CONTENTS

Annexes

Annex 4: Guideline development methods and process

A. Guideline development working groups

Please refer to Annex 1 for the names of members of each of the working groups (and declarations of interests). A summary of the key meetings held is provided at the end of this annex.

The WHO Guideline Steering Group

The WHO Guideline Steering Group led the guideline development process. Chaired by the WHO Department of Sexual and Reproductive Health and Research (SRH), it was composed of eight staff members from the Department, including seven from the Prevention of Unsafe Abortion (PUA) Unit and the Department’s human rights adviser. Gender, ethics, social accountability and human rights expertise among the Steering Group members ensured that key underlying principles were adequately reflected. The Steering Group members drafted the initial scope of the guideline; identified and drafted the priority questions in “PICO” format (population, intervention, comparator, outcome); and identified individuals to be invited to participate as guideline methodologists and as members of the Evidence Synthesis Teams (ESTs), the Evidence and Recommendation Review Groups (ERRGs), the Guideline Development Group (GDG) and the External Review Group (ERG) (see below). The members of these groups and the participation of other external contributors were only confirmed after completion of a process of declaration and management of any conflicts of interest, which was managed by the Steering Group in consultation with the Office of Compliance, Risk Management and Ethics (see section B). The Steering Group identified the chair of the GDG, and this was confirmed by the other GDG members. The Steering Group oversaw the work of the ESTs, organized the ERRG and GDG meetings, and drafted the recommendations based on the decisions of the ERRGs and GDG. The Steering Group did not determine or agree on the final recommendations as this was the role of the GDG. The Steering Group was responsible for drafting, revising and finalizing the guideline in collaboration with the ERRG, GDG and ERG members and other contributors, and for overseeing the publication and dissemination of the guideline and the development of related implementation tools. Finally, the Steering Group is responsible for monitoring new information and user needs and for determining when the guideline may need to be updated. The WHO Steering Group was supported by the wider WHO Secretariat, which included 19 WHO staff members and consultants from the SRH Department and other departments at WHO headquarters and representatives from WHO regional offices.

Guideline methodologists

The guideline methodologists worked closely with the WHO Steering Group and members of the Evidence Synthesis Teams (ESTs) to appraise the evidence from systematic reviews using GRADE methodology (see section D). In addition, the guideline methodologists oversaw all methodological issues and were responsible for the GRADE assessments of the certainty of the evidence. One guideline methodologist was appointed for the Clinical services domain and one for the Law and policy domain, while a team from Cochrane Response served this role for the Service delivery domain. [1] Appreciating that the public health impact of laws and policies is complex, that evidence related to law and policy is not a research area that lends itself to randomized controlled trials or comparative observational studies, and that this evidence cannot be readily synthesized using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, a pragmatic approach was applied (see details in section D).

Evidence Synthesis Teams (ESTs)

The ESTs planned and conducted the systematic reviews and prepared the GRADE Evidence-to-Decision (EtD) frameworks (which include evidence summaries, evidence profiles/tables and EtD tables). The ESTs comprised researchers from among WHO staff, consultants and fellows, as well as external collaborating research groups. For the Clinical services domain, the EST was formed of members of the Cochrane Fertility Regulation (CFR) Group, Family Planning fellows (WHO staff or interns), and the responsible technical officer from the Steering Group for this guideline. For the Service delivery domain, the EST comprised staff from Cochrane Response, Family Planning fellows (current and former WHO staff), and the responsible technical officer from the Steering Group. The CFR Group and Cochrane Response have updated their systematic reviews to provide the evidence base for many of the recommendations in these two domains. For the Law and policy domain, the EST included WHO consultants as well as external teams based at two centres:

  • The Policy Surveillance Program at the Center for Public Health Law Research (CPHLR), Temple University, Philadelphia, USA: Researchers within this programme created conceptual frameworks and legal mapping of the various interventions and the systems around them, and identified data for the empirical assessment of laws and policies.
  • Birmingham Law School, University of Birmingham, United Kingdom: The team in Birmingham provided expertise in health law and policy, human rights, comparative law, and global legal studies. This team conducted systematic reviews to provide the evidence base for the law and policy recommendations.

