Enabling access to quality abortion care: WHO's Abortion Care guideline
Authors: Caron R Kim, Antonella Lavelanet, Bela Ganatra
Journal: The Lancet Global Health (2022)

Fundamental to meeting the Sustainable Development Goals (SDGs) on health and wellbeing (SDG3) and gender equality (SDG5) is the recognition that access to sexual and reproductive health information and services is central to both individual and community health, as well as the realisation of human rights. Comprehensive abortion care, which includes information provision, abortion management, and post-abortion care, is an integral component of sexual and reproductive health and is a safe, simple health-care intervention that saves women's lives and safeguards their dignity and bodily autonomy. Globally, abortion remains common, with 30% (three out of ten) of all pregnancies ending in induced abortion.1Bearak J Popinchalk A Ganatra B et al.Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019.Lancet Glob Health. 2020; 8: e1152-e1161Summary Full Text Full Text PDF PubMed Scopus (155) Google Scholar However, estimates suggest that just over half (55%) of all abortions worldwide (and less than a quarter of all abortions in African and Latin America) can be considered as safe.2Ganatra B Gerdts C Rossier C et al.Global, regional, and subregional classification of abortions by safety, 2010-14: estimates from a Bayesian hierarchical model.Lancet. 2017; 390: 2372-2381Summary Full Text Full Text PDF PubMed Scopus (307) Google Scholar Barriers—such as the scarcity of accurate information or providers and facilities that can safely provide services, restriction of available methods of abortion, abortion-related stigma, high costs, third party consent and other legal restrictions—have made it difficult or impossible for many women to access abortion care, which can lead them to use unsafe methods and negatively affect their sexual and reproductive wellbeing and health. Fulfilling one of its core functions as a norms-setting agency, WHO has been providing recommendations related to abortion since 2003. With the release of the WHO Abortion Care guideline in March, 2022,3WHOAbortion care guideline.https://www.who.int/publications/i/item/9789240039483Date: March 9, 2022Date accessed: March 9, 2022Google Scholar WHO has consolidated and updated its recommendations, drawing on the evidence and data on the clinical, service delivery, legal, and human rights aspects of providing abortion care that have arisen over the past 10 years. In line with the WHO guideline process, formulation of recommendations by expert panels was based on available evidence and consideration of other criteria using the WHO-INTEGRATE framework.4Rehfuess EA Stratil JM Scheel IB Portela A Norris SL Baltussen R The WHO-INTEGRATE evidence to decision framework version 1.0: integrating WHO norms and values and a complexity perspective.BMJ Glob Health. 2019; 4e000844Crossref Google Scholar As a result, 54 evidence-based recommendations and two best practice statements focusing on the above-mentioned aspects of abortion care are presented in this updated guideline. While recognising that legal, regulatory, policy, and service-delivery contexts can vary from country to country, the WHO Abortion Care guideline aims to enable evidence-based decision making with respect to quality abortion care that is effective, efficient, accessible, acceptable, person-centred, equitable, and safe.5WHOQuality of care: a process for making strategic choices in health systems.https://apps.who.int/iris/bitstream/handle/10665/43470/9241563249_eng.pdf?sequence=1&isAllowed=yDate: 2006Date accessed: June 21, 2021Google Scholar The conceptual framework for abortion care in this guideline (figure) further recognizes and acknowledges the needs of all women, girls, and other pregnant individuals with respect to abortion, and is centred on the values and preferences of abortion seekers, considering them as autonomous agents—as well as beneficiaries—of health services. As demonstrated in the conceptual framework schematic (figure), quality abortion care exists within an enabling environment, which includes the availability and accessibility of information; a supportive, universally accessible, affordable, and well-functioning health system; and respect for human rights within a supportive framework of law and policy. Information should be accurate, non-biased, and evidence-based. The health system factors involve adequate resourcing of medicines and health products, workforce, and financial allocations with inclusion to universal health coverage schemes or health benefit packages. The recommendations concerning the laws and policies speak to the regulatory, policy, and programmatic barriers that hinder access to and timely provision of quality abortion care, including regulation through criminal law, grounds-based approaches, gestational age limits, mandatory waiting periods, third-party authorisation requirements, provider restrictions, and conscientious objection. Although no specific model of abortion care will meet the needs of everyone seeking an abortion, recommendations are presented through the continuum of care from pre-abortion to abortion and post abortion, moving through the what, who, where, and how of quality abortion care. While information and counselling are services noted throughout the continuum, clinical recommendations cover the what in pre-abortion (including services not recommended), the abortion itself, and post-abortion. Recommendations on the who reflect the broad range of health workers who can provide multiple components of abortion care, including the woman herself, with a dedicated section on self-management approaches. Furthermore, the guideline reflects the symbiotic relationship between her and the health workers, in their supportive role, and the various entry points to link to the health system. This idea is further emphasised in the where and how, with elements of abortion care that suggest care can take place in different locations and can be provided using various service delivery approaches, all of which can co-exist within any given context. Using this holistic approach to the provision of quality abortion care, the Abortion Care guideline carries a consistent message: access to quality abortion care is both a health and human rights issue. The recommendations and best practice statements in this guideline are only the first step and they still need to be operationalised and implemented. Achieving implementation of the recommendations and best practice statements, while keeping the woman at the centre of quality abortion care, will spur movement towards attaining the highest attainable standard of sexual and reproductive health. We declare no competing interests.