 1000 women

Rate

Additional

HIS

Abortions per 1000 live births

Ratio

Core

HIS/survey (population)

Maternal deaths attributed toabortion

Percentage

Core

HIS/survey (special)/vitalregistration

Area
Access:availability

Access:information

Access:quality

Outcome/
impactIndicatoraOther indicators relevant to achieving universal access to reproductive health can be found in reference 38.

b

Indicators that all countries should report.

cIndicators that countries could report based on their special needs, contextual characteristics, and capabilities (e.g. when coverage for core data is high).

d

Health information system.

Table adapted from reference 38.

Planning and managing safe abortion care

Safe abortion: technical and policy guidance for health systems

75

BOX 3.3
Questions and issues to consider for periodic assessment and evaluation of abortion services
These questions and issues are for assessment purposes only; for relevant WHO recommendations see
Chapters 2, 3 and 4.
Access to safe abortion services
What are the legal grounds for induced abortion?
yy on request;
yy socioeconomic reasons;yy health (unspecified; as defined by WHO; or withspecific conditions);
yy mental health (unspecified or with specificconditions);yy physical health (unspecified or with specificconditions);
yy rape;yy incest;
yy preservation of life.

What are the costs of abortion services towomen?
yy official fees:–– provider fees;–– facility fees;
yy informal fees for health-care providers;
yy transportation costs;
yy accommodation costs;
yy opportunity costs;
yy private insurance coverage;
yy social welfare coverage.

Are permissions from third parties required
before performing abortion?
yy parental/guardian or spousal/partner
authorization;yy authorization of medical commissions;
yy authorization by more than one specialist or
physician.

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Safe abortion: technical and policy guidance for health systems

Availability of safe abortion services
Are there enough facilities to provide safe care
for all women seeking abortion?
yy number of facilities offering safe abortion services
per 500 000 population.

What are the facility costs of providing safe
abortion care?
yy provider time;yy equipment/instruments and supplies;
yy medications;
yy in-service training;
yy other capital and recurring costs.

What abortion statistics are available?
yy total number of obstetric/gynaecologicaladmissions;
yy total number of induced abortions;
yy total number of immediate and delayedcomplications;yy percentage of complications requiring
hospitalization;
yy total number of presenting complications (as aresult of unsafe or spontaneous abortion).

What abortion methods are available andutilized?
For pregnancies of gestational age <12–14 weeks:
yy vacuum aspiration;
yy mifepristone and misoprostol;yy misoprostol alone;
yy dilatation and curettage.

Planning and managing safe abortion carebox 3.3 continued
For pregnancies of gestational age >12–14 weeks:
yy dilatation and evacuation;
yy mifepristone and misoprostol;yy misoprostol alone;
yy instillation with hypertonic saline;
yy ethacridine lactate.

Quality of care
Do abortion providers have the competencies
required to perform safe abortion?
yy confirmation of pregnancy;
yy estimation of gestational age;
yy appropriate surgical procedure technique;yy appropriate pain management;
yy appropriate medical abortion regimen;
yy appropriate follow-up.

Are good infection-prevention practices routinely
followed?
yy standard precautions routinely followed;
yy no-touch technique employed for surgicalmethods;
yy initial soaking of used instruments;
yy instrument cleaning;
yy high-level disinfection or sterilization of medical
instruments;
yy prophylactic antibiotics administered for surgicalmethods.

What pain-management options are available
and what pain management is actually provided?
yy verbal relaxation techniques;yy analgesia;
yy local anaesthesia;
yy sedation;yy general anaesthesia.

Planning and managing safe abortion care

What contraceptive methods are available andwhat methods are provided?
yy barrier methods:–– condoms;–– cervical barriers;
yy fertility-based awareness methods;
yy hormonal methods:–– pills;–– vaginal ring;–– skin patch;–– injectables;–– implants;
yy IUDs;
yy sterilization;yy emergency contraceptives.

What information, education and communicationmaterial is available and what information isroutinely provided?
yy for the procedure;
yy for follow-up care;yy for contraception;yy for other needs.

Is counselling routinely offered?
yy for the procedure;
yy for follow-up care;yy for contraception;yy for other needs.

Are services managed effectively and efficiently?
yy in-service training routinely provided;
yy adequate supervision;yy sufficient financing;yy sufficient procurement, distribution and restocking of instruments, medications and supplies;
yy adequate management information systems;
yy mechanisms for quality improvement/assurance;
yy mechanisms for monitoring and evaluation ofservices.

Safe abortion: technical and policy guidance for health systems

77

box 3.3 continued
Is an adequate referral system in place for:Do other potential service-delivery barriers exist?

yy induced abortion (especially for cases of conscientious objection to service provision);yy management of complications;
yy contraception;yy reproductive tract infections;
yy gender-based violence.

yy requirements for HIV and other tests that are notclinically indicated;
yy mandatory counselling beyond provision ofadequate information relevant to the woman’sabortion care;yy requirement for mandatory ultrasound prior toabortion;yy requirement for women to listen to fetal heartbeatprior to abortion;yy requirement for listing induced abortion on permanent medical records, where confidentiality
cannot be assured.

Are all aspects of a woman’s privacy maintained
regarding her abortion?
yy visual privacy during examination and procedure;
yy auditory privacy during counselling, examinationand procedure;
yy non-essential staff excluded from the room during
the procedure;
yy offer of home use of misoprostol following provision of mifepristone;
yy adequate toilets with privacy;
yy discreet signage for location of abortion services.

Is a woman’s confidentiality protected regarding
her abortion?
yy access to medical records restricted;
yy confidentiality maintained for all women, including
adolescents.

Are delays for seeking care minimized?
yy no mandatory waiting periods;
yy time required between requesting and schedulingthe procedure;
yy time waiting for the procedure;
yy total time in hospital/clinic.

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Safe abortion: technical and policy guidance for health systems

Women’s perspectives about abortion services
yy were the abortion provider and clinic staff friendly
and professional?
yy was sufficient information provided about theprocedure, contraception and follow-up?
yy did the woman have an opportunity to ask
questions?
yy were questions appropriately answered?
yy was privacy protected?
yy would the woman recommend the facility?
yy would the woman recommend the provider?

Provider perspectives
yy does the organization and implementationof abortion services meet evidence-based
standards?
yy is the quality of care sufficient?
yy how could job satisfaction be improved?
yy is supervisor support adequate?
yy are work incentives (e.g. salary, fees, professional
development opportunities) sufficient?

Planning and managing safe abortion care3.6 Financing
Health-service budgets should include sufficient
funds for the following types of costs:
yy equipment, medications and supplies required toprovide safe abortion care;yy staff time;
yy training programmes and supervision;
yy infrastructure upgrades;
yy record-keeping;yy monitoring and evaluation.
To the extent that the abortion programme can be
integrated within the national maternal and reproductive health programme, the marginal costs of putting
in place or improving abortion services will be minimized. In general, safe abortion services require few,
if any, additional provider skills, medications, equipment or supplies from those that should already beavailable for emergency obstetric and gynaecologicalcare.

3.6.1 Cost to the facility or health system
The provision of safe, legal abortion is considerably
less costly than treating the complications of unsafe
abortion (43–47). Costs for providing abortion carewith vacuum aspiration include infrequent, modest
capital investments, such as a suction machine or
MVA equipment; an examination table; a steam sterilizer or autoclave; renovation of waiting, consultation
and recovery rooms; and toilets. Recurrent costs
include those associated with purchasing instruments and supplies that will need to be restocked
regularly, such as cannulae and manual vacuum aspirators; antiseptic solutions and high-level disinfectants used for instrument processing; and drugs forpain management, infection prevention and medical
abortion.

Planning and managing safe abortion care

Decisions made about which abortion methods tooffer and how to organize services directly influence the cost of providing services and their affordability. Two organizational issues are of particularimportance: preferential use of vacuum aspiration or
medical abortion over D&C, and informing women tocome earlier rather than later for induced abortion.
yy Switching from D&C to vacuum aspiration or
medical abortion for uterine evacuation is safer for
the woman and can reduce health-system costs(23, 24). Vacuum aspiration can be performed
by a trained midlevel health-care provider in an
office or examination room, whereas D&C is often
performed in an operating theatre by a physician.
Also, vacuum aspiration usually requires lessmedication for pain than D&C (23, 47, 48).
yy If the health system effectively informs women tocome early in pregnancy for abortion, the use oflower-cost early procedures increases and use of
costlier later procedures declines. For example,
the introduction of combination mifepristone andmisoprostol has been associated with population shifts to abortion at earlier gestational ages
(49, 50). Home use of misoprostol contributes togreater flexibility for the woman and decreased
staff and facility utilization. This also enables services to be provided at lower levels of the healthsystem and thus closer to women’s residences,
thereby decreasing travel and time-associatedcosts.

3.6.2 Making services affordable for women
In many settings, national health insurance schemes
do not exist or do not cover large portions of the
population or do not include abortion within thebenefit package. Other sources of financing of healthservices are often employed, including requiringcontributions from individuals who use the health

Safe abortion: technical and policy guidance for health systems

79system. WHO recommends that payments fromindividuals for health services be collected as a typeof prepayment, rather than at the time of service
delivery (51). However, in many settings, user fees arecustomarily charged and can be an important barrier to services for poor women and adolescents. In
addition, women seeking abortion may be expectedto pay substantial informal fees (charges madeby providers on top of the official health-systemcharges) which, when combined with travel expenses
and opportunity costs such as time lost from paid
employment, pose a barrier for many women. The
barrier of high costs to women is likely to generatehigher costs for the health system, by increasing thenumber of women who attempt to self-induce abortion or go to unsafe providers and, as a result, require
hospitalization for serious complications (52, 53).
The respect, protection, and fulfilment of humanrights require that women can access legal abortion
services regardless of their ability to pay. Financing
mechanisms should ensure equitable access togood-quality services (54). Where user fees arecharged for abortion, such fees should be matched
to women’s ability to pay, and procedures should be
developed for exempting the poor and adolescentsfrom paying for services. As far as possible, abortion
services should be mandated for coverage underinsurance plans. Abortion should never be deniedor delayed because of a woman’s inability to pay.
Furthermore, all facilities should have proceduresin place to ensure that informal charges are notimposed by staff.