The Evidence and Recommendation Review Groups (ERRGs) and the Guideline Development Group (GDG)

Rather than having one Guideline Development Group (GDG) from the start of the guideline development process, for the development of this wide-ranging consolidated guideline, three separate ERRGs were formed – one for each of the three domains: Clinical services, Service delivery and Law and policy. For the final stage of the process, one GDG was formed comprising 3–4 members from each of the three ERRGs. The three ERRGs had 6–13 members representing all regions and a range of expertise, including one youth representative from the International Youth Alliance for Family Planning (IYAFP). The ERRG members were identified and invited by the WHO Steering Group, as were the human rights advisers who also contributed to the meetings by ensuring consideration of relevant human rights during recommendation formulation. Each ERRG undertook a detailed review of the evidence, formulated and agreed on draft recommendations during a series of 4–5 online meetings between March 2020 and March 2021. Prior to each meeting, background documents – the EtD frameworks and draft recommendations – were shared with the ERRG members. Consultations via email, Skype, Microsoft Teams, GoToMeeting and Zoom were conducted as needed in between meetings to ensure input was received from each ERRG member for each area under review.

In early 2021, representatives from each ERRG were invited by the WHO Steering Group to join the GDG for the final meeting in late April 2021, during which the draft recommendations from all three ERRGs were presented for review and finalization. The confirmed members of the GDG in turn confirmed the WHO Steering Group’s selection of a chair for the GDG. There were 18 GDG members (14 female, 4 male), representing all six WHO regions and a range of expertise, including a youth representative from IYAFP. A draft of the full guideline document, including the draft recommendations, was shared with all the GDG members to review in advance of the formal meeting, along with other relevant background documents (the EtD frameworks). During the meeting, the GDG reviewed and discussed the evidence and the draft recommendations, with the aim of reaching consensus on the certainty of the supporting evidence and the strength and direction of the new and updated recommendations (see Chapters 2 and 3). Subsequent to the GDG meeting, the members also had an opportunity to review the revised guideline document into which the decisions made during the GDG meeting had been integrated.

The External Review Group (ERG)

The WHO Steering Group, in consultation with the GDG, identified and confirmed nine technical experts and stakeholders with thematic area expertise relevant to the recommendations presented in this guideline to serve as members of the ERG. The ERG members were balanced in terms of geographic representation, and had no important conflicts of interest. Following the GDG meeting and the subsequent revisions to the draft guideline, the document was circulated to the ERG members. The role of the ERG members was to provide input regarding the accuracy, clarity of the language, implementation/adaptation considerations, and presentation of the guideline. The ERG also ensured that the GDG decision-making processes had considered and incorporated the contextual values and preferences of persons affected by the recommendations. Recommendations in the document, which had been finalized by the GDG, were not changed based on ERG input other than to improve clarity and readability, as needed. All comments from the ERG members were collated by the responsible technical officer and shared with the WHO Steering Group for review. No serious factual errors or concerns were identified that affected any of the recommendations or any major sections of the draft guideline.

Meeting observers and external partners

In accordance with guidance in the WHO handbook for guideline development, second edition
(2014), [2], representatives from a range of relevant professional organizations and United Nations agencies were invited to attend the GDG meeting in April 2021 as observers with no role in determining the recommendations (see Annex 1). The invited observers included the United Nations Population Fund (UNFPA), the Royal College of Obstetricians and Gynaecologists (RCOG), the International Federation of Gynecology and Obstetrics (FIGO), the International Confederation of Midwives (ICM) and the International Council of Nurses (ICN), and representatives from all attended except for ICN. In addition, a range of WHO/HRP’s implementing partner organizations were invited to review the draft guideline prior to submission to the GRC; these organizations included Ipas, the International Planned Parenthood Federation (IPPF), MSI Reproductive Choices, Pathfinder and Population Services International (PSI).

B. Management of declarations and conflicts of interests, and confidentiality

In accordance with the WHO handbook for guideline development, all invited members of the ERRGs, GDG, the ESTs, the ERG, and the GDG meeting observers, guideline reviewers representing implementing partner organizations, and other external contributors (e.g. consultants and collaborators) were asked to declare in writing any competing interests (academic, financial or other) at the time of invitation to participate in the guideline development or evidence review process. This was done by electronic submission of a signed WHO Declaration of Interests (DOI) form along with a copy of their curriculum vitae to the responsible technical officer prior to participation. In addition, internet searches were conducted on each invited member to assess any potential conflicts of interest that had not been disclosed. The management of conflicts of interest was explained to the invited participants, including the fact that no member would be allowed to participate in the meeting(s) if they failed to first complete and sign a DOI form.

