How to interpret this guideline?

Interpretation of the guideline recommendations
Recommended. The benefits of implementing this option outweigh the possible harms. This option can be implemented, including at scale.
Recommended in specific circumstances. The benefits of implementing this option outweigh the possible harms in specific circumstances. The specific circumstances are outlined for each recommendation. This option can be implemented under these specific circumstances.
Recommended in the context of rigorous research. There are important uncertainties about this option (related to benefits, harms, acceptability and feasibility) and appropriate, well designed and rigorous research is needed to address these uncertainties.
Recommended against. This option should not be implemented.
General considerations for guideline recommendations
  • The recommendations are intended to be implemented within the context of functioning mechanisms for referral, monitoring and supervision, as well as access to the necessary equipment and commodities.
  • The recommendations provide a range of options of types of health workers who can perform the specific tasks safely and effectively. The options are intended to be inclusive and do not imply either a preference for or an exclusion of any particular type of provider. The specific choice of health workers depends upon the needs and conditions of the local context.
  • It is assumed that any health worker discussed in this guideline has the basic training required of that type of health worker. In addition, the recommendations all assume that health workers will receive the training or information specific to the task, prior to the implementation of the recommendation option.

Lay health worker

For the purpose of this guideline, this refers to a person who performs functions related to health-care delivery/ information provision and was trained in some way in the context of the task, but has received no formal professional or paraprofessional certificate or tertiary education degree.

Pharmacy worker

For the purpose of this guideline, this refers to technicians and assistants who perform a variety of tasks associated with dispensing medicinal products under the guidance of a pharmacist. They inventory, prepare and store medications and other pharmaceutical compounds and supplies, and may dispense medicines and drugs to clients and instruct on their use as prescribed by health professionals.
Technicians typically receive 2–3 years training in a pharmaceutical school, with an award not equivalent to a university degree. Assistants have usually been through 2–3 years of secondary school with a subsequent period of on-the-job training or apprenticeship.

Pharmacist

For the purpose of this guideline, this refers to a health practitioner who dispenses medicinal products. A pharmacist can counsel on the proper use and adverse effects of drugs and medicines following prescriptions issued by medical doctors/health professionals. Education includes university-level training in theoretical and practical pharmacy, pharmaceutical chemistry or a related field.

Doctor of complementary systems of medicine

For the purpose of this guideline, this refers to a professional of traditional and complementary systems of medicine (non-allopathic physician) whose training includes a 4- or 5-year university degree that teaches the study of human anatomy, physiology, management of normal labour and the pharmacology of modern medicines used in obstetrics and gynecology, in addition to their systems of medicine. For the purpose of this guideline, these doctors are included with reference to the provision of elements of abortion-related care as per conventional medical practice.

Auxiliary nurse midwife and auxiliary nurse

For the purpose of this guideline, an auxiliary nurse is someone trained in basic nursing skills but not in nursing decision making. An auxiliary nurse midwife has basic nursing skills and some midwifery competencies but is not fully qualified as a midwife. The level of training may vary from a few months to 2–3 years. A period of on-the-job training may be included, and sometimes formalized in apprenticeships.

Nurse

For the purpose of this guideline, this refers to a person who has been legally authorized (registered) to practice after examination by a state board of nurse examiners or similar regulatory authority. Education includes 3 or more years in nursing school, and leads to a university or postgraduate university degree or the equivalent.

Midwife

For the purpose of this guideline, this refers to a person who has been registered by a state midwifery or similar regulatory authority and has been trained in the essential competencies for midwifery practice. Training typically lasts 3 or more years in nursing or midwifery school and leads to a university degree or the equivalent. A registered midwife has the full range of midwifery skills.

Advanced associate and associate clinician

For the purpose of this guideline, this refers to a professional clinician with basic competencies to diagnose and manage common medical and surgical conditions and also to perform some types of surgery. Training can vary by country, but generally requires 3–4 years post-secondary education in an established higher education institution. The clinician is registered and his or her practice is regulated by a national or subnational regulatory authority.

