Chapter 3. Recommendations and best practice statements across the continuum of abortion care

Service delivery Recommendation 5: Provision of counselling (3.2.2, 3.2.3)

3.2.2 Offering and providing counselling

Some individuals may wish to receive counselling before or after an abortion. Counselling is more than information provision. It is a focused, interactive process through which a person voluntarily receives support, information and non-directive guidance from a trained person (122), in an environment that is conducive to openly sharing thoughts, feelings, perceptions and personal experiences. In addition to the specific knowledge about abortion services and care required for both information provision and counselling, the latter also requires specialized counselling training. Counselling is a core element of provision of abortion and post-abortion care.

When offering and providing counselling, it is essential to apply the following guiding principles:

  • ensure that the individual is requesting the counselling and make it clear that counselling is not required;
  • ensure privacy and confidentiality;
  • ask the individual what they want or need, what their concerns are, given them the time they need, and actively listen to their expressed needs and preferences;
  • highlight relevant information during the counselling session (such as the information provided in section 3.2.1);
  • communicate information respectfully and non-judgementally, and in a manner understandable to/tailored to the individual;
  • support the individual and check to ensure they receive adequate responses to their questions and that they understand the information provided;
  • present all suitable options tailored to individual’s needs, while avoiding imposing one’s personal values and beliefs onto them; and
  • make it clear that the individual will need to decide what services to receive.

SERVICE DELIVERY Recommendation 5: Provision of counselling

Type of health worker Recommendation Rationalea
Community health workers (CHWs) Recommend Insufficient direct evidence was found for the safety, effectiveness or acceptability of this option, but indirect evidence did show that health promotion interventions by CHWs are generally well accepted, effective and feasible in many contexts, and that CHWs are often intermediaries between the health system and women seeking abortion-related care (moderate-certainty evidence). The expert panel affirmed the feasibility of this option and its ability to expand equitable access to quality abortion care.
Pharmacy workers Suggest

Condition: Balanced counselling is provided (i.e. about both medical and surgical methods) and there is access or referral to appropriate health services should the woman choose a surgical method.

Although no direct evidence was found on the safety, effectiveness or acceptability of this option, 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 the feasibility of this option and its ability to expand equitable access to quality abortion care.
Pharmacists Suggest

Condition: Balanced counselling is provided (i.e. about both medical and surgical methods) and there is access or referral to appropriate health services should the woman choose a surgical method.

Although no direct evidence was found on the safety, effectiveness or acceptability of this option, the skills and knowledge for this task (according to the competency framework) align with the competencies for this type of health worker.a Pharmacists are qualified to provide information about the medicines they dispense. There is evidence for the effectiveness of provision of counselling on the management of chronic illnesses by pharmacists (low certainty evidence). In many contexts, pharmacists are often consulted by women seeking advice on how to deal with delayed menstruation (moderate-certainty evidence). Pharmacists have been recommended to provide medical abortion at < 12 weeks across all three subtasks (Recommendation 28). Therefore, the expert panel affirmed that it is feasible for pharmacists to provide balanced counselling on abortion, including surgical options.
Traditional and complementary medicine professionals Recommend Although no direct evidence was found on the safety, effectiveness or acceptability of this option, 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

Nurses

Recommend Counselling is a core competency for these health workers a and this task is within their typical scope of practice.b
Midwives Recommend Counselling is a core competency for midwives a and this task is within their typical scope of practice.b
Associate/advanced associate clinicians Recommend Counselling is a core competency for these clinicians a and this task is within their typical scope of practice.b
Generalist medical practitioners Specialist medical practitioners Recommend Within their typical scope of practice,b therefore no assessment of the evidence was conducted.
Source: Recommendation updated from WHO (2015) (23).

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, since the other health workers already had a strong recommendation for this task. After review, the recommendations were upgraded for all four of those health worker categories, from “recommend against” to “suggest” for pharmacists and pharmacy workers, and from “suggest” to “recommend” for traditional and complementary medicine professionals and CHWs. A summary of the evidence is presented in Supplementary material 3, EtD framework on Pre- and post-abortion counselling.

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.

There is no requirement for location (on-site vs off-site), but privacy and confidentiality should be ensured during counselling, with particular attention needed to this requirement in the off-site (out-of-facility) settings, such as the pharmacies and community-based sites, where infrastructure and procedures may make this more challenging.

Implementation considerations
  • Counselling can be provided to those seeking abortion services but also jointly to their partners, family members or other individuals, should the woman wish them to be present.
  • While counselling should be made available and accessible, it should always be voluntary for women to choose whether or not they want to receive it.
  • Counselling should be person-centred and may need to be tailored according to the needs of the individual; young people, survivors of sexual and gender-based violence or members of marginalized groups may have different information or counselling requirements.
  • The content of and approach to counselling will need to be adjusted depending on the reason for seeking abortion services (e.g. induced abortion, intrauterine fetal demise [IUFD], fetal anomaly). Therefore, it is important for the counsellor to be aware of and sensitive to the individual’s situation and needs.
  • Different service-delivery models exist for pre- and post-abortion counselling, e.g. remote access via hotlines and telemedicine and through approaches such as harm reduction counselling and community-based outreach.

KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO COUNSELLING

  • Counselling must be entered into freely and voluntarily, i.e. it should not be mandatory. The right to refuse counselling when offered must be respected.
  • Where provided, counselling must be available to individuals in a way that respects privacy and confidentiality.
  • Counselling must be acceptable and of good quality, i.e. it must be provided in a way that can be understood by the recipient and it must be accurate and evidence based.
  • Counselling must be non-discriminatory and non-biased.
  • Dissemination of misinformation, withholding of information, and censorship should be prohibited.
  • Counselling should be available to all persons without the consent or authorization of a third party. This includes counselling being available to adolescents without the consent or authorization of a parent, guardian or other authority.

For further information and sources, please refer to Box 1.2 and Web annex A: Key international human rights standards on abortion.

3.2.3 Links to additional services

Individuals seeking abortion may require additional services (122). As needed, provide management or referral to other service providers for other health conditions or urgent needs. This includes facilitating linkages (access or referrals) to counselling and testing for sexually transmitted infections including HIV, contraception where desired, and support services for survivors of gender-based violence.