The responsible technical officer assessed the DOI forms and CVs received with reference to the WHO handbook for guideline development, in consultation with the Director of the SRH Department and with the input of the WHO Steering Group, to determine the existence (and severity) of any conflict of interest, and agree upon a management plan. One conflict arose for one ERRG member during the course of guideline development, and this person thus did not attend any meetings thereafter. There were no other cases of any conflict of interest (this is also reported in the ERRG and GDG members lists in Annex 1).

Biographical information for all ERRG and GDG members deemed not to have significant conflicts of interest (i.e. conflicts that precluded their participation in the GDG) were posted on the WHO SRH Department’s website for public comment for at least two weeks before the start of the respective meetings, with their consent (in 2020 for the ERRGs and in 2021 for the GDG). ERRG and GDG members were confirmed once this process was completed. On confirmation of their eligibility to participate, all ERRG, GDG and ERG experts were instructed to notify the responsible technical officer of any change in relevant interests during the course of their participation in the process. At the start of each meeting, all ERRG and GDG participants had the opportunity to verbally confirm, append or amend any declared interests so that all fellow GDG members and other attendees were made aware. They had a similar opportunity to do the same in writing before submitting comments on draft versions of the guideline.

Finally, it should be noted that each member of the ERRGs, GDG, ERG, ESTs and each guideline methodologist was asked to sign a confidentiality agreement relating to the guideline development process and outcomes. In addition, the responsible technical officer securely stored all received electronic and printed hard copies of the signed DOI forms and curriculum vitae to ensure that confidentiality was maintained.

C. Scope of the guidance: defining topic areas and outcomes of interest

In September 2018, an online survey was undertaken to initiate the process of updating WHO guidance on safe abortion. The objectives of this survey were (i) to identify relevant areas that require an update or new areas that need to be added to the guidance and (ii) to generate suggestions for making the guidelines more user-friendly. The survey was distributed within various networks in the sexual and reproductive health field and resulted in 122 responses.

Thereafter, scoping meetings for each of the three domains (Clinical services, Service delivery, and Law and policy) were conducted with a range of experts, between November 2018 and June 2019. The purpose of these meetings was to determine the key topic areas that required formulation of key questions in the “PICO” format (population, intervention, comparator, outcomes) and to formulate and discuss these questions. The PICO questions were further reviewed, modified and finalized in the follow-up email exchanges between the WHO Steering Group and the ERRG members for each domain. The topic areas for the final PICOs of each domain, as determined during the scoping meetings, are provided in Box A below. The PICO questions for each domain are provided in Annexes 8, 9 and 10.

In addition to the scoping meetings, three technical meetings also focused on issues relating to abortion care in humanitarian settings (June 2019), values and preferences relating to abortion care (September 2019), and youth concerns relating to abortion care (April 2021) (further details on these meetings and issues are presented in Box B at the end of this annex and in the Web annex B: Technical meetings during guideline development).

Box A: Topic areas per domain for development of PICOs for new and updated recommendations

Law and policyCriminalization
Grounds-based approaches
Gestational age limits
Mandatory waiting periods
Third-party authorization
Restrictions on abortion providers
Conscientious objection by a health worker
Clinical servicesRh isoimmunization
Pain management for medical and surgical abortion and for cervical priming
Cervical priming prior to surgical abortion
Self-management of medical abortion (all subtasks)
Medical abortion using new methods (regimens including letrozole)
Medical management of missed abortion
Follow-up care or additional services after abortion
Service deliveryHealth workers providing services: self,community health workers, pharmacy workers, pharmacists, traditional and complementary medicine professionals, auxiliary nurses, auxiliary nurse midwives, nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners, specialist medical practitioners

Services:
• Provision of information on safe abortion
• Counselling across the continuum of care
• Cervical priming with medication and osmotic dilators prior to surgical abortion
• Surgical abortion (vacuum aspiration [VA] and dilatation and evacuation [D&E])
• Medical management of induced abortion (all subtasks; including self-management)
• Medical management of intrauterine fetal demise (IUFD)
• Medical and surgical management of incomplete abortion
• Initial management of non-life-threatening complications
• Initiation and continuation of injectable contraceptives (including self-injection)

