Chapter 3. Recommendations and best practice statements across the continuum of abortion care
Self-management approaches for post-abortion contraception: Recommendations 51-54 (3.6.3)
3.6.3 Self-management approaches for post-abortion contraception
All contraceptive options may be considered after an abortion. For further information, refer to section 3.5.4: Post-abortion contraception. Many family planning methods are entirely self-managed (i.e. self-procured over the counter or online and self-administered) and generally available without a prescription, including barrier methods and some hormonal contraceptives, including some oral contraceptive pills (OCPs), and also emergency contraceptive pills. For methods that have traditionally required a prescription from a doctor and/or administration by a health-care provider, shifting to include the option of using self-management approaches, such as over-the counter OCPs and self-injection of hormonal contraceptives, may improve continuation of contraceptive use by removing barriers, such as the need to return to a health-care facility every three months for a repeat injection. These approaches could expand access to contraception for those facing challenges in accessing health-care settings regularly, and in places where there are shortages of health-care providers, thus potentially greatly reducing the incidence of unintended pregnancy.
SELF-MANAGEMENT Recommendation 51: Self-administration of injectable contraception (initiation and continuation)
Recommend the option of self-administration of injectable contraception in the post-abortion period.
- The administration of an injectable contraceptive involves using a syringe and may be intramuscular or subcutaneous. Compact pre-filled auto-disable devices have been developed to facilitate the self-administration process.
Source: Recommendation updated from WHO (2015) (23).
Note on updating of the recommendation: This was an existing recommendation for which evidence was reviewed using GRADE methodology. After review, the recommendation was upgraded from “suggest” to “recommend”.
No requirement for location (on-site vs off-site).
- There must be training in the technique for self-injection.
- There must be training in and the provision of mechanisms for the safe and secure storage and disposal of sharps (used injectable contraceptives), especially in settings with high HIV prevalence.
- The client must be able to procure injectable contraceptives on a regular basis without needing to repeatedly visit a health-care facility.
A systematic review was undertaken to address this key question. Studies with indirect populations (i.e. women of reproductive age willing to initiate or continue with injectable contraceptive) were also considered for inclusion. Seven studies reporting on self-administered injectable contraceptives were identified by the search strategy and included in the reviewed evidence; three randomized controlled trials were conducted in Malawi and the USA and four observational studies were conducted in Senegal, Uganda, the United Kingdom and the USA. The evidence was considered indirect since none of the women included in the reviewed studies were described as seeking contraception post-abortion. A summary of the evidence is presented in Supplementary material 3, EtD framework on Self-administration of injectable contraception.
There is evidence that continuation rates for self-administered injectable contraceptives are higher compared with injectable contraceptives being provided by clinic-based providers (very low- to low-certainty evidence). Satisfaction was higher among the self-administration group (very low- to moderate-certainty evidence). The option may result in time and financial savings for women. In addition, this option may increase choice and autonomy in contraceptive use within a rights-based framework.
SELF-MANAGEMENT Recommendation 52: Over-the-counter oral contraceptive pills
Recommend that over-the-counter oral contraceptive pills (OCPs) should be made available without a prescription for individuals using OCPs.
SELF-MANAGEMENT Recommendation 53: Over-the-counter emergency contraceptive pills
Recommend making over-the-counter emergency contraceptive pills available without a prescription to individuals who wish to use emergency contraception.
SELF-MANAGEMENT Recommendation 54: Condom use
The consistent and correct use of male and female condoms is highly effective in preventing the sexual transmission of HIV; reducing the risk of HIV transmission both from men to women and women to men in serodiscordant couples; reducing the risk of acquiring other STIs and associated conditions, including genital warts and cervical cancer; and preventing unintended pregnancy.
Source: Recommendations 15, 16 and 18 brought in from WHO (2021) (26).
No requirement for location (on-site vs off-site).
Implementation considerations for OCPs
- Provide up to one year’s supply of pills, depending on the woman’s preference and anticipated use.
- Programmes must balance the desirability of giving women maximum access to pills with concerns regarding contraceptive supply and logistics.
- The resupply system should be flexible, so that the woman can obtain pills easily in the amount and at the time she requires them.
KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO SELF-MANAGEMENT APPROACHES
- Sexual and reproductive health (SRH) care must be available, accessible, acceptable and of good quality.
- States must ensure availability of a wide range of modern, safe and affordable contraceptive methods.
- States must ensure adequate access to essential medicines in an affordable and non-discriminatory manner.
- States must respect autonomous decision-making, non-discrimination and equality. This means that States should repeal or reform laws and policies that nullify or impair the ability of certain individuals and groups to realize their right to SRH, including the criminalization of abortion or restrictive abortion laws.
- States must make accurate, evidence-based abortion information available to individuals on a confidential basis
- States must take steps to reduce maternal mortality and morbidity.
- In line with human rights requirements, self-management of abortion should not be criminalized. Criminalization of self-management of abortion may result in delays in or barriers to seeking assistance or post-abortion care where needed. Self-management of medical abortion should be available as an option on the basis of clinical appropriateness. It should not be restricted for non-clinical reasons such as age.
- Including a recommendation only on injectable contraception here does not imply that post-abortion contraceptive options for women should be limited to this method, or indeed to the methods covered by recommendations presented in section 3.5.4; all contraceptive methods can be considered after an abortion. ↩
- These are Recommendations 20a, b and c from WHO (2021) (REF – NEW SELF-CARE). ↩