Chapter 3. Recommendations and best practice statements across the continuum of abortion care
Background (3.1, 3.1.1)
As a standard approach to human rights-based health care, all norms, standards and clinical practice related to abortion should promote and protect:
- individuals’ health and human rights
- informed and voluntary decision-making
- autonomy in decision-making
- non-discrimination (including intersectional discrimination) and equality
- confidentiality and privacy
- adequate referral mechanisms
- the continuum of care.
New and updated recommendations presented in this guideline were formulated by the expert panels formed for the development of this guideline, including expert human rights advisers (all contributors are listed in Annex 1, and the roles of the groups of contributors are described in Annex 4). The evidence was first systematically reviewed for each prioritized topic and question, using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology (24, 119), and the level of certainty of that evidence was assessed (i.e. based on the quality of the evidence, including the types and sizes of studies conducted and their various limitations).
The direction (in favour or against) and strength of each recommendation was determined by the panel of experts based on the six substantive criteria of the WHO-INTEGRATE framework as applied to each intervention for the specified population – 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 – while also taking into account the meta-criterion: quality of evidence (118). The methods are described in full in Annex 4, including the differences in the methods applied for the recommendations relating to law and policy issues (Recommendations 1,2,3,6,7,21,22) compared with the other types of recommendations. The full Evidence-to-Decision (EtD) frameworks are provided online as supplementary materials, and hyperlinked cross-references to these are supplied with the rationale for each new and updated recommendation presented.
Recommendations in favour of an intervention are qualified as either strong or weak (with the conditions of use specified for the latter), with the third alternative being a recommendation against the intervention. To clearly indicate the strength and direction of each recommendation, the following wording is used:
- Recommend – a strong recommendation in favour of the intervention
- Suggest – a weak recommendation in favour of the intervention (requiring additional wording to qualify the recommendation, specifying the conditions of use)
- Recommend against – a strong recommendation against the intervention/in favour of the comparison.
New and updated recommendations resulted from the review of the PICO questions (i.e. population, intervention, comparator, outcomes) that had been identified during the scoping meetings for this guideline. While 10 recommendations in this guideline are completely “new” (as labelled in the Executive summary table and in this chapter), updated recommendations are those that had been published in prior WHO guidance but had undergone an updated process of scoping, search and review of relevant evidence, application of the GRADE methodology and reconsideration of the WHO-INTEGRATE criteria for the purposes of this guideline, which may or may not have resulted in any substantive change to the strength, direction or substance of the recommendation (19, 23, 120). Finally, there are some existing recommendations that are carried forward unchanged from previous WHO guidance; in these cases, the topic had not been scoped prior to the development of this guideline and thus no new search or review was conducted or, in some cases, an updated literature search was conducted to review the current evidence base but did not lead to any change in the existing recommendation. 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 has been developed into seven separate recommendations using GRADE methodology, but they are not considered to be “new” (i.e. Recommendations 1,2,3,6,7,21,22). A summary table linking the topics covered, the research/PICO questions, the systematic reviews conducted and the recommendation numbers is provided in Annex 7.
3.1.1 Structure of information in this chapter
The information and recommendations in this chapter are presented in sections that reflect the continuum of abortion care and modes of service delivery: (i) services applicable across the continuum of care, (ii) pre-abortion, (iii) abortion, (iv) post-abortion, (v) service-delivery options and self-management approaches. In each section, the following aspects are covered as appropriate: “what” (specific clinical interventions), “who” (which type of health worker can provide the intervention, or self-management), “where” (facility-based versus off-site/remote service-delivery models/no requirement for on-site versus off-site location), and “how” (service-delivery models, implementation considerations). It should be noted that four recommendations relating to law and policy considerations are presented in the pre-abortion section (section 3.3), while three were presented in Chapter 2, section 2.2.
For each topic covered in this chapter, brief background information is first supplied, followed by the recommendation boxes or tables, providing information on the “what” and the “who” for the intervention in question. Each recommendation is immediately followed by a list of related remarks (if any) from the expert panel that reviewed the evidence in detail, explaining the conditions and context in which the recommendation applies. When appropriate, there is also a section indicating where the intervention can be carried out – in particular whether the intervention must be undertaken at a particular level of health-care facility, or whether there is no such requirement and an “off-site” location (e.g. at home, or other location) would be appropriate if preferred by the individual or if that is the only option available (the “where” is often closely tied to the “who”, e.g. tasks provided by pharmacists would be provided in a pharmacy). The remarks for existing unchanged recommendations are repeated from the original cited guidance where still relevant, including revisions as appropriate, based on the results of any relevant updated evidence reviews conducted.
For each of the new/updated recommendations, additional information is presented in the following order after the box presenting the recommendation(s) and remarks:
- Rationale: This includes a brief summary of the type and extent of the evidence included in the review(s) that form the evidence base, and an explanation of the rationale for the direction (for or against) and strength of the recommendation (strong or weak), with reference to the key judgements on effects of the intervention (benefits and risks), the level of certainty of the evidence and any relevant information on the other criteria of the WHO-INTEGRATE framework. Any additional evidence of potential harms or unintended consequences is highlighted. Such considerations may have been derived from studies and additional evidence that may not directly address the PICO question but provide pertinent information in the absence of direct evidence. This may be extracted from single studies, systematic reviews or other relevant sources.
- Implementation considerations: Points to bear in mind regarding implementation, including those relating to “how”.
Finally, in each topic section, a box is presented listing any key human rights considerations relevant to the recommendation or broader topic, as well as a box providing cross-references and hyperlinks to related topics within this guideline.
Full details for all related PICO questions can be found in Annexes 8, 9 and 10, and the summaries of the evidence (i.e. from the systematic reviews; listed in Annex 7) and the EtD frameworks relevant to each new or updated recommendation are made available online as supplementary material.
- The expert panels included the Evidence and Recommendations Review Groups (ERRGs) for each of the three domains (Law and policy, Clinical services and Service delivery) and later the Guideline Development Group (GDG), and each phase and each meeting of these groups also involved at least one human rights adviser. For further details of the roles of these groups and the full methodology for the guideline development process, see Annex 4: Methods. ↩
- EtD frameworks for this guideline can be accessed online: Supplementary material 1: EtD frameworks for law and policy topics here; Supplementary material 2: EtD frameworks for clinical service topics here; Supplementary material 3: EtD frameworks for service delivery topics here. ↩
- Existing recommendations are presented exactly as in previous guidance or with wording updated to use the wording “recommend/recommend against” for strong recommendations and “suggest” for weak recommendations (previously termed “conditional” recommendations), and reference is provided to the original guidance for further details. ↩