Service-delivery methods:
• Community-based outreach models for provision of abortion care
• Medical abortion care provided through telemedicine
• Harm-reduction counselling on abortion care
• Social marketing methods for abortion services
• Self-sourcing of abortion medications online

D. Review of the evidence and formulation of recommendations

Defining and reviewing priority questions

The full list of PICO questions was confirmed during follow-up communications among the WHO Steering Group and the ERRG members after the scoping meetings for each domain, which were described in the previous section. All the PICO questions and related details are provided in Annexes 8, 9 and 10.

Systematic review methods (evidence retrieval)

A list of all reviews conducted for the development of this guideline is presented in Annex 7. Refer to the published systematic reviews and to the packages of supplementary materials online for information about the specific methods used, including search strategies. Refer to beginning of this annex for information about the Evidence Synthesis Teams (ESTs).

Sources for evidence relating to the PICOs of interest for the Clinical services and Service delivery domains included randomized controlled trials (RCTs) as well as non-randomized controlled trials, controlled before-and-after studies, interrupted time series and cohort studies. The following databases were searched from inception to December 2020, without language filters:

  • Global databases: ClinicalTrials.gov, Cochrane database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica database (Embase), POPLINE, PubMed.
  • Regional databases: African Index Medicus (AIM), Chinese Biomedical Literature Database, Global Index Medicus, Index Medicus for South-East Asia (IMSEAR), Index Medicus for WHO Eastern Mediterranean, Latin American and Caribbean Health Sciences Literature (LILACS), Western Pacific Regional Index Medicus.

In addition, a search of trial registry sites and organizational websites was conducted, and information from experts in the field was also used to identify any major ongoing or completed but unpublished trials that could be relevant to the guideline recommendations. Data from studies meeting the inclusion criteria were extracted using a standardized form and organized into Summary of Findings tables within the GRADE evidence summaries, using the online GRADE (Grading of Recommendations Assessment, Development and Evaluation) application.[3]

For the Law and policy domain, the primary databases searched included Google Scholar, JSTOR, Hein Online and PubMed, from 2010 to 2021. For this domain, in addition to RCTs and other types of studies, the reviews also included legal and policy analyses, regulatory documents, and legal and policy reviews.[4]

Assessment of the quality and certainty of the evidence for recommendations

In accordance with the WHO guideline development process, the GDG formulated the recommendations guided by the quality/certainty of the available evidence.[5] WHO has adopted the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to recommendation development, which defines the quality/certainty of evidence as the extent to which one can be confident that the reported estimates of effect (desirable or undesirable) available from the evidence are close to the actual effects of interest.[6] The GRADE approach specifies four levels of certainty of evidence, which should be interpreted as follows:

  • High – We are very confident that the true effect lies close to that of the estimate of the effect.
  • Moderate – We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
  • Low – Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
  • Very low – We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of the effect.

As a baseline, RCTs provide “high-quality” evidence, while non-randomized trials and observational studies provide “low-quality” evidence. This baseline quality rating may be downgraded based on consideration of study design limitations (risk of bias – assessed using the criteria outlined in the Cochrane handbook for systematic reviews of interventions along six domains)[7], inconsistency, imprecision, indirectness and publication bias. For observational studies, other considerations, such as magnitude of effect, could lead to upgrading of the rating if there are no limitations that indicated a need for downgrading. The EST members and guideline methodologists, in accordance with standard operating procedures approved by the WHO Steering Group, performed the grading of review evidence.

The GRADE approach to appraising the quality of quantitative evidence was used for all the critical outcomes identified in the PICO questions,[8] and a GRADE evidence profile (GRADE table) was prepared for each quantitative outcome within each PICO; these are presented in the supplementary materials available online.

With regard to the Law and policy domain, there was an existing composite recommendation in the 2012 Safe abortion guidance, which spoke to these issues and related interventions; the topics identified during the scoping process for this updated guideline (see Box A) stemmed from there. However, there was no existing standardized approach for assessing the quality or certainty of the evidence relating to laws and policies on abortion using a rights-based analysis.[9] Therefore, an innovative approach was developed to evaluate the evidence that effectively integrated human rights protection and enjoyment as part of health outcomes and analysis, while considering several important factors and their potential interactions.[10] This is in line with WHO’s norms and values, and thus underpins integrated evidence for application within an Evidence-to-Decision (EtD) framework.