3.7 The process of planning andmanaging safe abortion care
Establishing abortion services or strengthening
access to and the quality of care of existing abortion

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Safe abortion: technical and policy guidance for health systems

services at national or subnational level, to the full
extent of the law, should be driven by dedicated andcommitted stakeholders who can provide strong
leadership, identify and recruit other stakeholders,and mobilize funding and technical assistance tosupport a wide range of activities. Ideally, leadership would be situated in the ministry/departmentof health or another institution with the mandate toinfluence and mobilize national action. Important
stakeholders include: representatives from othergovernment ministries or departments, such as
education, gender and women’s affairs, justice, local
government, social welfare, and youth affairs; medical universities; professional health associations –particularly those of obstetrician-gynaecologists but
also those of family physicians, nurses, midwives andpharmacists; other public health cadres; women’s
health advocates; nongovernmental organizations
focused on women, youth, health, and human rights;
other relevant representatives of civil society; and key
development partners (55).
Principles underlying the process of improving
access to and the quality of abortion care include
the following. The process should be: country owned
and country led; evidence based; inclusive of multiple perspectives; participatory; embracing sex andgender equality and non-discrimination; health andhuman-rights based; and system focused (55).
Strengthening abortion services is a political andmanagerial challenge, in addition to being a clinicalor technical task. One methodology that has beenused effectively is the WHO Strategic Approach tostrengthening sexual and reproductive health policies
and programmes (55–60). The Strategic Approach
begins with the creation of an assessment teamrepresenting a broad range of stakeholders, such as
those mentioned above, who conduct a field-based
assessment to identify and prioritize needs related

Planning and managing safe abortion care

to abortion and contraceptive-service access, availability and quality of care. Based on the findings
and recommendations of the assessment team, apackage of policy and programme interventions are
implemented on a limited scale to provide local evidence of feasibility, effectiveness and acceptability.
If successful, the interventions are then scaled-up to
have broader impact.
Whatever methods are used, it is important that
actions to strengthen policies and services are basedon a thorough understanding of the service-delivery
system, the needs of providers, the needs of women,
and the existing social, cultural, legal, political andeconomic context. It is also important that multiple
perspectives are incorporated. This helps to ensurethat recommendations and plans based on theassessment will be broadly acceptable and therefore more likely to be implemented. It is particularly
important to include the perspectives on services
from users and potential users, as they are the main
source of identifying barriers to service use. It is also
important that the assessment examines people’s
access to sexual and reproductive health services
generally, and specifically their access to contraceptive information, counselling and methods, sincethese are important determinants of the incidence of
unintended pregnancy.

3.7.1 Assessing the current situation
Local contexts in need of improved abortion carevary considerably in terms of scale – from systemlevel to individual facilities – and with regard tospecific areas requiring strengthening. For improving
abortion care at facility level, see Section 3.5.2. At
the national or health-system level, the first step inassessing the current situation related to unintended
pregnancy and abortion involves collecting and analysing existing information on:

Planning and managing safe abortion careyy laws on sexuality, contraception, and abortion;yy ratified human rights agreements;
yy access to and availability of contraceptives;
yy sexuality education;
yy service-delivery standards and guidelines;
yy curricula of health-care and other relevant professional schools;
yy availability of abortion-related medical devices
and drugs;
yy facility- and national-level health statistics;
yy demographic/reproductive health surveys;
yy relevant research studies;yy health insurance or other measures to reduce outof-pocket expenditures for abortion services.
Following a thorough compilation and review of existing information, the field team can develop discussion guides for use with policy-makers, health-careproviders, women and other relevant community
members. Guiding questions for a field assessment
might include how policies, programmes and services can be strengthened to:yy prevent unintended pregnancy;
yy improve access to and the availability of safe
abortion;yy improve the quality of abortion care.
Exploring each of these in detail will help the team
to identify and prioritize the most critical policy andprogrammatic needs. A field guide is available withmore detailed information about the process of conducting a strategic assessment (61) (available from:http://www.who.int/reproductivehealth/publications/familyplanning/RHR_02_11).

Safe abortion: technical and policy guidance for health systems

81

3.7.2 Introducing interventions to strengthen
abortion care
New policy and programme interventions should be
guided by evidence-based best practices. Much of
the evidence for abortion policies and programmes
is reflected in the recommendations presented in thisguidance document. However, programme managers
often want to be assured through local evidence ofthe feasibility, effectiveness, acceptability and costof the introduction of changes in policy and programme design, or service-delivery practices, prior
to committing resources for their implementation ona larger scale. Even when interventions are based on
accepted international best practices, some evidenceof the capacity for local implementation and acceptability among community members is likely to benecessary to facilitate scaling-up. Depending on thequality of evidence required by policy-makers, testingof the intervention(s) could range from simple pilot
or demonstration projects to more rigorous implementation research incorporating quasi-experimental
designs.

3.7.3 Scaling-up policy and programmaticinterventions
Scaling-up involves expanding the health system’s
capacity for implementation of policy and programme interventions that have been demonstrated
to improve access to and the quality of abortion
care, in order to achieve population-level impact. Toooften, scaling-up is considered a matter of routine
programme implementation that does not needspecial attention. Once a package of interventions
has proved to be successful in a pilot or demonstration project, it is expected to be taken up by ahealth system and spread throughout, based on theassumption that success in the pilot phase is sufficient to catalyse large-scale change. While this82

Safe abortion: technical and policy guidance for health systems

sometimes happens, more frequently it does not.
Successful scaling-up requires systematic planning,
management, guidance and support for the process
by which interventions are expanded and institutionalized. Scaling-up also requires sufficient human andfinancial resources to support the process. Guidance
for the development of comprehensive strategies for
scaling-up and for management of the process isavailable from WHO and ExpandNet (62–64; http://
www.expandnet.net/tools.htm) - data accessed: 14
February 2013.
Systematic approaches to scaling-up recognize thatthe process takes place in a context of “real-world”
complexity, with multiple and often competing players and interests. Attention to technical concerns
is essential, but equally important are the political,
managerial and ownership issues that come into play,since interventions to improve access and quality ofcare often call for changes in values as well as practices. This is especially relevant for an issue such as
safe abortion.
Health systems are often limited in their ability todeliver the range of needed services that current policies mandate, and integrating a new set of interventions can place additional burdens on an alreadystressed system. Yet, when scaling-up is approachedsystematically and with sufficient financial and humanresources to support it, the process can be successful and contribute to achieving the goal of universal
access to reproductive health care, including safe
abortion.

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8322. Billings D et al. Constructing access to legal abortion services in Mexico City. Reproductive HealthMatters, 2002, 10:87–95.
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the availability and use of abortion care services.
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37. Monitoring emergency obstetric care: a handbook.
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38. World Health Organization, UNFPA. National-levelmonitoring of the achievement of universal access to
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40. Foy R et al. Theory-based identification of barriers toquality improvement: induced abortion care. Journal
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41. Morrison J. Audit of the care of women requesting induced abortion. Journal of Obstetrics andGynaecology, 2003, 23:521–524.
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46. Levin C et al. Exploring the costs and economic
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Chapter 4

Legalpolicyconsiderationsabortion:technical and policy guidance for health systems
86 and Safe

Legal and policy considerations

Chapter 4
Legal and policy considerations
Summaryyy Unsafe abortion is one of the four main causes ofmaternal mortality and morbidity. One of the reasons for unsafe abortion is because safe abortion
services are frequently not available, even when
they are legal for a variety of indications in almost
all countries.
yy International, regional and national human rights
bodies and courts increasingly recommend
decriminalization of abortion, and provision ofabortion care, to protect a woman’s life andhealth, and in cases of rape, based on a woman’scomplaint. Ensuring that laws, even when restrictive, are interpreted and implemented to promote
and protect women’s health is essential.
yy Additional barriers, that may or may not be codified in law, often impede women from reaching
the services for which they are eligible and contribute to unsafe abortion. These barriers include
lack of access to information; requiring third-party
authorization; restricting the type of health-careproviders and facilities that can lawfully provide
services; failing to guarantee access to affordable services; failing to guarantee confidentiality
and privacy; and allowing conscientious objection
without referrals on the part of health-care providers and facilities.
yy An enabling regulatory and policy environment isneeded to ensure that every woman who is legallyeligible has ready access to good-quality abortion
services. Policies should be geared to respecting,

Legal and policy considerations

protecting and fulfilling the human rights ofwomen, to achieving positive health outcomes for
women, to providing good-quality contraceptive
and family planning information and services, andto meeting the particular needs of poor women,adolescents, rape survivors and women livingwith HIV.

4.1 Women’s health and human rights
Unsafe abortion accounts for 13% of maternal
deaths (1), and 20% of the total mortality and disability burden due to pregnancy and childbirth (2).
Almost all deaths and morbidity from unsafe abortion occur in countries where abortion is severely
restricted in law and in practice. Every year, about
47 000 women die from complications of unsafe
abortion (3), an estimated 5 million women suffer
temporary or permanent disability, including infertility(4). Where there are few restrictions on access to safe
abortion, deaths and illness are dramatically reduced(5). This chapter highlights the inextricable link
between women’s health and human rights and theneed for laws and policies that promote and protect
both.
Most governments have ratified legally binding international treaties and conventions that protect humanrights, including the right to the highest attainable
standard of health, the right to non-discrimination,
the right to life, the right to liberty and the right tosecurity of the person, the right to be free fromSafe abortion: technical and policy guidance for health systems

87

inhuman and degrading treatment, and the right toeducation and information. These rights are further
recognized and defined in regional treaties, enacted
in national constitutions and laws of many countries.
In consideration of these human rights, governments agreed in the United Nations International
Conference on Population and Development, 1999
(ICPD+5) review and appraisal process that “incircumstances where abortion is not against the law,health systems should train and equip health-service

providers and should take other measures to ensurethat such abortion is safe and accessible. Additional
measures should be taken to safeguard women’s
health” (6). The original document, Safe abortion:technical and policy guidance for health systems,
published by the World Health Organization (WHO) in2003 started from this mandate (7).
Over the past 15 years, human rights have been
increasingly applied by international and regional
human rights bodies and national courts, including

