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Thinking (Re)Productively - May 2013

Who Technical And Policy Guidance Emphasizes The Health Systems' Responsibility To Provide Safe Abortion Services

Nathalie Kapp, Anna Glasier

Despite widespread availability and use of modern contraception, among 208 million pregnancies each year worldwide, 41% (85 million) are unintended. Many of these women will seek abortion, whether under safe or unsafe conditions.1 Indeed, the likelihood that a woman will seek an abortion for an unintended pregnancy is about the same regardless of legal restrictions.2 The rate of safe induced abortion has declined over recent years from 35 per 1000 women aged 1544 in 1995 to 26 per 1000 in 2008. In contrast, the rate of unsafe abortion has remained relatively constant since 2000 at around 14 per 1000 women aged 1544.3 Unsafe abortion occurs almost exclusively in low and middle income countries, where maternal mortality rates are high and access to safe services is limited. Deaths resulting from unsafe procedures number approximately 47,000 per year while an additional 5 million women are left disabled.3 Tragically, almost every one of these deaths and disabilities could have been prevented with the provision of safe abortion services.

Use of contraceptive methods and services decreases the chance of unintended pregnancy substantially, but even universal contraceptive use would never eliminate the need for induced abortion given the intrinsic failure rates, however small, of modern methods. Approximately 36 million women worldwide annually experience an unintended accidental pregnancy while using a contraceptive method.4 Additionally, contraception is not available in cases of forced sexual intercourse. Lack of access to contraception may pose a barrier to its use, particularly in low and middle income countries where 11% of women who want to avoid or postpone a pregnancy are not using any method of contraception.5 Women in Sub-Saharan Africa are even more likely than those in other low and middle income countries to report an unmet need; approximately 1 in 4 women in this region has an unmet need for family planning. The resulting unintended pregnancies pose serious risks to women's lives, and the case-fatality rate in Sub-Saharan Africa from complications of unsafe abortion is hundreds of times greater than that of abortion performed under safe conditions (2).

In 2012, the World Health Organization (WHO) released the second edition of Safe abortion: technical and policy guidance for health systems. First published in 2003, this update reflects the evidence from clinical studies on methods and technologies, as well as the human rights rationale, for providing safe abortion care services. Translated into multiple languages, the first edition of the WHO guidance has been widely used by governments, non-governmental organizations, providers of women's health services and activists in the field of women's health and human rights.

The extensive revision, begun in 2010, followed the WHO process for the guideline development. This process includes identification of priority questions and outcomes; evidence retrieval, assessment and synthesis; formulation of recommendations; and planning for dissemination, implementation, impact evaluation and updating. Each step of this process was led by WHO technical staff with input from a panel of international experts, including health service providers, program managers, researchers, methodologists, human rights lawyers and women's health and rights advocates. The revisions for the second edition reflect changes in the evidence regarding abortion methods, related care and delivery of these services, as well as the application of human rights to the provision of abortion care.

The guidance recommendations focus primarily on ensuring good quality through the use of appropriate technologies in abortion-related care and ensuring good access by eliminating barriers and provision of affordable services to all women and adolescents in need. Using either vacuum aspiration or medical abortion regimens of mifepristone and misoprostol to induce abortion, avoiding unnecessary laboratory testing and ultrasonography, administering routine antibiotics perioperatively and using cervical preparation for all surgical procedures beyond 1214 weeks are key recommendations highlighted in the guidelines. Other specific recommendations include an offer of pain medication to every woman having a medical or surgical abortion and prompt provision of information for and voluntary initiation of effective contraceptive methods following abortion. Respecting women's choice of abortion method and options for pain management are reinforced as an important aspect of quality care.

What sets this guidance apart from other technical and clinical guidelines (e.g., the UK Royal College of Obstetricians and Gynaecologists' The Care of Women Requesting Induced Abortion) is the emphasis on both the global public health impact of abortion and the human rights imperative for safe abortion care. Since the 1994 International Conference on Population and Development in Cairo, a concept of reproductive rights demands an approach to healthcare which is grounded in international human rights treaties and global consensus declarations. This concept calls for the respect, protection and fulfillment of human rights, including the right to the highest attainable standard of health; the right to decide freely and responsibly the number, spacing and timing of one's children and to have the information and means to do so; and the right to a sexual life free from coercion or violence. In order to realize these rights, States have the responsibility to ensure that health systems are equipped to provide safe abortion services within the extent of the law. As legal indications for abortion exist in almost all countries, safe provision of such services should decrease women's recourse to unsafe abortion in these settings. Vigorously pursuing decriminalization of abortion-related laws with concomitant provision of safe abortion services can ensure that women preserve their health by avoiding clandestine, unsafe abortion procedures. Access to services must also be equitable; currently, better-off women are more likely than poor women to receive safe abortion procedures even where abortion is legally restricted. Concern that the costs of providing safe abortion services may detract from funds available for maternity care are misplaced since it is clear that the provision of safe abortion procedures is less costly than the treatment of complications from unsafe ones.2

Over recent years, human rights have been increasingly applied by international and regional human rights bodies and regional and national courts in the context of abortion.1 United Nations treaty monitoring bodies have recommended that States reform laws that criminalize medical procedures that are needed only by women. They further recommend that States should make all efforts to ensure that women do not have to undergo life-threatening clandestine procedures and that abortion is available, at a minimum, to protect the life and health of a woman and in all cases of rape and incest. Additionally, States should ensure timely and affordable access to good-quality services and provide them while preserving women's dignity, confidentiality, with informed consent and in a manner responsive to her needs and choices. Other barriers that may need to be addressed to ensure women can access services include requiring third-party authorization, restricting the type of healthcare providers and facilities that can provide services, failing to ensure that affordable services are available, failing to guarantee confidentiality or privacy at service-delivery points and allowing conscientious refusal of care without referrals, either by facilities of providers.

In the update of the global guidance on safe abortion, the WHO makes recommendations for safe abortion services using evidence-based technologies while promoting the human rights obligations underlying the need to provide such services. Unsafe abortion and its associated mortality and disability are avoidable. Human rights obligations require that safe services should be available and accessible for all legal indications. The WHO guidance provides a framework for policy makers and service providers to improve dramatically the health and well-being of the world's women.

Acknowledgments 

Monica Dragoman, Ronnie Johnson, Bela Ganatra and Sharon Phillips from the Special Program of Research, Development and Research Training in Human Reproduction of the Department of Reproductive Health and Research, WHO.

References

  1. World Health Organization, Department of Reproductive Health and Research. Safe abortion: technical and policy guidance for health systems. 2nd ed. Geneva: World Health Organization; 2012;
  2. Sedgh G, Singh S, Shah IH, Ahman E, Henshaw E, Bankole A. Induced abortion incidence and trends worldwide from 1995 to 2008. Lancet. 2012;379:625632
  3. World Health Organization, Department of Reproductive Health and Research. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. 6th ed. Geneva: World Health Organization; 2011;
  4. Ali MM, Cleland J, Shah I. Causes and consequences of contraceptive discontinuation: evidence from 60 demographic and health surveys. Geneva: WHO; 2012;
  5. United Nations. The Millennium Development Goals report 2010: statistical annexes. New York: United Nations; 2010;