Non-specialist doctor

For the purpose of this guideline, this refers to a medical doctor who holds a university-level degree in basic medical education with or without further training in general practice or family medicine, but not in obstetrics and gynecology.

Specialist doctor

For the purpose of this guideline, specialization refers to postgraduate clinical training and specialization in obstetrics and gynecology.

Management of abortion and post-abortion care in the first trimester

Vacuum aspiration for induced abortion

Vacuum aspiration for induced abortion

The provision of vacuum aspiration includes the assessment of gestational age, cervical priming (if needed), the actual procedure, pain management including the provision of a paracervical block (if needed) and the assessment of completeness of abortion through the visual inspection of products. Health workers with the skills to perform a bimanual pelvic examination to diagnose and date a pregnancy, and to perform a transcervical procedure such as intrauterine device (IUD) insertion, can be trained to perform vacuum aspiration.

Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended in specific circumstances
Recommended in specific circumstances
Recommended
Recommended
Recommended
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 
Vacuum aspiration for management of uncomplicated incomplete abortion / miscarriage

Vacuum aspiration for management of uncomplicated incomplete abortion / miscarriage

Managing uncomplicated incomplete abortion with MVA/EVA (when uterine size is less than 13 weeks) includes recognizing the condition, assessing uterine size, the actual procedure and pain management. Uncomplicated incomplete abortion can result after an induced or spontaneous abortion (i.e. miscarriage). The management is identical and the recommendations apply to both situations.
Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended in specific circumstances
Recommended in specific circumstances
Recommended
Recommended
Recommended
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 
Medical abortion in the first trimester

Medical abortion in the first trimester

Medical abortion (MA) refers to the sequential use of mifepristone followed by misoprostol or, in settings where mifepristone is not available, the use of misoprostol alone. The specific dosage, routes and regimens are different at differing pregnancy durations. See Clinical practice handbook for safe abortion for further details.

MA is a process that takes place over a period of several days rather than being a discrete procedure. It includes several components or subtasks:

  • assessing eligibility for MA (diagnosing and dating the pregnancy, ruling out medical contraindications, screening for possible ectopic pregnancy);
  • administering the medications with instructions on their appropriate use and managing the common side-effects;
  • assessing that the abortion process is complete and that no further intervention is required.

One health worker can provide the entire package, but it is equally possible for the subtasks to be performed by different health workers and at different locations.

No recommendation on the full independent provision
Recommended against
No recommendation on the full independent provision
Recommended in specific circumstances
Recommended
Recommended
Recommended
Recommended
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 
Management of uncomplicated incomplete abortion/miscarriage with misoprostol

Management of uncomplicated incomplete abortion/miscarriage with misoprostol

Managing uncomplicated incomplete abortion with misoprostol (when uterine size is up to 13 weeks) includes recognizing the condition, assessing uterine size and administering oral or buccal misoprostol in the correct dose.

Recommended in the context of rigorous research
Recommended against
Recommended against
Recommended in specific circumstances
Recommended
Recommended
Recommended
Recommended
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 

Management of abortion and post-abortion care beyond 12 weeks

Provision of dilation and evacuation (D&E) for pregnancies beyond 12 weeks

Provision of dilation and evacuation (D&E) for pregnancies beyond 12 weeks

Dilatation and evacuation (D&E) is the surgical method for abortion after 12 – 14 weeks of pregnancy. The provision of D&E includes the preparation of the cervix, pain management including the provision of paracervial block , the procedure itself, and the assessment of completeness of abortion through the visual inspection of products.

Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against
Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended in the context of rigorous research
Recommended
Recommended (considered within typical scope of practice)
 
Cervical priming with osmotic dilators prior to dilation and evacuation (D&E)

Cervical preparation with osmotic dilators is recommended for all women undergoing dilation and evacuation(D&E). Cervical priming is not mandatory at lower pregnancy duration but it can be used.