BOX 4.1
Examples of application of human rights to safe abortion, in the context of comprehensive
reproductive health care, by international and regional human rights bodies
Human rights, as they are enshrined in international and regional treaties and in national constitutions, and theoutput of United Nations treaty monitoring bodies, including their general comments/recommendations andconcluding observations to States, as well as regional and national court decisions form a reference system forhuman rights accountability at international, regional and national levels. They give clear guidance to States (inthe case of concluding observations, to individual States) on the measures to be taken to ensure the respect,
protection and fulfilment of human rights.
UN treaty monitoring bodies, regional and national courts have given increasing attention to the issue of abortion
during the past decades, including maternal mortality due to unsafe abortion, criminalization of abortion, andrestrictive legislation that leads women to obtain illegal and unsafe abortions. Increasingly they have called upon
States to provide comprehensive sexual and reproductive health information and services to women and adolescents, eliminate regulatory and administrative barriers that impede women’s access to safe abortion services
and provide treatment for abortion complications. If they do not do so, States may not meet their treaty andconstitutional obligations to respect, protect and fulfil the right to life, the right to non-discrimination, the right tothe highest attainable standard of health, the right to be free from cruel, inhuman and degrading treatment andthe rights to privacy, confidentiality, information and education. UN treaty monitoring body recommendations
and regional court decisions to States include the following examples: 1
Ensuring comprehensive legal grounds for abortionyy Take action to prevent unsafe abortion, including by amending restrictive laws that threaten women’s, including adolescents’, lives (9).
yy Provide legal abortion in cases where the continued pregnancy endangers the health of women, including
adolescents (10).
yy Provide legal abortion in cases of rape and incest (11).
yy Amend laws that criminalize medical procedures, including abortion, needed only by women and/or thatpunish women who undergo those procedures (12).
1

88

The detailed references reflect a growing number of UN treaty monitoring body general comments/recommendations andconcluding observations, as well as regional treaty provisions and regional court decisions related to abortion.

Safe abortion: technical and policy guidance for health systems

Legal and policy considerations

the United Nations treaty monitoring bodies in thecontext of abortion (see Box 4.1). They recommended that States reform laws that criminalize medical procedures that are needed only by women, andthat punish women who undergo these procedures(8), both of which are applicable in the case of abortion. In order to protect women’s health and humanrights these human rights bodies recommended that
States should make all efforts to ensure that women
do not have to undergo life-threatening clandestine

abortions and that abortion should be legal at a minimum when continuation of the pregnancy endangers
the life (9) and health (10) of the woman and in casesof rape and incest (11). They also recommended that
States should ensure timely and affordable access togood-quality health services, which should be delivered in a way that ensures that a woman gives her
fully informed consent, respects her dignity, guarantees her confidentiality, and is sensitive to her needs
and perspectives (8).

box 4.1 continued
Planning and managing safe abortion careyy Ensure timely access to a range of good-quality sexual and reproductive health services, including for adolescents, which are delivered in a way that ensures a woman’s fully informed consent, respects her dignity,
guarantees her confidentiality and is sensitive to her needs and perspectives (13).
yy Reduce maternal morbidity and mortality in adolescents, particularly caused by early pregnancy and unsafe
abortion practices, and develop and implement programmes that provide access to sexual and reproductive
health services, including family planning, contraception and safe abortion services where abortion is notagainst the law (14).
yy Provide information on sexual and reproductive health, and mechanisms to ensure that all women, including
adolescents, have access to information about legal abortion services (15).
Eliminating regulatory, policy and access barriers
yy Remove third-party authorization requirements that interfere with women’s and adolescents’ right to makedecisions about reproduction and to exercise control over their bodies (16).
yy Eliminate barriers that impede women’s access to health services, such as high fees for health-care services,
the requirement for preliminary authorization by spouse, parent or hospital authorities, long distances fromhealth facilities and the absence of convenient and affordable public transport, and also ensure that the exercise of conscientious objection does not prevent individuals from accessing services to which they are legally
entitled (17).
yy Implement a legal and/or policy framework that enables women to access abortion where the medical procedure is permitted under the law (18).
Providing treatment of abortion complications
yy Provide timely treatment for abortion complications regardless of the law on induced abortion, to protect awoman’s life and health (19).
yy Eliminate the practice of extracting confessions for prosecution purposes from women seeking emergency
medical care as a result of illegal abortion and the legal requirement for doctors and other health-care personnel to report cases of women who have undergone abortion (20).

Legal and policy considerations

Safe abortion: technical and policy guidance for health systems

89Given the clear link between access to safe abortion
and women’s health, it is recommended that laws
and policies should respect and protect women’s
health and their human rights.

4.2 Laws and their implementation
within the context of human rights
Legal restrictions on abortion do not result in fewer
abortions nor do they result in significant increases inbirth rates (21, 22). Conversely, laws and policies thatfacilitate access to safe abortion do not increase therate or number of abortions. The principle effect is
to shift previously clandestine, unsafe procedures tolegal and safe ones (21, 23).
Restricting legal access to abortion does notdecrease the need for abortion, but it is likely toincrease the number of women seeking illegal andunsafe abortions, leading to increased morbidity andmortality. Legal restrictions also lead many women
to seek services in other countries/states (24, 25),
which is costly, delays access and creates social
inequities. Restricting abortion, with the intent ofboosting population has been well documented inseveral countries. In each case, abortion restrictions
resulted in an increase of illegal and unsafe abortions
and pregnancy-related mortality, with insignificant net
increase in the population (26–29).
Abortion laws began to be liberalized, through legislation and/or through broader legal interpretations
and applications, in the first part of the 20th century
when the extent of the public health problem ofunsafe abortion began to be recognized. Dating fromthe late 1960s, there has been a trend towards liberalization of the legal grounds for abortion (30). Since
1985, over 36 countries have liberalized their abortion laws, while only a few countries have imposed

90

Safe abortion: technical and policy guidance for health systems

further restrictions in their laws (31). These reforms
have come about through both judicial and legislative
action.
Evidence increasingly shows that, where abortionis legal on broad socioeconomic grounds and on awoman’s request, and where safe services are accessible, both unsafe abortion and abortion-related
mortality and morbidity are reduced (32–35)(see Figure 4.1).
Fifty-seven countries, representing almost 40% of
the world’s women, allow abortion upon request of
the pregnant woman (31, 36). In this context, theultimate decision on whether to continue or terminate
her pregnancy belongs to the woman alone. In somecriminal or penal codes abortion throughout pregnancy, or up to a set gestational limit, is no longer
subject to criminal regulation, and has been removed
as a distinct offence. In these situations, abortion
services have usually been integrated into the healthsystem and are governed by the laws, regulations
and medical standards that apply to all health services. Approximately 20% of the world’s women live
in countries that have laws that allow abortion basedon a woman’s social and economic circumstances(31), including the effect of continued pregnancy onher existing children and other family members.
Nonetheless, across the world, 40% of women ofchildbearing age live in countries that have highly
restrictive laws (31, 37), and/or where abortion, evenwhen lawful, is neither available nor accessible.

Legal and policy considerations

Figure 4.1 Deaths attributable to unsafe abortion per 100 000 live births, by legal grounds for abortion
> 200
200

150

100

50

0
Also inTo save the Also to Also in
Also forwomen’s preserve cases of cases of economic
rape orfetal
life only, or healthor socialincestimpairno grounds
reasonsment

Also on request

Every dot represents one country
Reproduced from: The World Health Report 2008 – primary health care now more than ever. Geneva, World Health Organization, 2008.

Legal and policy considerations

Safe abortion: technical and policy guidance for health systems

91

4.2.1 Understanding legal grounds forabortion
4.2.1.1 When there is a threat to the woman’s life
Almost all countries allow abortion to be performed
to save the life of the pregnant woman. This is consistent with the human right to life, which requires
protection by law, including when pregnancy is lifethreatening or a pregnant woman’s life is otherwise
endangered (9).
Both medical and social conditions can constitutelife-threatening conditions. Some countries provide
detailed lists of what they consider life-threatening
medical conditions. Such lists may be interpreted
restrictively or be considered exhaustive, when infact they are meant to provide illustrations of situations that are considered life-threatening and do notpreclude clinical judgement of what is life-threatening
for a particular woman. In some cases, physiciansargue that it is necessary to provide a safe abortion
because, if they did not, the woman would risk her
life by going to an unqualified practitioner (38). An
example of a life-threatening social condition is apregnancy that implicates so-called family “honour”.
For example, in some societies pregnancy out of
wedlock may result in a woman being subjected tophysical violence or even killed.
yy Even where protecting a woman’s life is the only
allowable reason for abortion, it is essential that
there are trained providers of abortion services,that services are available and known, and thattreatment for complications of unsafe abortionis widely available. Saving a woman’s life might
be necessary at any point in the pregnancy and,
when required, abortion should be undertaken
as promptly as possible to minimize risks to a
woman’s health. Treatment of complications fromunsafe abortion should be provided in ways that
preserve women’s dignity and equality.

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Safe abortion: technical and policy guidance for health systems

4.2.1.2 When there is a threat to a woman’s health
The fulfilment of human rights requires that women
can access safe abortion when it is indicated to protect their health (10). Physical health is widely understood to include conditions that aggravate pregnancy
and those aggravated by pregnancy. The scope ofmental health includes psychological distress ormental suffering caused by, for example, coercedor forced sexual acts and diagnosis of severe fetal
impairment (39). A woman’s social circumstances arealso taken into account to assess health risk.
yy In many countries, the law does not specify the
aspects of health that are concerned but merely
states that abortion is permitted to avert risk of
injury to the pregnant woman’s health. Since allcountries that are members of WHO accept its
constitutional description of health as “a state ofcomplete physical, mental and social well-being
and not merely the absence of disease or infirmity” (40), this description of complete healthis implied in the interpretation of laws that allow
abortion to protect women’s health.

4.2.1.3 When pregnancy is the result of rape orincest
The protection of women from cruel, inhuman anddegrading treatment requires that those who havebecome pregnant as the result of coerced or forced
sexual acts can lawfully access safe abortion services (41). Nearly 50% of countries reflect this standard and permit abortion in the specific case of rape,or more generally where pregnancy is the result of acriminal act, such as in cases of incest (36). Somecountries require as evidence the woman’s report of
the act to legal authorities. Others require forensic
evidence of sexual penetration or a police investigation to confirm that intercourse was involuntary or
exploitative. Delays owing to such requirements canresult in women being denied services because they

Legal and policy considerations

have exceeded gestational age limits prescribedby law. In many contexts, women who have been
victims of rape may fear being stigmatized further by
the police and others and will therefore avoid reporting the rape at all, thus precluding access to legal
abortion. Either situation can lead women to resort
to clandestine, unsafe services to terminate theirpregnancy.
yy Prompt, safe abortion services should be provided on the basis of a woman’s complaintrather than requiring forensic evidence or police
examination (42, 43). Administrative requirements
should be minimized and clear protocols established for both police and health-care providers
as this will facilitate referral and access to care(44, 45).

