Chapter 3. Recommendations and best practice statements across the continuum of abortion care

Methods of surgical abortion: Recommendations 23-26 (3.4.1)

3.4.1 Methods of surgical 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 and the assessment of completeness of abortion through the visual inspection of products of conception. 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 methods of surgical abortion at later gestational ages are vacuum aspiration and dilatation and evacuation (D&E). Although the recommendations in this section indicate differences before and after 14 weeks of gestation, it should be noted that there is flexibility in the use of one surgical method versus the other between the gestational ages of 12 and 16 weeks.

CLINICAL SERVICES Recommendation 23: Vacuum aspiration for induced abortion at gestational ages < 14 weeks

For surgical abortion at < 14 weeks:

a. Recommend vacuum aspiration.

b. Recommend against the practice of dilatation and sharp curettage (D&C), including sharp curette checks (i.e. to “complete” the abortion) following vacuum aspiration.

Remarks:

  • Observational studies indicate that vacuum aspiration is associated with fewer complications than D&C; however, randomized controlled trials were underpowered to detect a difference in complication rates.
  • No evidence supports the use of sharp curette checks following vacuum aspiration.
  • The quality of the evidence based on randomized controlled trials is low to moderate.

Source: Recommendation 1 carried forward from WHO (2012) (19). Some of the wording has been revised, and the gestational age range has been changed from “up to 12 to 14 weeks” to “before 14 weeks” (< 14 weeks).

SERVICE DELIVERY Recommendation 24: Vacuum aspiration for induced abortion at gestational ages < 14 weeks

Type of health worker Recommendation Rationalea
Traditional and complementary medicine professionals Recommend Very low-certainty evidence was found for the effectiveness of this option for components of the task (e.g. assessing uterine size with bimanual examination as part of medical abortion provision). The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a These professionals perform transcervical procedures (e.g. IUD insertion) in some settings. The expert panel affirmed that the benefits outweigh possible harms and this option has the potential to increase equitable access to quality abortion care in regions where these professionals constitute a significant proportion of the health workforce.
Auxiliary nurses/ANMs Suggest

Condition: In contexts where established health system mechanisms involve auxiliary nurses/ANMs in providing basic emergency obstetric care, and where referral and monitoring systems are strong.

Although insufficient direct evidence was found for the safety and effectiveness of this option, the benefits outweigh any possible harms. This option has been shown to be feasible, including at scale in low-resource settings, and has the potential to decrease inequities by extending quality abortion care to rural and underserved populations.
Nurses Recommend Evidence was found for the safety and effectiveness (low certainty) and for women’s satisfaction (low certainty) with this option. Women often consider care received from nurses as more supportive compared with other health workers (moderate-certainty evidence). This option is feasible and may decrease inequities by extending quality abortion care to underserved populations.
Midwives Recommend This task is recognized as a core competency in midwifery.a Evidence was found for the safety and effectiveness (moderate certainty) and for women’s satisfaction with the overall abortion experience (low certainty) with this option. Women often consider care received from midwives as more supportive compared with other health workers (moderate-certainty evidence). This option has been shown to be feasible, including in low-resource settings.
Associate/advanced associate clinicians Recommend Evidence was found for the safety and effectiveness (moderate certainty) and for women’s satisfaction with the overall abortion experience (low certainty) with this option. This option is feasible in all resource settings, and may decrease inequities by extending quality abortion care to underserved populations.
Generalist medical practitioners Specialist medical practitioners Recommend Within their typical scope of practice,b therefore no assessment of the evidence was conducted.
Source: Recommendation updated from WHO (2015) (23).

Note on updating of the recommendation: This was an existing recommendation for which evidence relating to traditional and complementary medicine professionals, auxiliary nurses and auxiliary nurse midwives was reviewed using GRADE methodology. After review, only the recommendation for traditional and complementary medicine professionals was upgraded, from “suggest” to “recommend”; the recommendations for all the other health worker categories remained unchanged. A summary of the evidence is presented in Supplementary material 3, EtD framework for Vacuum aspiration for all indications < 14 weeks.

a For this and all health worker recommendations, given the limited evidence for many of the health worker–task combinations, the discussions of the expert panel focused on the competency framework in WHO’s 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women’s values and preferences.

b For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.

In a health-care facility. Both types of vacuum aspiration can be performed in a primary care facility and on an outpatient basis.

Implementation considerations
  • While MVA is more commonly used and more likely in primary care settings, the skills required for EVA are similar, thus the recommendations above apply to the provision of either form of vacuum aspiration.
  • MVA is used earlier in pregnancy and in the absence of access to a stable source of electricity.
  • Dilatation and sharp curettage (D&C) should be replaced with MVA.

