Chapter 3. Recommendations and best practice statements across the continuum of abortion care
Abortion management is needed for both induced and spontaneous abortion, including for clinical indications such as missed abortion and intrauterine fetal demise (fetal death).
Recommended management options include medical management, or surgical management using manual or electric vacuum aspiration (MVA or EVA) or dilatation and evacuation (D&E). The method of surgical abortion would depend on gestational age: generally vacuum aspiration at < 14 weeks of gestation and D&E at ≥ 14 weeks, but there is flexibility in the use of these methods between 12 and 16 weeks. Medical abortion regimens include sequential use of mifepristone followed by misoprostol or, in settings where mifepristone is not available (or is restricted for certain clinical indications), the use of misoprostol alone. A new alternative medical method, in particular using letrozole in combination with misoprostol, is also available.
For missed abortion and intrauterine fetal demise (see sections 3.4.5 and 3.4.6), in addition to the options of medical and surgical management, expectant management can be offered as an option on the condition that the woman is first informed of the longer time for expulsion of the pregnancy tissue and the increased risk of incomplete emptying of the uterus (the same applies in the case of incomplete abortion, which is addressed in section 3.5.2 on post-abortion care).
Medical abortion care for all indications plays a crucial role in providing wider access to safe, effective and acceptable abortion care. This may increase the availability and accessibility of abortion and realization of the right to SRH. Across all resource settings, the use of medical abortion has contributed to the expansion of health worker roles, more efficient use of resources and reduced maternal mortality and morbidity from unsafe abortions. Moreover, medical abortion – particularly in early pregnancy – can now be provided at the primary-care level and on an outpatient basis, or from a pharmacy, which further increases access to abortion care. Medical abortion care reduces the need for skilled surgical abortion providers and offers a non-invasive and highly acceptable and safe option to pregnant women. As a matter of international human rights law, States must provide essential medicines listed under WHO’s Action Programme on Essential Drugs, which include abortion medicines (46, para. 12a).
The recommendations presented below address surgical and medical management of abortion. Implementation of all of the recommendations in this section are conditional upon women’s values and preferences, the acceptability of each intervention, and the availability of resources to provide the chosen method safely. It should be noted that a woman’s choice of method for abortion management may be limited or not applicable if she has medical contraindications to one of the methods. The recommendations below relate only to the method of abortion, and should not be read as suggesting gestational age limits for the availability of abortion.