4.2.1.4 When there is fetal impairment
Countries with otherwise restrictive abortion laws are
increasingly permitting abortion upon diagnosis offetal impairment or anomalies due to genetic or othercauses. Several countries specify the kinds of impairment, such as those considered to be incompatible
with life or independent life, while others provide lists
of impairments (36). Such lists tend to be restrictive
and are therefore a barrier to women accessing safe
abortion services. In some countries, no reference
is made in the law to fetal impairment; rather, healthprotection or social reasons are interpreted to include
distress of the pregnant woman caused by the diagnosis of fetal impairment (46, 47).
yy Prenatal tests and other medical diagnostic
services cannot legally be refused because thewoman may decide to terminate her pregnancy.
A woman is entitled to know the status of her
pregnancy and to act on this information.

Legal and policy considerations

4.2.1.5 For economic and social reasons
In countries that permit abortion for economic andsocial reasons, the legal grounds are interpreted byreference to whether continued pregnancy would
affect the actual or foreseeable circumstances of
the woman, including her achievement of the highest attainable standard of health. Some laws specify
allowable reasons, such as pregnancy outside ofmarriage, failed contraception, or intellectual disability affecting capacity to care for a child, while others
only imply them (48). Laws may also require distressas a result of changed circumstance, for example,
the distress of caring and providing for a child additional to existing family members.

4.2.1.6 On request
Nearly a third of UN Member States allow abortion
upon the free and informed request of the pregnant woman (36). Allowing abortion on request has
emerged as countries have recognized that women
seek abortions on one, and often more than one of
the above grounds, and they accept all of these as
legitimate, without requiring a specific reason. This
legal ground recognizes the conditions for a woman’s
free choice. Most countries that allow abortion onrequest set limitations for this ground based on duration of pregnancy.

4.2.1.7 Limits on length of pregnancy
Laws or policies that impose time limits on the lengthof pregnancy for which abortion can be performed
may have negative consequences for women who
have exceeded the limit. Such policies/laws force
some women to seek services from unsafe providers, or self-induce with misoprostol or a less-safe
method, or force them to seek services in othercountries, which is costly, delays access (thusincreasing health risk) and creates social inequities.

Safe abortion: technical and policy guidance for health systems

93

In addition, some service-delivery contexts restrict
the services they offer by gestational limits that are
not evidence based. For example, some countries
offer outpatient abortion services only up to 8 weeks
gestation when they could be safely provided evenafter 12–14 weeks gestation (see Chapters 2 and 3).
Also some countries offer vacuum aspiration only up
to 6 or 8 weeks, when it can be safely provided to
12–14 weeks gestation by trained health-care personnel. These policies also encourage the continued
use of less-safe procedures, such as dilatation andcurettage.

4.2.2 Legal, regulatory or administrative
barriers to safe abortion access in thecontext of human rights
The legal grounds, and the scope of their interpretation, are only one dimension of the legal and policy
environment that affects women’s access to safe
abortion. Health system and service-delivery barriers
as they are explained in Chapter 3 may also be codified in laws, regulations, policies and practices. Laws,
policies and practices that restrict access to abortion
information and services can deter women from careseeking and create a “chilling effect” (suppressionof actions because of fear of reprisals or penalties)
for the provision of safe, legal services. Examples ofbarriers include:
yy prohibiting access to information on legal abortion services, or failing to provide public information on the legal status of abortion;yy requiring third-party authorization from one ormore medical professionals or a hospital committee, court or police, parent or guardian or awoman’s partner or spouse;
yy restricting available methods of abortion, including surgical and medical methods through, forinstance, lack of regulatory approval for essential
medicines;

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Safe abortion: technical and policy guidance for health systems

yy restricting the range of health-care providers andfacilities that can safely provide services, e.g. tophysicians in inpatient facilities with sophisticatedequipment;
yy failing to assure referral in case of conscientious
objection;yy requiring mandatory waiting periods;
yy censoring, withholding or intentionally misrepresenting health-related information;
yy excluding coverage for abortion services underhealth insurance, or failing to eliminate or reduce
service fees for poor women and adolescents(see Chapter 3);
yy failing to guarantee confidentiality and privacy,
including for treatment of abortion complications(see Chapter 3);
yy requiring women to provide the names of practitioners before providing them with treatment forcomplications from illegal abortion;yy restrictive interpretation of legal grounds.
These barriers contribute to unsafe abortion because
they:
yy deter women from seeking care and providers
from delivering services within the formal healthsystem;yy cause delay in access to services, which may
result in denial of services due to gestational
limits on the legal grounds;
yy create complex and burdensome administrative
procedures;
yy increase the costs of accessing abortion services;
yy limit the availability of services and their equitable
geographic distribution.
Details of selected policy barriers follow.

Legal and policy considerations

4.2.2.1 Access to information
Access to information is a key determinant of safe
abortion. Criminal laws, including on the provision ofabortion-related information, and the stigmatizationof abortion deter many women from requesting information from their regular health-care providers about
legal services. Women may prefer not to consult theirregular health-care providers, or to seek care outside
their communities.
Many women and health-care providers (as well as
police and court officers) do not know what the law
allows with regard to abortion (50, 51). For instance,
in a country where abortion is permitted up to 20
weeks of pregnancy to protect a woman’s heathand for contraceptive failure, a survey revealed that
more than 75% of married women and men were notaware that abortion was legal in these circumstances(52). Public health policies or regulations may contain special provisions that clarify how to interpret an
abortion law. In many countries, however, no formalinterpretation or enabling regulation exists (53). The
fear of violating a law produces a chilling effect.
Women are deterred from seeking services within theformal health sector. Health-care professionals tend
to be overly cautious when deciding whether thelegal grounds for abortion are met, thereby denying
women services to which they are lawfully entitled. In
other cases, there is inadequate or conflicting information, for instance, about appropriate dosages ofdrugs for medical abortion.
yy The provision of information about safe, legal
abortion is crucial to protect women’s health andtheir human rights. States should decriminalize
the provision of information related to legal abortion and should provide clear guidance on how
legal grounds for abortion are to be interpreted
and applied, as well as information on how andwhere to access lawful services. Legislators,

Legal and policy considerations

judges, prosecutors and policy-makers also needto understand the human rights and health dimensions of legal access to safe abortion services,made available through training or other appropriately targeted information.

4.2.2.2 Third-party authorization
The requirement for partner or parental authorization
may deter women from seeking safe, legal services(54). Access to care may also be unduly delayed byburdensome procedures of medical authorization,
especially where required specialists or hospital committees are inaccessible. The requirement for authorization by spouse, parent or hospital authorities may
violate the right to privacy and women’s accessto health care on the basis of equality of men andwomen (8,16). Negotiating authorization procedures
disproportionately burdens poor women, adolescents, those with little education, and those subjected to, or at risk of, domestic conflict and violence,creating inequality in access. Parental authorization– often based on an arbitrary age limit – denies therecognition of evolving capacities of young women(55).
yy Third-party authorization should not be required
for women to obtain abortion services. To protect the best interests and welfare of minors, andtaking into consideration their evolving capacities,
policies and practices should encourage, but notrequire, parents’ engagement through support,
information and education (see also Chapter 3).

4.2.2.3 Provision of essential medicines
Medical methods of abortion may be unavailable
due to the lack of regulatory approval or registration for essential medicines. Both mifepristone andmisoprostol have been included on the WHO model
list of essential medicines since 2005 (56, 57), yetmany countries have not yet registered the drugs or

Safe abortion: technical and policy guidance for health systems

95

placed them on their national list of essential drugs.
Sometimes legal restrictions may also be placed on
the distribution of medicines after their approval.
yy Registration and distribution of adequate supplies of drugs for medical abortion (see Chapter 3)
are essential for improving the quality of abortion services, for any legal indication. Access toessential medicines is also necessary to avoid
injury to women’s health caused by use of unregistered drugs purchased through channels thatare uncontrolled for quality.

4.2.2.4 Regulation of facilities and providers
Restrictions on the range of providers (e.g. gynaecologists only) or facilities (e.g. tertiary level only) thatare legally authorized to provide abortion reduce theavailability of services and their equitable geographic
distribution, requiring women to travel greater distances for care, thereby raising costs and delaying
access (58).
yy The regulation of facilities and providers shouldbe evidence-based to protect against overmedicalized, arbitrary or otherwise unreasonablerequirements. Facility and provider regulation
should be based on criteria currently required forprovision of safe abortion care (see Chapter 3).
Vacuum aspiration and the medical methods recommended in Chapter 2 can be safely provided
at primary health-care level by midlevel providers(59, 60). The regulation of providers and facilities should be directed to ensuring that WHOrecommended methods can be provided bothsafely and efficiently.

4.2.2.5 Conscientious objection
Health-care professionals sometimes exempt themselves from abortion care on the basis of conscientious objection to the procedure, while not referring

96

Safe abortion: technical and policy guidance for health systems

the woman to an abortion provider. In the absenceof a readily available abortion-care provider, thispractice can delay care for women in need of safe
abortion, which increases risks to their health andlife. While the right to freedom of thought, conscience, and religion is protected by international
human rights law, international human rights law also
stipulates that freedom to manifest one’s religion or
beliefs might be subject to limitations necessary toprotect the fundamental human rights of others (61).
Therefore laws and regulations should not entitle
providers and institutions to impede women’s accessto lawful health services (62).
yy Health-care professionals who claim conscientious objection must refer the woman to anotherwilling and trained provider in the same, oranother easily accessible health-care facility,in accordance with national law. Where referral is not possible, the health-care professional
who objects must provide abortion to save thewoman’s life or to prevent damage to her health.
Health services should be organized in such a
way as to ensure that an effective exercise of thefreedom of conscience of health professionals in
the professional context does not prevent patientsfrom obtaining access to services to which they
are entitled under the applicable legislation.

