1 Safe abortion : technical and policy guidance for Health systems - Second edition Safe abortion : technical and policy guidance For more information, please contact: Department of Reproductive Health and Research World Health Organization for Health systems Avenue Appia 20, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 4171. E-mail: Second edition ISBN 978 92 4 154843 4. Safe abortion : technical and policy guidance for 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).
2 WHO Library Cataloguing-in-Publication Data Safe abortion : technical and policy guidance for Health systems 2nd ed. , Induced - methods , Induced - standards. care - Organization and administration care - standards welfare policy Health Organization . ISBN 978 92 4 154843 4 (NLM classification: WQ 440). World Health Organization 2012. All rights reserved. Publications of the World Health Organization are available on the WHO web site ( ). or can be purchased from WHO Press, World Health Organization , 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press through the WHO web site ( ). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.)
3 Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in ii 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 gonadotrophin HIV human immunodeficiency virus HLD high-level disinfection ICPD International Conference on Population and Development IUD intrauterine device IV intravenous KCl potassium chloride LMP last menstrual period MVA manual vacuum aspiration NGO nongovernmental Organization PG prostaglandin Rh Rhesus (blood group).
4 RTI reproductive tract infection STI sexually transmitted infection UN United Nations UNFPA United Nations Population Fund UNPD United Nations Population Division USA United States of America WHO World Health Organization Safe abortion : technical and policy guidance for Health systems iii Definitions used in this document yy Medical methods of abortion (medical abortion ): use of pharmacological drugs to terminate preg- yy Duration or gestational age of pregnancy (gesta- nancy. Sometimes the terms non-surgical abor- tion): the number of days or weeks since the first tion or medication abortion are also used. day of the woman's last normal menstrual period (LMP) in women with regular cycles (for women yy Menstrual regulation: uterine evacuation without with irregular cycles, the gestational age may laboratory or ultrasound confirmation of preg- need to be determined by physical or ultrasound nancy for women who report recent delayed examination).
5 The first trimester is generally menses. considered to consist of the first 12 or the first 14 yy Osmotic dilators: short, thin rods made of sea- weeks of pregnancy (see Table 1). weed (laminaria) or synthetic material. After place- ment in the cervical os, the dilators absorb mois- ture and expand, gradually dilating the cervix. Table 1. Equivalent gestational ages in weeks and days during the first trimester yy Routes of misoprostol administration: Weeks of gestation Days of gestation oral pills are swallowed immediately;. <1 0 6. buccal pills are placed between the cheek 1 7 13. and gums and swallowed after 30 minutes;. 2 14 20. 3 21 27. sublingual pills are placed under the tongue and swallowed after 30 minutes;. 4 28 34. 5 35 41 vaginal pills are placed in the vaginal for- 6 42 48 nices (deepest portions of the vagina) and 7 49 55 the woman is instructed to lie down for 8 56 62 30 minutes. 9 63 69 yy Surgical methods of abortion (surgical abortion ): 10 70 76 use of transcervical procedures for terminat- 11 77 83 ing pregnancy, including vacuum aspiration and 12 84 90 dilatation and evacuation (D&E).
6 (See Chapter 2, 13 91 97 Section for a more detailed description of 14 98 104 methods of surgical abortion .). Adapted from: International statistical classification of diseases and Health related problems, 10th revision ICD-10, Vol. 2, Human Rights terminology 2008 Edition. Geneva, World Health Organization , 2009. yy International human rights treaty: also sometimes called a Covenant or a Convention, is adopted by the international community of States, normally at the United Nations General Assembly. Each treaty sets out a range of human rights, and cor- responding obligations which are legally binding on States that have ratified the treaty. Annex 7. includes a list of these treaties. iv Safe abortion : technical and policy guidance for Health systems yy Treaty monitoring body: each of the international human rights treaties is monitored by a desig- nated treaty monitoring body (see Annex 7). The treaty monitoring bodies are committees com- posed of independent experts.
7 Their main func- tion is to monitor the States' compliance with the treaty in question, including through the examina- tion of State reports. yy General comments/recommendations: a treaty monitoring body's interpretation of the content of human rights provisions on thematic issues or its methods of work. General comments seek to clarify the reporting duties of State parties with respect to certain provisions and suggest approaches to implementing treaty provisions. yy Concluding observations: following submission of a State report and a constructive dialogue with the State party to the particular convention, treaty monitoring bodies issue concluding observa- tions to the reporting State, which are compiled in an annual report and sent to the United Nations General Assembly. yy Regional human rights treaties: States adopted human rights treaties in Africa, the Americas, Europe and the Middle East. Regional human rights bodies, such as the African Union, the Organization of American States, the Council of Europe, the European Union, and the League of Arab States monitor States' compliance with the treaties.
8 To date, there are no regional human rights treaties in South-East Asia or the Western Pacific. Annex 7 includes a list of regional human rights treaties. yy Human rights standards: the meaning and scope of human rights as interpreted and applied by the human rights bodies tasked with this work, international, regional and national courts, and human rights committees. Safe abortion : technical and policy guidance for Health systems v vi Safe abortion : technical and policy guidance for Health systems CONTENTS. Executive summary 1. Process of guideline development 10. Background 10. Methods 10. Decision-making during the technical consultation 12. Document preparation and peer review 12. Dissemination of the guidance document 12. Updating the guidelines 13. Chapter 1 16. Safe abortion care: the public Health and human rights rationale 17. Background 17. Public Health and human rights 18. Pregnancies and abortions 19.
9 Health consequences of unsafe abortion 19. Contraceptive use, accidental pregnancies and unmet need for family planning 22. Regulatory and policy context 23. Economic costs of unsafe abortion 26. Chapter 2 30. Clinical care for women undergoing abortion 31. Pre- abortion care 32. Methods of abortion 37. Post- abortion care and follow-up 52. Chapter 3 62. Planning and managing safe abortion care 63. Introduction 64. Constellation of services 64. Evidence-based standards and guidelines 65. Equipping facilities and training Health -care providers 69. Monitoring, evaluation and quality improvement 72. Financing 79. The process of planning and managing safe abortion care 80. Safe abortion : technical and policy guidance for Health systems vii Chapter 4 86. Legal and policy considerations 87. Women's Health and human rights 87. Laws and their implementation within the context of human rights 90. Creating an enabling environment 98.
10 Annex 1 Research gaps identified at the technical consultation 105. Annex 2 Final GRADE questions and outcomes 106. Annex 3 Standard GRADE criteria for grading of evidence 109. Annex 4 Participants in the technical consultation 110. Annex 5 Recommendations from the technical consultation for the second edition of Safe abortion : technical and policy guidance for Health systems 113. Annex 6 Post- abortion medical eligibility for contraceptive use 120. Annex 7 Core international and regional human rights treaties 122. viii Safe abortion : technical and policy guidance for Health systems Executive summary Over the past two decades, the Health evidence, Safe abortion : technical and policy guidance for technologies and human rights rationale for providing Health systems (2). In this process, the WHO stand- safe, comprehensive abortion care have evolved ards for guideline development have been followed, greatly. Despite these advances, an estimated including: identification of priority questions and 22 million abortions continue to be performed outcomes; retrieval, assessment and synthesis of unsafely each year, resulting in the death of an evidence; formulation of recommendations; and plan- estimated 47 000 women and disabilities for an ning for dissemination, implementation, impact evalu- additional 5 million women (1).