Chapter 1. Introduction
Guideline objective, rationale, target audience, inclusivity and structure (1.2, 1.2.1, 1.2.2, 1.2.3, 1.2.4)
Guidelines are the fundamental means through which WHO fulfils its technical leadership in health (24). WHO guidelines are subject to a rigorous quality assurance process that generates recommendations for clinical practice or public health policy with the aim of achieving the best possible individual or collective health outcomes. Towards this aim, WHO has made a commitment to integrate human rights into health-care programmes and policies at national and regional levels by looking at underlying determinants of health as part of a comprehensive approach to health and human rights.
1.2.1 Objective and rationale
The objective of this guideline is to present the complete set of all WHO recommendations and best practice statements relating to abortion, with the goal of enabling evidence-based quality abortion care globally.
This guideline updates and replaces the recommendations in the following previous WHO guidance:
- Safe abortion: technical and policy guidance for health systems, second edition (2012)
- Health worker roles in providing safe abortion care and post-abortion contraception (previously known as the “task sharing” guidance) (2015), and
- Medical management of abortion (2018).
This guideline is intended to provide concrete information and guidance, integrating aspects of care across all domains needed to provide quality abortion care: Law and policy, Clinical services and Service delivery. This guidance contains new recommendations consolidated with existing recommendations that remain unchanged and some that have been updated after re-assessment, using the same rigorous methods for both new and updated recommendations (see Annex 4: Methods). Among the recommendations are seven concerning the laws and policies that should or should not be in place, in order to fully implement and sustain quality abortion care: three recommendations relating to abortion regulation are presented in Chapter 2 and four more relating to laws and policies affecting clinical and health worker practices are presented in Chapter 3. All the other recommendations address methods of abortion and related clinical care as well as service delivery by a range of health workers and approaches, including self-management by the abortion seeker, reflecting recent changes in all these aspects of abortion care. Emerging areas of interest and research priorities in abortion care are identified in Chapter 4.
As a key part of the rationale for developing this updated and consolidated guideline, important contextual information – which is integral to this guidance, as context for the recommendations and best practice statements – is presented in the remainder of this first chapter. This information is not in the form of WHO recommendations but rather it describes the underlying determinants of quality abortion care, and thus must be carefully considered. Section 1.3 below describes an enabling environment for comprehensive abortion care (i.e. a law and policy framework supportive of human rights; access to information; and health system factors) and section 1.4 delves further into key health system considerations (universal health coverage and primary health care; health financing; health workforce training; health-care commodities; and monitoring and evaluation). Where relevant, this document incorporates and builds upon considerations captured in other existing WHO guidance, including Consolidated guideline on the sexual and reproductive health and rights of women living with HIV (25) and WHO consolidated guideline on self-care interventions for health: sexual and reproductive health and rights (26).
1.2.2 Target audience
This guidance seeks to provide recommendations for national and subnational policy-makers, implementers and managers of sexual and reproductive health (SRH) programmes, members of nongovernmental organizations and other civil society organizations and professional societies, as well as health workers and other stakeholders in the field of sexual and reproductive health and rights (SRHR), to support them in ensuring that evidence-based, quality abortion care is available and accessible globally.
1.2.3 Equity, inclusivity and people-centred care
The needs of all individuals with respect to abortion are recognized and acknowledged in this guidance. A human rights approach that advances gender equality is essential and must be applied in all contexts providing services to people seeking health care. To provide quality abortion care throughout the health system, services should also be integrated where possible with other SRH services, such as evidence-based HIV and sexually transmitted infection (STI) testing and treatment, and family planning/contraception, and should be friendly and welcoming to youth and people from sexual and gender minorities, people living with disabilities, and all groups in vulnerable and marginalized situations.
WHO guidelines systematically incorporate consideration of the values and preferences of end-users of the recommended or suggested interventions into the process of developing the guidance. To gain more in-depth understanding of the values and preferences of individuals seeking abortion care, WHO conducted a global survey and convened a technical meeting on this subject with stakeholders in September 2019 attended by 19 participants from 15 different countries/organizations. The key themes that emerged were the importance of equity, inclusivity and meeting the needs of those living in the most vulnerable and marginalized situations. In addition, a youth-led technical meeting was convened in April 2021 with 16 youths (representing 13 countries across all WHO regions) from the Youth for Abortion Task Force, to learn about the concerns of youth. The Task Force was formed by the International Youth Alliance for Family Planning (IYAFP) – a collective of young individuals, youth associations, organizations and communities with a common mission to support provision of and access to comprehensive reproductive health services (see Web annex B: Technical meetings during guideline development). Women living with HIV are one example among many of a marginalized population with unique vulnerabilities in the context of abortion care. Women living with HIV face unique challenges and are vulnerable to SRH-related human rights violations within their families and communities, as well as at health-care facilities where they seek care. An enabling environment is essential to promote more effective interventions and better health outcomes for all abortion seekers (see section 1.3).
All individuals have the right to non-discrimination and equality in SRH care and services. The right to be free from discrimination is stated in the Universal Declaration of Human Rights and in other universal human rights treaties and regional human rights instruments. It has been affirmed that the right to non-discrimination guaranteed by the International Covenant on Economic, Social and Cultural Rights (ICESCR) includes sexual orientation, gender identity and sex characteristics. The international human rights system has been strengthening the promotion and protection of human rights without distinction. The protection of persons based on their sexual orientation and gender identity are based on international law, complemented and supplemented by State practice (27). As stated in the 2018 report of the Independent Expert on protection against violence and discrimination based on sexual orientation and gender identity to the United Nations General Assembly, “The right to effective recognition of one’s gender identity is linked to the right to equal recognition before the law” (28, para. 20).
In this guideline, we recognize that most of the available evidence on abortion can be assumed to be derived from research among study populations of cisgender women, and we also recognize that cisgender women, transgender men, nonbinary, gender-fluid and intersex individuals with a female reproductive system and capable of becoming pregnant may require abortion care. To be concise and facilitate readability of this guideline, when referring to all gender diverse people who may require abortion care, we use the word “women” most often, although we also variously use the terms “individual”, “person” and “abortion seeker”. Providers of SRH services, including abortion care, must consider the needs of – and provide equal care to – all individuals; gender identity or its expression must not lead to discrimination.
This guideline takes an integrated, people-centred approach to health services (29). People-centred care requires that individuals have the education and support they need to make decisions and participate in their own health care (30). Individual health preferences may vary; no one model of abortion care will meet the needs of everyone seeking abortion care. The core values of dignity, autonomy, equality, confidentiality, communication, social support, supportive care, and trust are foundational to abortion care and are reflected throughout this guidance (31).
1.2.4 Conceptual structure of the guideline
As illustrated in Figure 1.1, this guideline is centred on the values and preferences of abortion seekers, and considers them as active participants in as well as beneficiaries of health services. This guidance emphasizes that – as a woman, girl or other pregnant person moves through the abortion care pathway (pre-abortion, abortion, post-abortion) – health services must be integrated within the health sector to ensure that service delivery meets their needs equitably and without discrimination. As each individual moves through this pathway, the guideline provides specific recommendations on the interventions needed (i.e. the “what”), and guidance on the individuals who may safely carry them out (i.e. the “who”). The guideline also provides information on the locations where services can be provided (i.e. the “where”) and outlines service-delivery models that can be used (i.e. the “how”). The enabling environment, described in the remainder of this chapter, provides the context for the effective implementation of these interventions.