4.2.2.6 Waiting periods
Mandatory waiting periods are often required bylaws or regulations and/or administrative procedures imposed by facilities or individual providers.
Mandatory waiting periods can have the effect ofdelaying care, which can jeopardize women’s ability
to access safe, legal abortion services and demeans
women as competent decision-makers (24, 43).
yy States and other providers of health services
should ensure that abortion care is delivered in a

Legal and policy considerations

manner that respects women as decision-makers.
Waiting periods should not jeopardize women’s
access to safe, legal abortion services. Statesshould consider eliminating waiting periods thatare not medically required, and expanding services to serve all eligible women promptly.

4.2.2.7 Censoring, withholding or intentionally
misrepresenting health-related information
Women have a right to be fully informed of theiroptions for health care by properly trained personnel,
including information about the likely benefits andpotential adverse effects of proposed procedures
and available alternatives (8). Censoring, withholding
or intentionally misrepresenting information about
abortion services can result in a lack of access toservices or delays, which increase health risks for
women. Provision of information is an essential partof good-quality abortion services (see Box 4.2 andalso see Chapter 2 “Information and couselling”).
Information must be complete, accurate and easy
to understand, and be given in a way that facilitatesa woman being able to freely give her fully informed
consent, respects her dignity, guarantees her privacy
and confidentiality and is sensitive to her needs andperspectives (8).
yy States should refrain from limiting access tomeans of maintaining sexual and reproductive
health, including censoring, withholding or intentionally misrepresenting health-related information(63).

4.2.2.8 Access to treatment for abortion
complications
Health-care providers are obligated to provide
life-saving medical care to any woman who suffers
abortion-related complications, including treatmentof complications from unsafe abortion, regardless of
the legal grounds for abortion (19). However, in somecases, treatment of abortion complications is administered only on condition that the woman provides
information about the person(s) who performed theillegal abortion. This has been considered torture andinhuman and degrading treatment (20).

BOX 4.2
Essential information for women
yy Women have the right to decide freely and responsibly whether and when to have children without
coercion, discrimination or violence.
yy How pregnancy occurs, its signs and symptoms, and where to obtain a pregnancy test.
yy How to prevent unintended pregnancy, including where and how to obtain contraceptive methods,
including condoms.
yy Where and how to obtain safe, legal abortion services and their cost.
yy The details of legal limitations on the maximum gestational age when abortion can be obtained.
yy That abortion is a very safe procedure but the risk of complications increases with increasing gestational age.
yy How to recognize complications of miscarriage and unsafe abortion, the life-saving importance of
seeking treatment immediately, and when and where to obtain services.

Legal and policy considerations

Safe abortion: technical and policy guidance for health systems

97

yy The practice of extracting confessions fromwomen seeking emergency medical care as aresult of illegal abortion, and the legal requirement for doctors and other health-care personnel
to report cases of women who have undergone
abortion, must be eliminated. States have an
obligation to provide immediate and unconditional
treatment to anyone seeking emergency medicalcare (19, 20, 41).

4.2.2.9 Restrictive interpretation of laws on
abortion
The respect, protection and fulfilment of human rights
require that governments ensure abortion services
that are allowable by law are accessible in practice(10, 64). Institutional and administrative mechanisms
should be in place and should protect against unduly
restrictive interpretations of legal grounds. Thesemechanisms should allow service provider andfacility administrator decisions to be reviewed by anindependent body, should take into consideration theviews of the pregnant woman, and should provide
timely resolution of review processes (64).

4.3. Creating an enabling environment
An enabling environment is needed to ensure thatevery woman who is legally eligible has ready accessto safe abortion care. Policies should be geared torespecting, protecting and fulfilling the human rights
of women, to achieving positive health outcomesfor women, to providing good-quality contraceptive
information and services, and to meeting the particular needs of groups such as poor women, adolescents, rape survivors and women living with HIV. The
respect, protection, and fulfilment of human rights
require that comprehensive regulations and policies
be in place and they address all elements listed in
Section 4.2.2, to ensure that abortion is safe and98

Safe abortion: technical and policy guidance for health systems

accessible. Existing policies should be examined toascertain where there are gaps and where improvements are needed (see also Chapter 3).
Policies should aim to:yy respect, protect and fulfil the human rights ofwomen, including women’s dignity, autonomy andequality;
yy promote and protect the health of women, asa state of complete physical, mental and social
well-being;
yy minimize the rate of unintended pregnancy byproviding good-quality contraceptive informationand services, including a broad range of contraceptive methods, emergency contraception andcomprehensive sexuality education;yy prevent and address stigma and discrimination
against women who seek abortion services ortreatment for abortion complications;
yy reduce maternal mortality and morbidity due tounsafe abortion, by ensuring that every woman
entitled to legal abortion care can access safe
and timely services including post-abortion
contraception;
yy meet the particular needs of women belonging tovulnerable and disadvantaged groups, such as
poor women, adolescents, single women, refugees and displaced women, women living with
HIV, and survivors of rape.
While countries differ in prevailing national healthsystem conditions and constraints on available
resources, all countries can take immediate andtargeted steps to elaborate comprehensive policesthat expand access to sexual and reproductive healthservices, including safe abortion care.

Legal and policy considerations

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and practices. Reproductive Health, 2005, 2:10.
50. Jewkes R et al. Why are women still aborting outside
designated facilities in metropolitan South Africa?
British Journal of Obstetrics and Gynaecology, 2005,
112:1236–1242.
51. Morroni C, Myer L, Tibazarwa K. Knowledge of theabortion legislation among South African women: across-sectional study. Reproductive Health, 2006,
3:7.

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52. Iyengar K, Iyengar SD. Elective abortion as a primary
health service in rural India: experience with manualvacuum aspiration. Reproductive Health Matters,
2002, 10:54–63.

63. Committee on Economic Social and Cultural Rights.
General comment no. 14: The right to the highest attainable standard of health (article 12), 2000.
United Nations.

53. Cook RJ, Erdman JN, Dickens BM. Achieving transparency in implementing abortion laws. International
Journal of Gynecology and Obstetrics, 2007,
99:157–161.

64. Committee on the Elimination of Discrimination
against Women, L.C. v. Peru, CEDAW/
C/50/D/22/2009, 4 November 2011. United Nations;
European Court of Human Rights. Case of Tysiac v.
Poland. Application no. 5410/03. Council of Europe,
2007; Paulina del Carmen Ramirez Jacinto, Mexico,
Friendly Settlement, Report No. 21/07, Petition
161–01, 9 March 2007. Inter-American Commission
on Human Rights, 2007.

54. Mundigo A, Indriso C. Abortion in the developingworld. London and New York, Zed Books, 1999.
55. Cook RJ, Erdman JN, Dickens BM. Respecting
adolescents’ confidentiality and reproductive andsexual choices. International Journal of Gynecology
and Obstetrics, 2007, 92:182–187.
56. WHO model list of essential medicines, 16th ed.
Geneva, World Health Organization, 2010.
57. PATH, World Health Organization, United Nations
Population Fund. Essential medicines for reproductive health: guiding principles for their inclusion on
national medicines lists. Seattle, WA, PATH, 2006.
58. Scott Jones B, Weitz TA. Legal barriers to secondtrimester abortion provision and public healthconsequences. American Journal of Public Health,
2009, 99(4):623–630.
59. Warriner IK et al. Rates of complication in firsttrimester manual vacuum abortion done by doctors
and mid-level providers in South Africa and Vietnam:a randomised controlled equivalence trial. Lancet,
2006, 368:1965–1972
60. Warriner IK et al. Can midlevel health-care providers administer early medical abortion as safely
and effectively as doctors? A randomised controlled equivalence trial in Nepal. Lancet, 2011,
377:1155–1161.
61. International Covenant on Civil and Political Rights,
entry into force 23 March 1976, Article 18. United
Nations.
62. European Court of Human Rights, Kontaktinformation-Therapie and Hagen v. Austria, 57 Eur.
Ct. H.R. 81. Council of Europe, 1988.

Legal and policy considerations

Safe abortion: technical and policy guidance for health systems

103

ANNEXES

Annexes
104 Safe abortion: technical and policy guidance for health systems

ANNEX 1
Research gaps identified at the technical consultation

yy The efficacy of lower doses (such as 600 μg) of misoprostol when used following
mifepristone (200 mg) at earlier gestational ages or for certain routes of administration.
yy Whether a benefit exists when a starting dose, higher than the repeat dose of misoprostol, isused during second-trimester medical abortion.
yy Identification of the most effective combined regimen of medical abortion between 9 and
12 weeks of gestation.
yy Identification of the interval between mifepristone and misoprostol that women prefer, giventhat the timing that achieves the highest efficacy for abortion is between 24 and 48 hours.
yy Evaluation of whether cervical preparation has an effect on the pain experienced by women
during surgical abortion.
yy Evaluation of whether cervical preparation has an effect on surgical abortion complicationsin the late first trimester (9–12 weeks of gestation).
yy The risks and benefits of cervical preparation, and whether they vary by provider experiencelevel.
yy Identification of whether the pharmacokinetics of carboprost are similar to those ofgemeprost.
yy Evaluation of algorithms for follow-up after medical and surgical abortion.
yy Evaluation of the safety of contraceptive use (particularly IUDs, implants and injectables)
following medical abortion.
yy Evaluation of the safe period of delay after a septic abortion when an IUD may be inserted.
yy Evaluation of the best pain-management options for both first- and second-trimester
abortions, including the timing of their administration.
yy Evaluation of the role of incentives to providers for provision of abortion, and whether it
differentially affects access to abortion services.
yy Identification of how women pay for abortions and whether this information can be used toprovide more equitable services.
yy Evaluation of the effect of Internet provision, telemedicine, social marketing and other similar
services on the safe provision of, and access to abortion services.