The outcomes of interest for the Law and policy domain were informed by the conceptual frameworks and legal mapping initially performed by the EST team at Temple University (see section A), which mapped the various interventions and the systems around them and identified empirical research assessing the health effects of laws and policies. This mapping emphasized policy surveillance, advancing technology and methods for legal evaluation, teaching policy surveillance methods, and sharing credible scientific data with researchers, policy-makers and the public to make the case for laws that improve health. Next, the team developed causal logic models for the legal interventions on abortion to display plausible pathways from the implementation of the restriction to health and socioeconomic outcomes. The third step involved using the models as a guide to conduct a second rapid scan, in order to identify non-legal studies investigating whether the processes and outcomes posited in the models do, in fact, occur, and with what frequency and severity, and with what consequences. This evidence, in turn, supported plausible inferences of causality for practical policy and guideline development purposes. The Identifying Data for the Empirical Assessment of Law (IDEAL) method attempts to create an objective framework for crystallizing the various influences and consequences attributable to the impact of specific abortion restrictions, leading to the identification of untapped scientific evidence on plausible effects of the law.[11]

The quantitative evidence retrieved from all types of studies and documents was assessed for precision, directness and magnitude of effect, while the qualitative evidence was assessed for adequacy, and compiled in an EtD table. An overarching Rights Analysis Table, which identified human rights standards relevant to the specific interventions, was applied to the evidence table, leading to the development of a Human Rights to Evidence Table, organized by outcome of interest. The full methods are described in de Londras et al. (2021).[12]

Formulation of recommendations and determining the strength of recommendations

The WHO Steering Group supervised and finalized the preparation of evidence summaries, including GRADE tables and Summary of Findings tables, for each PICO question. For the Clinical services and Service delivery domains, the evidence summaries followed the new Evidence-to-Decision (EtD) framework, known as the WHO-INTEGRATE framework. This new framework is broader and better suited to system-level interventions. The six substantive criteria of the WHO-INTEGRATE framework are the following: balance of health benefits and harms; human rights and sociocultural acceptability; health equity, non-discrimination and equality; societal implications; financial and economic considerations; and feasibility and health system considerations. The additional meta-criterion is quality of evidence (i.e. type, size and limitations of the available studies used as evidence). The WHO-INTEGRATE framework allows for the fact that some interventions are complex and have multiple components interacting synergistically or dissynergistically, may be non-linear in their effects, or may be context dependent. This framework is better able to accommodate recommendation formulation for the Law and policy domain, as well as the Clinical services and Service delivery domains, thus allowing guideline users to make informed decisions on all interventions. Also integral to the recommendation formulation process across all domains is the values placed on the outcomes and the preferences of the women affected by the recommendations. Taking this into account along with all the criteria of the WHO-INTEGRATE framework, as applied to each intervention for the specified population, new and updated recommendations were formulated by the ERRG and GDG members and qualified as either strong (“recommend”) or weak (“suggest”; with specified conditions for application) recommendations in favour of the intervention, or as strong recommendations against the intervention/in favour of the comparator.

Recommendations were considered “new” (as labelled in the table at the end of the Executive Summary and in Chapter 3) if no recommendation existed in a previous WHO guideline on the specific topic or intervention in question for the specified population. In particular it should be noted that the 2012 Safe abortion guidance provided a composite recommendation related to law and policy; in this guideline, this was developed sinto seven separate recommendations, but they are not considered to be “new” (i.e. Recommendations 1,2,3,6,7,21,22).

E. Decision-making by the GDG during guideline development

The GDG meeting took place in April 2021 to review, revise and finalize the draft recommendations from all three domains that had been prepared by the ERRGs, as described above. Decision-making was based on discussion of the synthesized evidence and the use of the DECIDE Framework.[13] The final adoption of each recommendation was made by consensus, defined as full agreement among all GDG participants when at all possible – this is the preferred method. In one instance, voting was used since consensus could not be reached. The decision on how to present the medical abortion regimens was made based on the large majority voting in support of upholding the way it is described and presented in the previous guidelines. WHO staff attending the meeting, EST members, methodologists and meeting observers were not allowed to vote.

