Health worker role in providing safe abortion care and post-abortion contraception
How to interpret this guideline?
- The recommendations are intended to be implemented within the context of functioning mechanisms for referral, monitoring and supervision, as well as access to the necessary equipment and commodities.
- The recommendations provide a range of options of types of health workers who can perform the specific tasks safely and effectively. The options are intended to be inclusive and do not imply either a preference for or an exclusion of any particular type of provider. The specific choice of health workers depends upon the needs and conditions of the local context.
- It is assumed that any health worker discussed in this guideline has the basic training required of that type of health worker. In addition, the recommendations all assume that health workers will receive the training or information specific to the task, prior to the implementation of the recommendation option.
Lay health worker
For the purpose of this guideline, this refers to a person who performs functions related to health-care delivery/ information provision and was trained in some way in the context of the task, but has received no formal professional or paraprofessional certificate or tertiary education degree.
For the purpose of this guideline, this refers to technicians and assistants who perform a variety of tasks associated with dispensing medicinal products under the guidance of a pharmacist. They inventory, prepare and store medications and other pharmaceutical compounds and supplies, and may dispense medicines and drugs to clients and instruct on their use as prescribed by health professionals.
Technicians typically receive 2-3 years training in a pharmaceutical school, with an award not equivalent to a university degree. Assistants have usually been through 2-3 years of secondary school with a subsequent period of on-the-job training or apprenticeship.
For the purpose of this guideline, this refers to a health practitioner who dispenses medicinal products. A pharmacist can counsel on the proper use and adverse effects of drugs and medicines following prescriptions issued by medical doctors/health professionals. Education includes university-level training in theoretical and practical pharmacy, pharmaceutical chemistry or a related field.
Doctor of complementary systems of medicine
For the purpose of this guideline, this refers to a professional of traditional and complementary systems of medicine (non-allopathic physician) whose training includes a 4- or 5-year university degree that teaches the study of human anatomy, physiology, management of normal labour and the pharmacology of modern medicines used in obstetrics and gynecology, in addition to their systems of medicine. For the purpose of this guideline, these doctors are included with reference to the provision of elements of abortion-related care as per conventional medical practice.
Auxiliary nurse midwife and auxiliary nurse
For the purpose of this guideline, an auxiliary nurse is someone trained in basic nursing skills but not in nursing decision making. An auxiliary nurse midwife has basic nursing skills and some midwifery competencies but is not fully qualified as a midwife. The level of training may vary from a few months to 2-3 years. A period of on-the-job training may be included, and sometimes formalized in apprenticeships.
For the purpose of this guideline, this refers to a person who has been legally authorized (registered) to practice after examination by a state board of nurse examiners or similar regulatory authority. Education includes 3 or more years in nursing school, and leads to a university or postgraduate university degree or the equivalent.
For the purpose of this guideline, this refers to a person who has been registered by a state midwifery or similar regulatory authority and has been trained in the essential competencies for midwifery practice. Training typically lasts 3 or more years in nursing or midwifery school and leads to a university degree or the equivalent. A registered midwife has the full range of midwifery skills.
Advanced associate and associate clinician
For the purpose of this guideline, this refers to a professional clinician with basic competencies to diagnose and manage common medical and surgical conditions and also to perform some types of surgery. Training can vary by country, but generally requires 3-4 years post-secondary education in an established higher education institution. The clinician is registered and his or her practice is regulated by a national or subnational regulatory authority.
For the purpose of this guideline, this refers to a medical doctor who holds a university-level degree in basic medical education with or without further training in general practice or family medicine, but not in obstetrics and gynecology.
For the purpose of this guideline, specialization refers to postgraduate clinical training and specialization in obstetrics and gynecology.
* considered within typical scope of practice; evidence not assessed
** considered outside of typical scope of practice; evidence not assessed.
Self-management of the medical abortion process in the first trimester
Given the nature of the medical abortion (MA) process, it is possible for women to play a role in managing some of the components by themselves outside of a health-care facility. Such self-assessment and self-management approaches can be empowering for women and help to triage care, leading to a more optimal use of health resources.
Role of self-management of medical abortion in the first trimester by WOMEN
Recommendation: No recommendation on the full independent management of medical abortion.
Recommendations were made for the following subtasks:
Additional remarks: A follow-up visit after MA using mifepristone-misoprostol is not mandatory.
Available evidence for managing the medications and process without direct supervision of the provider is for pregnancy duration of nine weeks (63 days or less).
Self-management approaches reflect an active extension of health systems and health care. These recommendations are NOT an endorsement of clandestine self-use by women without access to information or a trained health-care provider/health-care facility as backup. All women should have access to health services should they want to need it.
Implementation considerations: Mechanisms to ensure access and linkages to post-abortion contraception services need to be established.
Medical abortion in the first trimester
Medical abortion (MA) refers to the sequential use of mifepristone followed by misoprostol or, in settings where mifepristone is not available, the use of misoprostol alone. The specific dosage, routes and regimens are different at differing pregnancy durations. See Clinical practice handbook for safe abortion for further details.
MA is a process that takes place over a period of several days rather than being a discrete procedure. It includes several components or subtasks:
- assessing eligibility for MA (diagnosing and dating the pregnancy, ruling out medical contraindications, screening for possible ectopic pregnancy);
- administering the medications with instructions on their appropriate use and managing the common side-effects;
- assessing that the abortion process is complete and that no further intervention is required.
One health worker can provide the entire package, but it is equally possible for the subtasks to be performed by different health workers and at different locations.
Self-administration of injectable contraception
Contraception can be initiated immediately post-abortion and all contraceptive options may be used. Recommendations are made on the self-administration of injectable contraceptives by women themselves.
Recommendation: Recommended in contexts where mechanisms to provide the woman with appropriate information and training exist, referral linkages to a health-care provider are strong and where monitoring and follow-up can be ensured.
Additional remarks: The administration of an injectable contraceptive involves using a standard syringe and may be intramuscular or subcutaneous. Compact pre-filled auto-disable devices may be used as well but are still not widely available.
Implementation considerations: The following are important considerations when making the self-injection option available:
- adequate arrangements for storage and for keeping sharps safely at home;
- training in and the provision of mechanisms for the safe and safe and secure disposal of used injectable contraceptives (especially in settings with high HIV prevalence);
- ensuring a way to procure injectable contraceptives on a regular basis without needing to repeatedly visit a health-care facility.