Safe abortion: technical and policy guidance for health systems

105Annex 2
Final GRADE questions and outcomes
1. When mifepristone is not available, what is the recommended method of medical
abortion up to 12 weeks of gestation?
a. Outcome 1: failure to complete abortion				b. Outcome 2: ongoing pregnancy					c. Outcome 3: side-effects (overall, individual)			
d. Outcome 4: abortion interval from initiation of treatment		e. Outcome 5: other procedure-related complications			

2. What method of pain control should be used for surgical abortion up to 12–14 weeks
of gestation?
a. Outcome 1: effectiveness in decreasing procedural pain		b. Outcome 2: side-effects (overall, individual)			
c. Outcome 3: complications related to pain-control methods		

3. Should antibiotics be used to prevent post-abortion infection?
a. Outcome 1: infection							b. Outcome 2: side-effects (overall, individual)			
c. Outcome 3: complications						d. Outcome 4: cost							4. What is the recommended medical regimen for abortion up to 12 weeks ofgestation?1
a. Outcome 1: failure to complete abortion				b. Outcome 2: ongoing pregnancy					c. Outcome 3: side-effects (overall, individual)			
d. Outcome 4: abortion interval from initiation of treatment		e. Outcome 5: other procedure-related complications			

106

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5. What is the recommended method of abortion after 12 weeks of gestation?
a. Outcome 1: failure to complete abortion				b. Outcome 2: ongoing pregnancy					c. Outcome 3: side-effects (overall, individual)			
d. Outcome 4: abortion interval from initiation of treatment
e. Outcome 5: other procedure-related complications													6. How should incomplete abortion be treated?
a. Outcome 1: failure to complete abortion				b. Outcome 2: side-effects (overall, individual)			
c. Outcome 3: abortion interval from initiation of treatment		
d. Outcome 4: other procedure-related complications			

7. What method of medical abortion should be used beyond 12 weeks of gestation?
a. Outcome 1: complete abortion					b. Outcome 2: side-effects (overall, individual)			
c. Outcome 3: procedure-related complications			d. Outcome 4: abortion interval from initiation of treatment		

8. How should cervical preparation prior to surgical abortion be accomplished?
a. Outcome 1: successful cervical dilatation				b. Outcome 2: degree (in mm) of cervical dilatation			c. Outcome 3: patient acceptability					d. Outcome 4: procedure duration					e. Outcome 5: interval from treatment to completed abortion		f. Outcome 6: side-effects (overall, individual)			
g. Outcome 7: complications						9. Who should receive cervical preparation prior to surgical abortion?
a. Outcome 1: no need for further dilatation				b. Outcome 2: degree (in mm) of cervical dilatation			c. Outcome 3: patient preference					d. Outcome 4: complications						Safe abortion: technical and policy guidance for health systems

10710. What methods of pain control should be used for medical abortion?
a. Outcome 1: side-effects (overall, individual)			
b. Outcome 2: complications						c. Outcome 3: abortion interval from initiation of treatment		
d. Outcome 4: effectiveness in relieving procedural pain		11. Should pre-abortion ultrasound be recommended?
a. Outcome 1: complications						b. Outcome 2: failure to complete abortion				

12. What method of surgical abortion should be used prior to 12 weeks of gestation?
a. Outcome 1: failure to complete abortion				b. Outcome 2: side-effects (overall, individual)			
c. Outcome 3: other procedure-related complications			

13. Should women have routine follow-up following induced abortion?
a. Outcome 1: complications						b. Outcome 2: cost							c. Outcome 3: patient acceptability					

1Note that in the recommendations (Annex 5), this question was separated into two recommendations,based on gestational age <9 weeks and gestational age 9–12 weeks

108

Safe abortion: technical and policy guidance for health systems

Annex 3
Standard GRADE criteria for grading of evidence
See references 19–23.
DomainStudy design
Study design
limitations

Grade
0
–1
0
–1
–2
Note:

Characteristic
All randomized controlled trials
All observational studies
Most of the pooled effect provided by studies, with low risk of bias
Most of the pooled effect provided by studies with moderate risk of bias
Most of the pooled effect provided by studies with high risk of bias
Low risk of bias: no limitations or minor limitations
Moderate risk of bias: serious limitations or potentially very serious limitations including unclear concealment of allocation or serious limitations, excluding limitations on randomization or concealmentof allocation

Inconsistency

Indirectness
Imprecision0–1High risk of bias: limitations for randomization, concealment of allocation, including small blocked
randomization (<10) or other very serious, crucial methodological limitations
No severe heterogeneity (I2 < 60% or χ2 ≥ 0.05)
Severe, non-explained, heterogeneity (I2 ≥ 60% or χ2 < 0.05)

0–1
0

If heterogeneity could be caused by publication bias or imprecision due to small studies, downgrade
only for publication bias or imprecision (i.e. the same weakness should not be downgraded twice)
No indirectness
Presence of indirect comparison, population, intervention, comparator, or outcome
The confidence interval is precise according to the figure below
suggested
appreciable benefit

risk ratio

suggested
appreciable harm

preciseimprecise

0.75

–1
–2
Note:

Publication bias

0
–1

1.0

1.25

The total cumulative study population is not very small (i.e. sample size is more than 300 participants)
and the total number of events is more than 30
One of the above-mentioned conditions is not fulfilled
The two above-mentioned are not fulfilled
If the total number of events is less than 30 and the total cumulative sample size is appropriately large(e.g. above 3000 patients), consider not downgrading the evidence. If there are no events in bothintervention and control groups, the quality of evidence in the specific outcome should be regarded
as very low.
No evident asymmetry in the funnel plot or fewer than five studies to be plotted
Evident asymmetry in the funnel plot with at least five studies

Safe abortion: technical and policy guidance for health systems

109Annex 4
Participants in the technicalconsultation
Dr Marijke Alblas
Clinician, health advocate
Independent medical consultant
Cape Town
South Africa
Ms Marge Berer
Health advocate
EditorReproductive Health Matters
LondonUnited Kingdom of Great Britain and Northern Ireland
Dr Mohsina Bilgrami
Programme manager, policy-maker, health advocate
Managing Director
Marie Stopes Society
KarachiPakistan
Dr Paul Blumenthal
Clinician, researcher
Professor of Obstetrics and Gynecology
Stanford University School of Medicine
Stanford, CA
United States of America
Dr Lidia Casas-Becerra
Lawyer, researcher, health advocate
Professor of Law
Diego Portales Law School
Universidad Diego Portales
Santiago
Chile
Dr Laura Castleman
Clinician, programme manager
Medical Director
Ipas
Birmingham, MI
USA

110

Safe abortion: technical and policy guidance for health systems

Ms Jane Cottingham
Researcher, health advocate
Independent consultant in sexual and reproductive
health and rights
Carouge, GE
Switzerland
Dr Kelly Culwell
Clinician, health advocate, programme manager
Senior adviser
International Planned Parenthood Federation
LondonUnited Kingdom of Great Britain and Northern Ireland
Dr Teresa Depiñeres
Researcher, clinician, programme manager
Senior Technical Advisor
Fundacion Orientame
BogotaColombia
Dr Joanna Erdman
Lawyer, researcher, health advocate
Adjunct Professor, Faculty of Law
University of Toronto
Ontario
CanadaDr Aníbal Faúndes
Clinician, health advocate
Professor of Obstetrics and Gynaecology
State University of Campinas
Campinas, São Paulo
BrazilProfessor Mahmoud Fathalla
Clinician, researcher, health advocate
Assiut University
AssiutEgypt
Dr Kristina Gemzell-Danielsson
Researcher, clinician, policy-makerProfessor of Obstetrics and Gynaecology
Karolinska University Hospital
Stockholm
SwedenDr Anna Glasier
Clinician, researcher
Lead Clinician, Sexual Health
NHS Lothian and University of Edinburgh
Edinburgh
ScotlandMs Bonnie Scott Jones
Lawyer, health advocate
Deputy Director
Center for Reproductive Rights
New York, NY
United States of America

Dr Türkiz Gökgöl
Researcher, policy-maker, programme manager
Director of International Programs
The Susan Thompson Buffett Foundation
Omaha, NE
United States of America

Dr Vasantha Kandiah
Researcher
Consultant
Population and Family Planning Development Board
Kuala Lumpur
Malaysia

Dr David Grimes
Methodologist, epidemiologist, researcher
Distinguished scientist
Family Health International
Durham, NC
United States of America

Dr Nguyen Duy Khe
Programme manager
Head, Mother and Child Healthcare Department
Ministry of Health
Hanoi
Viet Nam

Dr Selma Hajri
Clinician, researcher
Consultant in reproductive health
Coordinator
African Network for Medical Abortion (ANMA)
Tunis
Tunisia

Dr Chisale Mhango
Programme manager
Director, Reproductive Health Unit
Ministry of Health
Lilongwe
MalawiDr Pak Chung Ho
Clinician, researcher
Professor of Obstetrics and Gynaecology
Queen Mary HospitalHong Kong
People’s Republic of China
Dr Sharad Iyengar
Clinician, policy-maker
Chief Executive
Action Research & Training for Health
Udaipur
India
Ms Heidi Bart Johnston
Temporary Adviser
Reproductive Health and Rights Consultant
Wetzikon
Switzerland

Dr Suneeta Mittal
Clinician, researcher, health advocate
Head, Department of Obstetrics and Gynecology
All India Institute of Medical Sciences
Ansari Nagar, New Delhi
India
Dr Nuriye Ortayli
Clinician, programme manager
Senior Adviser
UNFPA
New York, NY
United States of America
Dr Mariana Romero
Researcher, health advocate
Associate researcher
CEDES
Buenos Aires
Argentina

Safe abortion: technical and policy guidance for health systems

111

Dr Helena von Hertzen
Researcher
Consultant
Concept Foundation
GenevaSwitzerland
Dr Beverly Winikoff
Methodologist, epidemiologist, researcher
President
Gynuity Health Projects
New York, NY
United States of America
Ms Patricia Ann Whyte
Temporary Adviser
Senior research fellow
Deakin Strategic Centre in Population HealthFaculty of Health, Deakin University
Victoria
Australia

Additional peer reviewers
Ms Rebecca Cook
Chair in International Human Rights Law
Faculty of Law
University of Toronto
Toronto, Ontario
CanadaMs Laura Katsive
Program Officer
Wellspring Advisors, LLC
New York
United States of America
Dr Paul FA Van Look
Consultant in Sexual and Reproductive HealthVal d’Illiez
Switzerland

112

Safe abortion: technical and policy guidance for health systems

WHO regional advisers
Dr Khadiddiatou Mbaye, Regional Office for Africa
Dr Gunta Lazdane, Regional Office for Europe

WHO Secretariat
Dr Katherine Ba-Thike
Dr Dalia Brahmi
Dr Peter Fajans
Dr Bela Ganatra
Dr Emily Jackson
Dr Ronald Johnson
Dr Nathalie Kapp
Ms Eszter Kismodi
Dr Regina Kulier
Dr Michael Mbizvo
Dr Lale Say
Dr Iqbal ShahDr João Paulo Dias de Souza

Observers
Dr Mari Mathiesen
Member of the Management Board
Estonian Health Insurance Fund
Lembitu
Estonia
Dr Helvi Tarien
Head of Health Services Department
Estonian Health Insurance Fund
Lembitu
EstoniaAnnex 5
Recommendations from the technical consultation forthe second edition of Safe abortion: technical and policy
guidance for health systems
Recommendation 1: surgical abortion up to
gestational age 12 to 14 weeks
Vacuum aspiration is the recommended techniqueof surgical abortion for pregnancies of up to 12 to
14 weeks of gestation. The procedure should not beroutinely completed by sharp curettage. Dilatationand sharp curettage (D&C), if still practised, should
be replaced by vacuum aspiration.
(Strength of recommendation: strong)
Remarksyy 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.
yy No evidence supports the use of sharp curette
checks (i.e. the use of sharp curettage to “complete” the abortion) following vacuum aspiration.
yy The quality of the evidence based on randomized
controlled trials is low to moderate.