F. Compilation, review and presentation of the guideline content

The WHO responsible technical officer led the writing of the guideline with external/consultant writers, with significant input from the ESTs, the guideline methodologists and other members of the WHO Steering Group. In advance of the GDG meeting, an early draft of the full guideline document was prepared. The guideline methodologists drafted the GRADE evidence summaries and the WHO Steering Group members drafted corresponding Evidence-to-Decision (EtD) frameworks. The full draft and these supplementary materials were shared electronically with all GDG members (see Annex 1) two weeks before the GDG meeting, which was held during the last week of April 2021.

Following the GDG meeting, revisions were made to accurately reflect the deliberations and decisions of the GDG members on the recommendations and to incorporate their feedback on the draft. Subsequently, the revised draft guideline was shared electronically with all GDG members for two weeks for further comment. It was simultaneously shared for comment with all members of the External Review Group (ERG), the GDG meeting observers, and the representatives of implementing partner organizations (see section A and Annex 1), who were unconnected with the process of guideline development.

Next, the Steering Group carefully evaluated the written input of all the reviewers (via email and direct comments/edits on the draft document) for inclusion in the final guideline document and the revised version was reviewed by the director of the WHO SRH Department and edited for clarity. The final draft was submitted for review at a meeting of the WHO Guidelines Review Committee (GRC) and was fully approved by the GRC in August 2021 after some requested revisions had been completed.

Evidence derived from the systematic reviews in support of the new and updated recommendations was summarized in EtD frameworks to provide the evidence base on effectiveness that informed the new recommendations in this guideline. These EtD frameworks are presented separately in the three packets of supplementary materials available online:

Box B: Key meetings during guideline development (in Geneva, Switzerland, or online)

Scoping meetings: November 2018 – June 2019

Two-day scoping meetings were held for each of the three domains of this guideline, during which external experts on the subject areas and methodology (see Annex 1) identified the priority topics and the specific areas requiring new or updated recommendations or good practice statements.

  • Law and policy domain: Geneva, November 2018. This meeting facilitated discussion and the development of new approaches to guideline development for (i) abortion law and policy, and (ii) integration of human rights.
  • Clinical services domain: Virtual meeting, December 2018.
  • Service delivery domain: Geneva, June 2019.

Technical meetings:

(i) Implementation considerations for abortion care in humanitarian settings: A two-day technical meeting was held in Geneva in June 2019. This meeting convened approximately 20 experts in the fields of humanitarian aid, conflict settings, abortion care and human rights (including three youth representatives) together with 20 representatives from the WHO Secretariat. The expert participants came from nine countries in the regions of Africa, the Eastern Mediterranean, Europe and North America. During the meeting participants identified specific barriers and facilitating factors for implementation of safe abortion in humanitarian/emergency settings. Common barriers that were identified included: stigma, the role of social norms and values, the lack of clinical skills and knowledge, and perceived legal barriers. Practices that facilitate implementation of quality abortion care in these settings are: engagement with key stakeholders (in particular with community and religious leaders), developing a concrete implementation strategy with identification of potential entry points, and ensuring data collection and monitoring. For further details, see Web annex B: Technical meetings during guideline development.

(ii) Global abortion values and preferences: An online survey was prepared and disseminated in October and November 2018. In September 2019, a two-day technical meeting was convened in Geneva with a diverse range of stakeholders, including 19 participants from 15 different organizations/countries (including three youth representatives) and 8 members of the WHO Secretariat. For the first time, this was a meeting focused solely on unpacking the meaning of “values and preferences” in relation to abortion. By the end of the meeting, the information generated from the rich discussions formed a basis for the guideline development discussions on the values and preferences of women, which was one of the key criteria in the recommendation formulation process. For further details, including a summary of the literature review findings, see Web annex B: Technical meetings during guideline development.

