Chapter 3. Recommendations and best practice statements across the continuum of abortion care
Self-management Recommendation 50: Self-management of medical abortion in whole or in part at gestational ages < 12 weeks (3.6.2)
3.6.2 Self-management approaches for medical abortion in whole or in part
Self-care, as defined the in Glossary, is a broad-based concept and can encompass numerous actions that are intended to empower the individual to enhance their own health. Self-management approaches are one component of self-care. Given the nature of the medical abortion process, it is possible for women to manage the process by themselves in whole or part. While individuals may conduct some or all elements related to the abortion process (self-assessment of eligibility, self-administration of medicines and self-assessment of the success of the abortion) entirely on their own, more typically, self-management co-exists with interactions with trained health workers or with a health-care facility and in conjunction with service-delivery approaches described in section 3.6.1. It is the individual (i.e. the “self”) who drives the process of deciding which aspects of the abortion care will be self-managed and which aspects will be supported or provided by trained health workers or in a health-care facility.
Women may self-manage parts or all of the abortion process for a variety of reasons related to individual circumstances and preferences. For some women, this may be the only feasible option within their context and for others it may represent an active choice. However, from the perspective of the health system, self-management should not be considered a “last resort” option or a substitute for a non-functioning health system. Self-management must be recognized as a potentially empowering and active extension of the health system and task-sharing approaches. A supportive enabling environment as described in Chapter 1, section 1.3, is equally applicable to self-management approaches as it is to other elements of care provision.
SELF-MANAGEMENT Recommendation 50: Self-management of medical abortion in whole or in part at gestational ages < 12 weeks
For medical abortion at < 12 weeks (using the combination of mifepristone plus misoprostol or using misoprostol alone): Recommend the option of self-management of the medical abortion process in whole or any of the three component parts of the process:
- self-assessment of eligibility (determining pregnancy duration; ruling out contraindications)
- self-administration of abortion medicines outside of a health-care facility and without the direct supervision of a trained health worker, and management of the abortion process
- self-assessment of the success of the abortion.
Remarks:
- There was more evidence for self-management of medical abortion (with either of the regimens) for pregnancies before 10 weeks of gestation.
- This recommendation applies to the combination regimen of mifepristone plus misoprostol, and the use of misoprostol alone. The included studies informing these recommendations did not assess the letrozole plus misoprostol regimen.
- All individuals engaging in self-management of medical abortion must also have access to accurate information, quality-assured medicines including for pain management, the support of trained health workers and access to a health-care facility and to referral services if they need or desire it.
- Restrictions on prescribing and dispensing authority for abortion medicines may need to be modified or other mechanisms put in place for self-management within the regulatory framework of the health system.
Source: Recommendation updated from WHO (2015) (23).
Note on updating of the recommendation: This was an existing recommendation for which evidence for all of the subtasks was reviewed using GRADE methodology. After review, the recommendations for all subtasks were upgraded to “recommend” – from “suggest” for self-administration and self-assessment of outcome, and from “only in the context of rigorous research” for self-assessment of eligibility.
No requirement for location (on-site vs off-site).
Implementation considerations
- Every individual must have access to accurate information about the self-management process as well as other options available within their local context, to enable informed decision making on whether to self-manage all or parts of the process.
- Self-assessment of eligibility includes the assessment of pregnancy duration based on LMP. Paper or digital tools to assist recall and calculate duration or checklists may assist in the self-assessment of eligibility. When menstrual cycles are irregular or women have other concerns, she should be encouraged to seek support from a trained health worker where possible.
- Self-administration of medicines and management of the medical abortion process involves taking all or some of the abortion medicines without the direct supervision of a health worker. It is important that all sources from which medicines are procured provide quality-assured medicines.
- Women should also have information about pain during the process and should be able to obtain medicines for pain management.
- Women should also have information about the requirements of managing abortion-related bleeding at home, and should have access/referral to emergency care if this becomes necessary.
- Self-assessment of the success of abortion can be done using check lists of signs and symptoms. Other tools (e.g. low-sensitivity pregnancy tests), if available, may be used to assist the woman in self-assessing completion. Low-sensitivity urine pregnancy tests are different from ordinary pregnancy tests. The use of a high-sensitivity pregnancy test (a multi-level pregnancy test [MLPT]) alone or in conjunction with checklists has been shown to have a higher sensitivity for detecting successful abortion. Access should be available to a health worker or health-care facility to confirm the success of abortion or to manage side-effects or complications.
- As part of the enabling environment, health workers and managers should recognize self-management as a legitimate pathway to abortion care, and should work to adapt health systems to facilitate and support women in their self-management of abortion – for example, by adapting clinical protocols used at their facility.
- Mechanisms need to be established to ensure access or referrals to post-abortion contraception services and provision of contraception for women who want them.
- While self-management can support efficiencies within health systems in the long term, it should not mean that the burden of the cost of health services is simply transferred from the provider or facility to the woman herself.
Rationale
Two systematic reviews were undertaken to address this key question. The first review focused on the self-assessment of eligibility and self-assessment of success. A total of 14 studies reporting on these two sub-tasks were identified by the search strategy. The four studies on self-assessment of eligibility took place in South Africa, the United Kingdom and the USA. Ten studies on self-assessment of success took place in Austria, Finland, India, Mexico, Nepal, Norway, South Africa, Sweden, Uzbekistan and Viet Nam. The second review was on the self-administration of medicines and included 18 studies, which took place in Albania, Bangladesh, China, France, India, Nigeria, Tunisia, Turkey and Viet Nam. A summary of the evidence is presented in Supplementary material 2, EtD framework on Self-management of medical abortion.
Self-assessment of eligibility: There is low-certainty evidence on the safety, effectiveness and acceptability of self-assessment of eligibility for a medical abortion, using the start date of last menstrual period (LMP) alone or in combination with other tools (e.g. checklists). The expert panel discussed the feasibility of this intervention in certain scenarios such as the woman having regular menses, a known LMP and the availability of validated tools. When they have the necessary information, women are able to determine their eligibility for medical abortion. Given this and taking into account the values and preferences and high acceptability of this approach, the panel determined that the intervention was favoured.
Self-administration of medicines: There is evidence that the option of self-administering medicines for medical abortion is effective (moderate certainty) and safe (low certainty). Women reported high satisfaction with taking their own medicines for the abortion (very low-certainty evidence). There was high adherence to the medical abortion regimen (low-certainty evidence). The high acceptability and feasibility favoured this intervention.
Self-assessment of success: There is high-certainty evidence that self-assessment of abortion outcome/success (using tools such as a low-sensitivity pregnant test or multi-level pregnancy test) is as effective as assessment by a trained health worker. Low-certainty evidence indicated that more women in the self-assessment group expressed satisfaction with the process.