Recommendation 2: medical abortion up to
gestational age 9 weeks (63 days)
Recommendation 2.1
The recommended method for medical abortion is
mifepristone followed by misoprostol.
(Strength of recommendation: strong)
Remarksyy Randomized controlled trials demonstrate superior effectiveness of the combined regimen (mifepristone followed by misoprostol) when comparedwith misoprostol used alone.
yy The quality of the evidence based on randomized
controlled trials is moderate.

Recommendation 2.2
Mifepristone should always be administered orally.
The recommended dose is 200 mg.
(Strength of recommendation: strong)
Remarksyy Randomized controlled trials indicate that 200 mgof mifepristone is as efficacious as 600 mg.
yy The quality of the evidence based on randomized
controlled trials is moderate.

Safe abortion: technical and policy guidance for health systems

113

Recommendation 2.3
For vaginal, buccal or sublingual routes, the recommended dose of misoprostol is 800 μg. For oral
administration, the recommended dose of misoprostol is 400 μg.
(Strength of recommendation: strong)
Remarksyy The efficacy of misoprostol may vary depending
upon gestational age, the route of administration,or the frequency of dosing. Research is currently
ongoing to determine in what clinical situations,
if any, a lower dose of misoprostol might be usedwith comparable efficacy.
yy The quality of the evidence based on randomized
controlled trials is moderate.

Recommendation 2.4
Recommended dosages and routes of administration
for mifepristone followed by misoprostol:
Mifepristone should always be administered orally.
The recommended dose is 200 mg.
Administration of misoprostol is recommended
1 to 2 days (24 to 48 hours) following ingestion of
mifepristone.
yy For vaginal, buccal or sublingual routes, the recommended dose of misoprostol is 800 μg.
yy For oral administration, the recommended dose of
misoprostol is 400 μg.
yy With gestations up to 7 weeks (49 days) misoprostol may be administered by vaginal, buccal,
sublingual or oral routes. After 7 weeks of gestation, oral administration of misoprostol should not
be used.

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Safe abortion: technical and policy guidance for health systems

yy With gestations up to 9 weeks (63 days) misoprostol can be administered by vaginal, buccal
or sublingual routes.
(Strength of recommendation: strong)
Remarksyy Vaginal administration of misoprostol is recommended based on its higher effectiveness andlower rates of side-effects than other routes ofadministration; however, some women may prefera non-vaginal route.
yy The quality of the evidence based on randomized
controlled trials is moderate.

Recommendation 2.5
Administration of misoprostol is recommended
1 to 2 days (24 to 48 hours) following ingestion of
mifepristone.
(Strength of recommendation: strong)
Remarkyy The quality of the evidence based on randomized
controlled trials is moderate.

Recommendation 3: medical abortion for gesgestational age between 9 and 12 weeks(63 and 84 days)
The recommended method for medical abortion is
200 mg mifepristone administered orally followed 36
to 48 hours later by 800 μg misoprostol administeredvaginally. Subsequent misoprostol doses should be
400 μg, administered either vaginally or sublingually,
every 3 hours up to four further doses, until expulsionof the products of conception.
(Strength of recommendation: weak)Remarks
yy The regimen for medical abortion between 9
and 12 weeks of gestation is an area of ongoing research; this recommendation is likely to beaffected as studies are completed.
yy The quality of evidence based on one randomized
controlled trial and one observational study is low.

Recommendation 4: medical abortion up to
gestational age 12 weeks (84 days) where
mifepristone is not available
The recommended method of medical abortion
where mifepristone is not available is 800 μg of misoprostol administered by vaginal or sublingual routes.
Up to three repeat doses of 800 μg can be administered at intervals of at least 3 hours, but for no longer
than 12 hours.
(Strength of recommendation: strong)
Remarksyy Sublingual misoprostol is associated with higher
rates of side-effects than vaginal administration.
In nulliparous women, the sublingual route isalso less efficacious when intervals greater than
3 hours between repeat doses are used.
yy The quality of the evidence based on one randomized controlled trial is high.
yy Mifepristone with misoprostol is more effective
than misoprostol used alone, and is associatedwith fewer side-effects. Methotrexate combinedwith misoprostol, a regimen used in some areas
but not recommended by WHO, is less effective
than mifepristone with misoprostol, but is more
effective than misoprostol used alone.

Recommendation 5: methods of abortion after
gestational age 12 to 14 weeks(84 to 98 days)
Dilatation and evacuation (D&E) and medical methods (mifepristone and misoprostol; misoprostol
alone) are both recommended methods for abortionfor gestations over 12 to 14 weeks. Facilities should
offer at least one, and preferably both, methods if
possible, depending on provider experience and theavailability of training.
(Strength of recommendation: strong)
Remarksyy Evidence for this question is limited by women’s
willingness to be randomized in clinical trials
between surgical and medical methods of abortion.
yy The quality of the evidence based on randomized
controlled trials is low.
yy A woman’s choice of abortion method may belimited or not applicable if she has medical contraindications to one of the methods.

Recommendation 6: medical abortion after
gestational age 12 weeks (84 days)
The recommended method for medical abortion is
200 mg mifepristone administered orally followed
36 to 48 hours later by repeated doses of
misoprostol.
(Strength of recommendation: strong)–– With gestations between 12 and 24 weeks, theinitial misoprostol dose following oral mifepristone administration may be either 800 μg
administered vaginally or 400 μg administeredorally. Subsequent misoprostol doses should
be 400 μg, administered either vaginally or sublingually, every 3 hours up to four further doses.

Safe abortion: technical and policy guidance for health systems

115

–– For pregnancies beyond 24 weeks, the doseof misoprostol should be reduced, due to thegreater sensitivity of the uterus to prostaglandins, but the lack of clinical studies precludes
specific dosing recommendations.
(Strength of recommendation: strong)
The recommended method of medical abortion
where mifepristone is not available is 400 μg of
misoprostol administered vaginally or sublingually,
repeated every 3 hours for up to five doses.

Recommendation 7: cervical preparation prior
to surgical abortion up to gestational age 12
to 14 weeks (84 to 98 days)
Recommendation 7.1
Prior to surgical abortion, cervical preparation is recommended for all women with a pregnancy over 12
to 14 weeks of gestation. Its use may be considered
for women with a pregnancy of any gestational age.
(Strength of recommendation: strong)(Strength of recommendation: strong)

Remarks

Remarks

yy Consideration should be given to the increasein time and side-effects, including pain, vaginal
bleeding and precipitous abortion, associatedwith cervical preparation if used at gestational
ages <12 to 14 weeks.

yy An interval of less than 36 hours between administration of mifepristone and misoprostol is associated with a longer interval to abortion and higher
rates of incomplete abortion.
yy Ethacridine lactate is associated with a similarinterval to abortion as regimens using misoprostol
alone; studies have not compared the safety or
efficacy of its use to that of combined mifepristone and misoprostol.
yy Women with a uterine scar have a very low(0.28%) risk of uterine rupture during medical
abortion in the second trimester.
yy When using misoprostol alone in nulliparous
women, vaginal administration of misoprostol ismore effective than sublingual administration.
yy The quality of the evidence based on randomized
controlled trials is low to moderate.

yy Lack of availability of cervical preparation should
not limit access to abortion services.
yy The quality of the evidence based on randomized
controlled trials is low.

Recommendation 7.2
Any one of these methods of cervical preparation before surgical abortion in the first trimester isrecommended:–– oral mifepristone 200 mg (24 to 48 hours inadvance); or–– misoprostol 400 μg administered sublingually,
2 to 3 hours prior to the procedure; or–– misoprostol 400 μg administered vaginally
3 hours prior to the procedure; or–– laminaria placed intracervically 6 to 24 hours
prior to the procedure.
(Strength of recommendation: strong)

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Safe abortion: technical and policy guidance for health systems

Remarks
yy Cost, local availability of and training in the useof cervical preparatory methods will affect the
choice of method to use.
yy The quality of the evidence based on randomized
controlled trials is low to moderate.

Recommendation 8: cervical preparation
prior to surgical abortion for gestational age≥14 weeks (98 days)
Recommendation 8.1
All women undergoing dilatation and evacuation(D&E) with a pregnancy over 14 weeks of gestation should receive cervical preparation prior to theprocedure.
(Strength of recommendation: strong)
Remarkyy The quality of the evidence based on randomized
controlled trials is low to moderate.

Recommendation 8.2
The recommended methods of cervical preparation
prior to dilatation and evacuation (D&E) after 14 weeks
of gestation are osmotic dilators or misoprostol.
(Strength of recommendation: strong)
Remarksyy Osmotic dilators reduce procedure time and theneed for further dilatation when compared withuse of misoprostol. The effect of misoprostol
prior to D&E for pregnancies of gestational age
over 20 weeks has not been the subject of clinicalresearch.
yy The quality of the evidence based on randomized
controlled trials is moderate.

