Chapter 3. Recommendations and best practice statements across the continuum of abortion care
Management of non-life-threatening complications: infection and haemorrhage: Recommendations 39-40 (3.5.3)
3.5.3 Management of non-life-threatening complications: infection and haemorrhage
Initial and basic management includes recognizing the complication, stabilizing the woman, providing oral or parenteral antibiotics and intravenous fluids prior to referral to an appropriate health-care provider/facility.
SERVICE DELIVERY Recommendation 39: Initial management of non-life-threatening post-abortion infection*
| Type of health worker | Recommendation | Rationalea |
|---|---|---|
| Traditional and complementary medicine professionals | Recommend | Although no direct evidence was found for the management of post-abortion infection by these health workers, their basic training covers the skills required for this task. 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 this option is feasible and that it has the potential to increase equitable access to post-abortion care. |
| Auxiliary nurses/ANMs Nurses Midwives Associate/advanced associate clinicians | Recommend | Although no direct evidence was found for the management of post-abortion infection by these health workers, the management of puerperal sepsis with intramuscular antibiotics, which requires similar skills, is within their typical scope of practice (138).b |
| Generalist medical practitioners Specialist medical practitioners | Recommend | Within their typical scope of practice,b therefore no assessment of the evidence was conducted. |
Note on updating of the recommendation: This was an existing recommendation for which evidence relating to traditional and complementary medicine professionals, pharmacists, pharmacy workers and community health workers was reviewed using GRADE methodology. After review, the recommendation was only upgraded for traditional and complementary medicine professionals, from “suggest” to “recommend.” For all other health worker categories reviewed, the recommendations remain “recommend against” (not listed). A summary of the evidence is presented in Supplementary material 3, EtD framework on Diagnosis and management of abortion-related complications.
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.
* For the pharmacists, pharmacy workers and community health workers, it is important that they are equipped with the knowledge to recognize signs and symptoms of this complication.
No requirement for location (on-site vs off-site).
Implementation considerations
- It is important that pharmacists, pharmacy workers and community health workers are equipped with the knowledge to recognize signs and symptoms of the complications of unsafe abortion and to know where to refer women in their communities.
- Restrictions on prescribing authority for some categories of providers may need to be modified or other mechanisms put in place for allowing such providers to administer the antibiotics within the regulatory framework of the health system.
SERVICE DELIVERY Recommendation 40: Initial management of non-life-threatening post-abortion haemorrhage*
| Type of health worker | Recommendation | Rationalea |
|---|---|---|
| Traditional and complementary medicine professionals | Recommend | No direct evidence was found for the management of post-abortion haemorrhage by these professionals, but their basic training covers the skills required for this task. The skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a |
| Auxiliary nurses/ANMs | Recommend | Although no direct evidence was found for the management of post-abortion haemorrhage by these health workers, the initial management of post-partum haemorrhage with intravenous (IV) fluids, which requires similar skills, is a task that these health workers are recommended to do (138). |
| Nurses Midwives Associate/advanced associate clinicians | Recommend | Although no direct evidence was found for the management of post-abortion haemorrhage by these health workers, the initial management of post-partum haemorrhage with IV fluids, which requires similar skills, is within their typical scope of practice (138). |
| Generalist medical practitioners Specialist medical practitioners | Recommend | Within their typical scope of practice,b therefore no assessment of the evidence was conducted. |
Note on updating of the recommendation: This was an existing recommendation for which evidence relating to traditional and complementary medicine professionals, pharmacists, pharmacy workers and community health workers was reviewed using GRADE methodology. After review, the recommendation was only upgraded for traditional and complementary medicine professionals, from “suggest” to “recommend”. For all other health worker categories reviewed, the recommendations remain “recommend against” (not listed). A summary of the evidence is presented in Supplementary material 3, EtD framework on Diagnosis and management of abortion-related complications.
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.
* For the pharmacists, pharmacy workers and community health workers, it is important that they are equipped with the knowledge to recognize signs and symptoms of these complications.
No requirement for location (on-site vs off-site).
Implementation consideration
- Initial management of haemorrhage and infection is also a signal function of basic emergency obstetric care (EmOC) and training and implementation can be integrated with EmOC services.
KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO NON-LIFE-THREATENING COMPLICATIONS
- Regardless of whether abortion is legal, States are required to ensure access to post-abortion care where it is needed.
- Post-abortion care must be available on a confidential basis, including in situations where abortion is illegal.
- Post-abortion care must be available without the threat of criminal prosecution or punitive measures. States must not require health workers to report persons suspected of undertaking unlawful abortion, or require them to provide any potentially incriminating information during or as a prerequisite to receiving post-abortion care.
For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.