Chapter 3. Recommendations and best practice statements across the continuum of abortion care
Law & policy Recommendation 21: Provider restrictions (3.3.8)
3.3.8 Restrictions (in law or policy) on health workers who may lawfully provide abortion care
In a number of countries, law and policy restrict which type of health workers may lawfully provide abortion care (137), most often limiting this to gynaecologists. Since the advent of vacuum aspiration and medical abortion, however, abortion can be safely provided by a wide range of health workers in diverse settings, and safely self-managed in earlier pregnancy (see Recommendations 24, 28, 30, 33). Provider restrictions are inconsistent with WHO’s support for the optimization of the roles of health workers; such restrictions are arbitrary and not evidence based (138). Reflecting States’ obligation to respect, protect and fulfil the right to health, health-care facilities, goods and services must be available, accessible, adequate and of good quality (46). This includes facilities, goods and services for SRH care. Thus, States must ensure an adequate number of medical and professional personnel and skilled providers in the health system as well as adequate stocks of essential medicines (46). Furthermore, the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, has stressed that abortion law must be evidence based (37) (see Chapter 1, section 1.3.1[i], and also Web annex A: Key international human rights standards on abortion).
LAW & POLICY Recommendation 21: Provider restrictions
Recommend against regulation on who can provide and manage abortion that is inconsistent with WHO guidance.
- Where law or policy regulate who may provide or manage abortion, that regulation should be consistent with WHO guidance, which is presented throughout this chapter.
Note on updating of the recommendation: This and other law and policy recommendations are not new recommendations. WHO’s 2012 Safe abortion guidance provided a composite recommendation related to law and policy (19); in this guideline, this has been developed into seven separate recommendations using GRADE methodology.
In order to identify the impacts of provider restrictions on abortion seekers and health workers, a systematic review of studies published between 2010 and 2019 was undertaken, identifying seven studies conducted in Australia, Ethiopia, Nepal and the USA. A summary of the evidence from these studies is presented in Supplementary material 1, EtD framework for Provider restrictions. The reviewed evidence showed that restrictions on who can provide and manage abortion resulted in delays to and burdens in accessing abortion. By contrast, expanding the range of health workers who can provide abortion care improved timely access to early medical and surgical abortion; reduced costs, travel and waiting time; shifted components of care away from physicians; made abortion more available including in rural areas and at primary health care level; prevented unsafe self-management of abortion; and reduced system costs. This evidence indicates that provider restrictions produce inefficiencies, administrative burdens and workload burdens within health systems, and reduce in practice the number of available providers.
KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO PROVIDER RESTRICTIONS
- Availability, accessibility, acceptability and quality must be central to the regulation of sexual and reproductive health care.
- Abortion regulation should be based on human rights and evidence.
- States must ensure an adequate number of medical and professional personnel and skilled providers in the health system as well as adequate stocks of essential medicines.