CLINICAL SERVICES Recommendation 25: Methods of surgical abortion at gestational ages ≥ 14 weeks

For surgical abortion at ≥ 14 weeks: Recommend dilatation and evacuation (D&E).

Remark:

  • Vacuum aspiration can be used during a D&E (i.e. for the purpose of amniotomy or tissue removal at the end of the D&E).

Source: Recommendation 5 carried forward from WHO (2012) (19). The wording has been revised to use the word “recommend” to indicate that this is a strong recommendation, and the gestational age has been changed from “over 12 to 14 weeks” to “14 weeks and above” (≥ 14 weeks), and medical methods were removed (medical methods at later gestational ages are covered in Recommendation 29 in this guidance).

SERVICE DELIVERY Recommendation 26: Dilatation and evacuation (D&E) for surgical abortion at gestational ages ≥ 14 weeks

Type of health worker Recommendation Rationalea
Traditional and complementary medicine professionals Suggest

Condition: In settings where established health system mechanisms exist to include these health workers in other tasks related to maternal and reproductive health.

Although no direct evidence was found for the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a This type of health worker has been suggested (weak recommendation) to do other transcervical procedures, such as cervical priming with osmotic dilators, vacuum aspiration and inserting an IUD (see Recommendations 20, 24 and 43). The expert panel affirmed that this option has the potential to increase equitable access to quality abortion care in regions where these professionals constitute a significant proportion of the health workforce.
Midwives Suggest

Condition: In settings where established health system mechanisms exist to include these health workers in other tasks related to maternal and reproductive health.

Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a This type of health worker has been recommended to do other transcervical procedures, such as cervical priming with osmotic dilators, vacuum aspiration and inserting an IUD (see Recommendations 20, 24 and 43).
Associate/advanced associate clinicians Suggest

Condition: In settings where established health system mechanisms exist to include these health workers in other tasks related to maternal and reproductive health.

Although no direct evidence was found on the safety or effectiveness of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a The expert panel affirmed that the potential benefits outweigh the possible harms, and this option has the potential to increase equitable access to quality abortion care beyond 14 weeks of gestation.
Generalist medical practitioners Recommend No direct evidence was found on the safety or effectiveness of this option as compared with provision by specialist medical practitioners. However, it appears to be feasible in both high- and low-resource settings where D&E use is common. Such doctors routinely perform other surgical procedures, such as caesarean section, vacuum aspiration and tubal ligation. The potential benefits of this option outweigh the harms. A specialist provider may not always be available on-site and this option may therefore increase equitable access to quality abortion care.
Specialist medical practitioners Recommend Within their typical scope of practice,b therefore no assessment of the evidence was conducted.
Source: Recommendation updated from WHO (2015) (23).

Note on updating of the recommendation: This was an existing recommendation for which evidence relating to associate/advanced associate clinicians (previously only suggested in the context of rigorous research), midwives and traditional and complementary medicine professionals (both previously recommended against) was reviewed using GRADE methodology. After review, the recommendations were upgraded for all of them to a weak recommendation (“suggest”). The gestational age range was also amended from “beyond 12 weeks” to “14 weeks and above” (≥ 14 weeks) to align with Recommendation 25 on this topic. A summary of the evidence is presented in Supplementary material 3, EtD framework for D&E for surgical abortion ≥ 14 weeks.

a For this and all health worker recommendations, given the limited evidence for many of the health worker–task combinations, the discussions of the expert panel focused on the competency framework in WHO’s 2011 publication, Sexual and reproductive health: core competencies in primary care (121), which provides information on the competencies (including skills and knowledge) required for each task, and also the WHO-INTEGRATE criteria, in particular on the feasibility, equity and acceptability of the intervention and women’s values and preferences.

b For typical scope of work/practice, please refer to Annex 5: Health worker categories and roles.

In a health-care facility. The procedure can be provided on an outpatient basis.

Implementation considerations
  • For all providers, skills needed for D&E provision are greater than for a vacuum aspiration done in earlier pregnancy and training needs are higher.
  • D&E includes the use of vacuum aspiration and therefore skills and knowledge of vacuum aspiration are relevant for this task.
  • Health workers providing abortion or caring for women undergoing abortion at gestational ages ≥ 12 weeks may have additional needs for professional and mentoring support.

KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO SURGICAL ABORTION

  • Health-care facilities, commodities and services must be available, accessible, acceptable and of good quality. This means they must be evidence-based and scientifically and medically appropriate and up to date.
  • AT < 14 WEEKS OF GESTATION: As dilatation and sharp curettage (D&C) causes pain and suffering to women and is not recommended for use, its use is incompatible with numerous human rights including the right to health.
  • AT ≥ 14 WEEKS OF GESTATION: States must ensure adequate access to essential medicines in an affordable and non-discriminatory manner.

For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.