(iii) Youth concerns relating to abortion care: For each of the scoping and technical meetings for this guideline, mentioned in this box, there were representatives from the International Youth Alliance for Family Planning (IYAFP) to provide a youth perspective, and one representative from IYAFP also served on each ERRG and one on the final GDG. In addition, a dedicated two-day technical meeting was held online in April 2021, bringing together 16 members of the IYAFP Youth for Abortion Taskforce which IYAFP had formed to support and inform the guideline development process, and 4 WHO staff members from the Preventing Unsafe Abortion (PUA) Unit of WHO’s Department of Sexual and Reproductive Health and Research. Participants included youths (up to age 30) with demonstrated leadership skills in the field of adolescent sexual and reproductive health and rights, representing 13 countries across the WHO regions. The meeting discussions centred around three key themes: youth’s values and preferences related to abortion services, addressing barriers and abortion stigma, and scaling up promising practices and interventions. Key issues discussed included the elements of an enabling environment and meaningful youth engagement. IYAFP members are developing a position paper as the main output of the meeting. For further details, see Web annex B: Technical meetings during guideline development.

Evidence and Recommendations Review Group (ERRG) meetings: March 2020 – March 2021

The ERRG meetings (4–5 meetings for each of the three domains) all occurred online, each one taking place across two days, facilitated by the WHO responsible technical officer and other members of the WHO Steering Group. At these meetings, members of the Evidence Synthesis Teams presented their systematic reviews of the evidence, and the ERRG members (see section A and Annex 1) discussed and reviewed the evidence and formulated draft recommendations, implementation considerations and good practice statements to be presented for further review, revision and finalization by the GDG.

  • Clinical services domain: March 2020, May 2020, June 2020, September 2020, February 2021
  • Service delivery domain: Pre-ERRG June 2020, October 2020, January 2021, early March 2021, late March 2021
  • Law and policy domain: March-April 2020, June 2020, August–September 2020, March 2021.

Guideline Development Group (GDG) meeting

Online, 27–30 April 2021. During the GDG meeting, the GDG members reviewed, discussed, revised and finalized the draft recommendations, implementation considerations and good practice statements from all three domains.

WHO Guidelines Review Committee (GRC) meeting

7 July 2021.

Footnotes

  1. Cochrane Response is an evidence consultancy business operated by the Cochrane Collaboration.  It provides tailored and responsive evidence services, and accessible review formats. ↩
  2. WHO handbook for guideline development, second edition. Geneva: World Health Organization; 2014 (https://apps.who.int/iris/handle/10665/145714) ↩
  3. GRADEpro GDT. GRADEpro Guideline Development Tool [Software] (developed by Evidence Prime, Inc.). McMaster University; 2020 (https://gradepro.org/) ↩
  4. de Londras F, Cleeve A, Rodriguez M, Lavelanet A. Integrating rights and evidence: a technical advance in abortion guideline development. BMJ Glob Health. 2021;6(2). ↩
  5. WHO handbook for guideline development, 2014. ↩
  6. Schünemann H, Brożek J, Guyatt G, Oxman A, editors. GRADE handbook for grading the quality of evidence and the strength of recommendations. The GRADE Working Group; 2013 (https://gdt.gradepro.org/app/handbook/handbook.html). ↩
  7. Each included study is assessed and rated to be at low, high or unclear risk of bias for sequence generation, allocation concealment, blinding of study personnel and participants, attrition, selective reporting and other sources of bias (Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, Welch V, editors. Cochrane handbook for systematic reviews of interventions, Version 6.2. The Cochrane Collaboration; 2021 [https://training.cochrane.org/handbook/current]). ↩
  8. Schünemann et al., editors, GRADE Handbook, 2013. ↩
  9. Rehfuess E, Stratil JM, Portela A, Baltussen R, Scheel IB, Norris SL. The WHO-INTEGRATE evidence to decision framework version 1.0: integrating WHO norms and values and a complexity perspective. BMJ Glob Health. 2019;4:e000844. ↩
  10. de Londras et al., 2021. ↩
  11. Burris S, Ghorashi AR, Cloud LF, Rebouché R, Skuster P, Lavelanet A. Identifying data for the empirical assessment of law (IDEAL): a realist approach to research gaps on the health effects of abortion law. BMJ Glob Health. 2021;6:e005120. doi:10.1136/bmjgh-2021-005120. ↩
  12. de Londras et al., 2021. ↩
  13. Evidence to Decision frameworks (EtDs) for policy makers [website]. Cochrane Norway; 2021 (https://www.cochrane.no/decide-frameworks-policy-makers). ↩

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