Recommendation 9: follow-up after induced
abortion
There is no medical need for a routine follow-up visit
following uncomplicated surgical abortion or medical
abortion using mifepristone followed by misoprostol.
However, women should be advised that additional
services are available to them if needed or desired.
(Strength of recommendation: strong)
Remarksyy Women must be adequately informed regarding
symptoms of ongoing pregnancy and other medical reasons, such as prolonged heavy bleeding or
fever, to return for follow-up.
yy Alternative follow-up strategies to in-clinic visits
after first-trimester medical abortion are the subject of ongoing research.
yy The quality of the evidence based on observational studies and indirect evidence is low.

Recommendation 10: treatment of incomplete
abortion
If uterine size at the time of treatment is equivalent
to a pregnancy of gestational age 13 weeks or less,either vacuum aspiration or treatment with misoprostol is recommended for women with incomplete
abortion. The recommended regimen of misoprostol
is a single dose given either sublingually (400 μg) ororally (600 μg).
(Strength of recommendation: strong)
Remarksyy Expectant management of incomplete abortion
can be as effective as misoprostol, but the process takes more time. The decision for treatment
or expectant management of incomplete abortion
should be based on the clinical condition of thewoman and her preferences for treatment.

Safe abortion: technical and policy guidance for health systems

117

yy This recommendation is extrapolated fromresearch conducted in women with reported
spontaneous abortion. Missed abortion is a different condition from incomplete abortion following
either spontaneous or induced abortion.

yy The quality of the evidence based on randomized
controlled trials for surgical abortion is moderate.
The quality of the evidence based on one observational trial for medical abortion is very low; forsurgical abortion it is moderate.

yy Based on the recommendation for surgical abortion through the first trimester, vacuum aspiration
may also be used in women with a uterine size of
14 weeks of gestation.

Recommendation 12: ultrasound use prior toinduced abortionyy Misoprostol may also be used vaginally. Studies
of vaginal misoprostol have used doses ranging
from 400 μg to 800 μg, and comparative dosing
trials have not been reported.

(Strength of recommendation: strong)yy The quality of the evidence based on randomized
controlled trials is low.

Recommendation 11: antibiotic prophylaxis for
induced abortion
All women having surgical abortion, regardless of
their risk of pelvic inflammatory infection, should
receive appropriate prophylactic antibiotics pre- or
peri-operatively.

Remarkyy The quality of the evidence based on a randomized controlled trial and observational studies
is very low.

Recommendation 13: contraception following
abortion
Women may start hormonal contraception at the timeof surgical abortion, or as early as the time of administration of the first pill of a medical abortion regimen.

(Strength of recommendation: strong)(Strength of recommendation: strong)

For women having medical abortion, routine use ofprophylactic antibiotics is not recommended.

Following medical abortion, an IUD may be inserted
when it is reasonably certain that the woman is nolonger pregnant.

(Strength of recommendation: strong)
Remarks

118

Use of routine pre-abortion ultrasound scanning is
not necessary.

Remarksyy Lack of antibiotics should not limit access toabortion services.

yy Initiation of hormonal contraception during medical abortion prior to expulsion of the pregnancy
has not been the subject of clinical trials.

yy Single-dose administration of nitroimidazoles,
tetracyclines or penicillins has been shown to beeffective.

yy The quality of evidence based on randomized
controlled trials is very low.

Safe abortion: technical and policy guidance for health systems

Recommendation 14: pain management durduring abortion
All women should routinely be offered pain medication (e.g. non-steroidal anti-inflammatory drugs)
during both medical and surgical abortions.
(Strength of recommendation: strong)

General anaesthesia is not routinely recommended
for vacuum aspiration abortion or D&E.
(Strength of recommendation: strong)
Remarksyy Some women may require additional narcotic pain
medication, especially during second-trimester
abortion.
yy The use of regional anaesthesia during medical
abortion for pregnancies of gestational age over
12 weeks has not been the subject of clinical
trials.
yy General anaesthesia is associated with higher
rates of side-effects and adverse events thanother methods of pain management.
yy The quality of the evidence based on randomized
controlled trials is low.

yy Medication for pain management for both medical
and surgical abortions should always be offered,and provided without delay to women who desire
it. In most cases, analgesics, local anaesthesia
and/or conscious sedation supplemented byverbal reassurance are sufficient, although theneed for pain management increases with gestational age.
yy The timing of pain medication administration has
been inadequately and poorly studied, which precludes making recommendations about specificregimen(s); however, providing pain management
is an important part of safe abortion care.
yy Intravenous narcotics and/or tranquillizers andparacervical block are widely used, despite being
inadequately studied.
yy Non-steroidal anti-inflammatory drugs havedemonstrated effectiveness in decreasing pain; incontrast, paracetamol has been shown to be ineffective at decreasing pain associated with surgical or medical abortion.

Safe abortion: technical and policy guidance for health systems

119Annex 6
Post-abortion medical eligibility for contraceptive use1
Table A1. Summary table of post-abortion medical eligibility recommendations for hormonal contraceptives,
intrauterine devices and barrier contraceptive methods
Postabortion
condition

COC

CIC

Patch &
vaginal
ring

POP

DMPA,
NET-EN

LNG/ CopperLNGCondom Spermicide
ETG
bearing releasing
implants
IUD
IUD

Diaphragm

First
trimester

1

1

1

1

1

1

1

1

1

1

1

Secondtrimester

1

1

1

1

1

1

2

2

1

1

1

Immediate
post-septic
abortion

1

1

1

1

1

1

4

4

1

1

1

CIC, combined injectable contraceptive; COC, combined oral contraceptive; DMPA/NET-EN, progestogen-only injectables: depot medroxyprogesterone acetate/norethisterone enanthate; IUD, intrauterine device; LNG/ETG, progestogenonly implants: levenorgestrel/etonorgestrel; POP, progesterone-only pill.

Definition of categories
yy 1: a condition for which there is no restriction for the use of the contraceptive method.
yy 2: a condition where the advantages of using the method generally outweigh the theoretical or proven risks.
yy 3: a condition where the theoretical or proven risks usually outweigh the advantages of using the method.
yy 4: a condition which represents an unacceptable health risk if the contraceptive method is used.

1

120

Based on Medical eligibility criteria for contraceptive use, 4th ed. Geneva, World Health Organization, 2009.

Safe abortion: technical and policy guidance for health systems

Table A2. Post-abortion medical eligibility recommendations for female
surgical sterilization
Post-abortion condition

Female surgical sterilization

UncomplicatedA

Post-abortal sepsis or fever

D

Severe post-abortal haemorrhage

D

Severe trauma to the genital tract; cervicalDor vaginal tear at the time of abortion
Uterine perforation

S

Acute haematometra

D

Definition of categories
yy A = (accept): there is no reason to deny sterilization to a person with this condition.
yy C = (caution): the procedure is normally conducted in a routine setting, but with extra
preparation and precautions.
yy D = (delay): the procedure is delayed until the condition is evaluated and/or corrected;
alternative temporary methods of contraception should be provided.
yy S = (special): the procedure should be undertaken in a setting with an experienced
surgeon and staff, and equipment is needed to provide general anaesthesia, andother back-up medical support. For these conditions, the capacity to decide on themost appropriate procedure and anaesthesia regimen is also needed. Alternative temporary methods of contraception should be provided, if referral is required or there isotherwise any delay.

Safe abortion: technical and policy guidance for health systems

121Annex 7
Core international and regional human rights treaties
Table A3. Core international human rights treaties

122International human rights treaty (date of entry into force)

Treaty monitoring body

International Convention on the Elimination of All Forms of Racial
Discrimination (ICERD) (1969)

Committee on the Elimination of Racial
Discrimination

International Covenant on Economic, Social and Cultural Rights(ICESCR) (1976)

Committee on Economic, Social and Cultural
RightsInternational Covenant on Civil and Political Rights (ICCPR) (1976)

Human Rights Committee

Convention on the Elimination of Discrimination Against Women(CEDAW) (1981)

Committee on the Elimination ofDiscrimination Against Women

Convention against Torture and Other Cruel, Inhuman or
Degrading Treatment or Punishment (CAT) (1987)

Committee Against Torture

Convention on the Rights of the Child (CRC) (1990)

Committee on the Rights of the ChildInternational Convention on the Protection of the Rights of all
Migrant Workers and Members of their Families (2003)

Committee on Migrant Workers

Convention on the Rights of Persons with Disabilities (CRPD)(2008)

Committee on the Rights of Persons with
Disabilities

Safe abortion: technical and policy guidance for health systems

Table A4. Regional human rights treaties
Regional human rights treaty (date of entry into force)

Treaty monitoring body

American Declaration on the Rights and Duties of Man(1948)

Inter-American Commission on Human Rights

Convention for the Protection of Human Rights andFundamental Freedoms (as amended by Protocols 1, 4, 6,
7, 12 and 13) (1953)

European Court of Human Rights

American Convention on Human Rights (1978)

Inter-American Commission on Human Rights

African Charter on Human and Peoples’ Rights (1986)

African Commission on Human and Peoples’ Rights

Inter-American Convention on the Prevention, Punishment
and Eradication of Violence Against Women (“Conventionof Belem do Para”) (1994)

Inter-American Commission on Human Rights

European Social Charter (1961)/Revised European Social
Charter (1996)

European Committee on Social Rights

African Charter on the Rights and Welfare of the Child(1999)

African Committee of Experts on the Rights andWelfare of the Child

Additional Protocol to the American Convention on Human
Rights in the Area of Economic, Social and Cultural Rights(“Protocol of San Salvador”) (1999)

Inter-American Commission on Human Rights

Protocol to the African Charter on Human and Peoples’
Rights on the Rights of Women in Africa (2005)

African Commission on Human and Peoples’ Rights

Arab Charter on Human Rights (2008)

Arab Human Rights Committee

Charter of Fundamental Rights of the European Union(2009)

General Court/European Court of Justice

Safe abortion: technical and policy guidance for health systems

123

Safe abortion: technical and policy guidance for health systems - Second edition

For more information, please contact:
Department of Reproductive Health and Research
World Health Organization
Avenue Appia 20, CH-1211 Geneva 27, Switzerland
Fax: +41 22 791 4171
E-mail: reproductivehealth@who.int
www.who.int/reproductivehealthISBN 978 92 4 154843 4

Safe abortion:technical and policy guidancefor health systems
Second edition