Osmotic dilators are placed 6 – 24 hours prior to the procedure. As such, placement can be performed by a health professional other than the provider who will conduct the D&E.

Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against
Recommended against
Recommended in specific circumstances
Recommended in specific circumstances
Recommended in specific circumstances
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 
Cervical priming with medications prior to dilation and evacuation (D&E)

Cervical preparation with medications is recommended for all women undergoing dilation and evacuation (D&E). Cervical priming is not mandatory at lower pregnancy duration but it can be used.

If mifepristone is used, it is given orally 24 – 48 hours before the procedure; if misoprostol is being used it is given sublingually or vaginally 2 – 3 hours before. Thus it is possible for priming to be initiated by a provider other than the one performing the D&E.

Recommended against
Recommended against
Recommended against
Recommended in specific circumstances
Recommended in specific circumstances
Recommended in specific circumstances
Recommended in specific circumstances
Recommended in specific circumstances
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 
Provision of medical abortion beyond 12 weeks

Provision of medical abortion beyond 12 weeks

The provision of medical abortion using mifepristone and misoprostol (or misoprostol alone in settings where mifepristone is not available) for pregnancies beyond 12 weeks is a facility-based procedure and women should remain under observation until the process is complete. The specific dosage, routes and regimens are detailed here in the Clinical practice handbook for safe abortion .

Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against
Recommended against
Recommended in specific circumstances
Recommended in specific circumstances
Recommended in specific circumstances
Recommended
Recommended (considered within typical scope of practice)
 

Management of non-life-threatening complications

Initial management of non-life threatening post-abortion infection

Initial management of non-life threatening post-abortion infection

Initial and basic management includes recognizing the complication, stabilizing the woman, providing oral or parenteral antibiotics and intravenous fluids prior to referral to an appropriate health-care provider/facility to provide definitive care.

Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended in specific circumstances
Recommended
Recommended
Recommended
Recommended
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 
Initial management of non-life-threatening post-abortion haemorrhage

Initial management of non-life-threatening post-abortion haemorrhage

Initial and basic management includes recognizing the complication, stabilizing the woman, providing oral or parenteral antibiotics and intravenous fluids prior to referral to an appropriate health-care provider/facility to provide definitive care.

Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended in specific circumstances
Recommended
Recommended
Recommended
Recommended
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 

Provision of post-abortion contraception

Insertion and removal of an intrauterine device

Insertion and removal of an intrauterine device

Contraception can be initiated immediately post-abortion and all contraceptive options may be used. Criteria laid out in the Medical eligibility criteria for contraceptive use and principles of voluntary contraceptive provision within a human rights framework should be adhered to.

Recommended against
Recommended against
Recommended against
Recommended in specific circumstances

Recommended (auxiliary nurse midwives)

Recommended within the context of rigorous research (auxiliary nurses)

Recommended
Recommended
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 
Initiation and continuation of injectable contraceptives

Initiation and continuation of injectable contraceptives

Contraception can be initiated immediately post-abortion and all contraceptive options may be used. Criteria laid out in the Medical eligibility criteria for contraceptive use and principles of voluntary contraceptive provision within a human rights framework should be adhered to.

Recommended in specific circumstances
Recommended in specific circumstances
Recommended
Recommended in specific circumstances
Recommended
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 
Insertion and removal of implants

Insertion and removal of implants

Contraception can be initiated immediately post-abortion and all contraceptive options may be used. Criteria laid out in the Medical eligibility criteria for contraceptive use and principles of voluntary contraceptive provision within a human rights framework should be adhered to.

Recommended in the context of rigorous research
Recommended against
Recommended against
Recommended in specific circumstances
Recommended in specific circumstances
Recommended
Recommended
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 
Tubal ligation

Tubal ligation

Contraception can be initiated immediately post-abortion and all contraceptive options may be used. Criteria laid out in the Medical eligibility criteria for contraceptive use and principles of voluntary contraceptive provision within a human rights framework should be adhered to.

Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against (considered outside of typical scope of practice)
Recommended against
Recommended in the context of rigorous research
Recommended in the context of rigorous research
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 

Pre- and post-abortion counseling

Pre- and post-abortion counselling

Pre- and post-abortion counselling

The provision of scientifically accurate and easy-to-understand information to all women undergoing an abortion, and non-directive voluntary counselling to women who request it, is a core element of good quality abortion services. Comprehensive contraceptive information and services should be routinely integrated with abortion and post-abortion care.

Counselling refers to a focused, interactive process through which the woman voluntarily receives support, information and non-directive guidance from a trained person. It requires a much higher level of specific knowledge than providing general information about safe abortion care.

Recommended in specific circumstances
Recommended against
Recommended against
Recommended in specific circumstances
Recommended
Recommended
Recommended
Recommended
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 

Provision of information on safe abortion

Information on safe abortion

Information on safe abortion

The provision of general information related to safe abortion care, for example: where and how to obtain methods of contraception; where and how to obtain safe, legal abortion services and cost information; specifics of local laws; and the importance of seeking care early. This information could be provided to women seeking these services but also to other women or men.

Recommended
Recommended in specific circumstances
Recommended
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
Recommended (considered within typical scope of practice)
 

* considered within typical scope of practice; evidence not assessed

** considered outside of typical scope of practice; evidence not assessed.

Self Management

Self-management of the medical abortion process in the first trimester

Given the nature of the medical abortion (MA) process, it is possible for women to play a role in managing some of the components by themselves outside of a health-care facility. Such self-assessment and self-management approaches can be empowering for women and help to triage care, leading to a more optimal use of health resources.

Role of self-management of medical abortion in the first trimester by WOMEN

Recommendation: No recommendation on the full independent management of medical abortion.

Recommendations were made for the following subtasks:

Self-assessing eligibility for medical abortion
Recommended within the context of rigorous research
Research needs: Further research is required to develop appropriate assessment tools.
Managing the mifepristone and misoprostol medication without direct supervision of a health-care provider
Recommended in circumstances where women have a source of accurate information and access to a health-care provider should they need or want it at any stage of the process.
 
Self-assessing completeness of the abortion process using pregnancy tests and checklists
Recommended in circumstances where both mifepristone and misoprostol are being used and where women have a source of accurate information and access to a health-care provider should they need or want it at any stage of the process.
Research needs: The efficacy of MA is lower when misoprostol alone is used; hence the self-assessment of completeness when misoprostol alone is used requires further research.

Additional remarks: A follow-up visit after MA using mifepristone-misoprostol is not mandatory.

Available evidence for managing the medications and process without direct supervision of the provider is for pregnancy durations of nine weeks (63 days or less).

Self-management approaches reflect an active extension of health systems and health care. These recommendations are NOT an endorsement of clandestine self-use by women without access to information or a trained health-care provider/health-care facility as backup. All women should have access to health services should they want to need it.

Implementation considerations: Mechanisms to ensure access and linkages to post-abortion contraception services need to be established.

Self-administration of injectable contraception

Contraception can be initiated immediately post-abortion and all contraceptive options may be used. Recommendations are made on the self-administration of injectable contraceptives by women themselves.

Recommendation: Recommended in contexts where mechanisms to provide the woman with appropriate information and training exist, referral linkages to a health-care provider are strong and where monitoring and follow-up can be ensured.

Additional remarks: The administration of an injectable contraceptive involves using a standard syringe and may be intramuscular or subcutaneous. Compact pre-filled auto-disable devices may be used as well but are still not widely available.

Implementation considerations: The following are important considerations when making the self-injection option available:

  • adequate arrangements for storage and for keeping sharps safely at home;
  • training in and the provision of mechanisms for the safe and safe and secure disposal of used injectable contraceptives (especially in settings with high HIV prevalence);
  • ensuring a way to procure injectable contraceptives on a regular basis without needing to repeatedly visit a health-care facility.