Abortion Care

Publication Date: March 7, 2022
Last Updated: May 10, 2022

ABORTION REGULATION

Criminalization

Recommend the full decriminalization of abortion. (S)
  • Decriminalization means removing abortion from all penal/criminal laws, not applying other criminal offences (e.g. murder, manslaughter) to abortion, and ensuring there are no criminal penalties for having, assisting with, providing information about, or providing abortion, for all relevant actors.
  • Decriminalization would ensure that anyone who has experienced pregnancy loss does not come under suspicion of illegal abortion when they seek care.
  • Decriminalization of abortion does not make women, girls or other pregnant persons vulnerable to forced or coerced abortion. Forced or coerced abortion would constitute serious assaults as these would be non-consensual interventions.
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Grounds-based approaches

Recommend against laws and other regulations that restrict abortion by grounds. (S)
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Recommend that abortion be available on the request of the woman, girl or other pregnant person. (S)
  • Grounds-based approaches to restricting access to abortion should be revised in favour of making abortion available on the request of the woman, girl or other pregnant person.
  • Until they are replaced with abortion on request, any existing grounds should be formulated and applied in a manner consistent with international human rights law. This means that the content, interpretation and application of grounds-based law and policy should be revised to ensure human rights compliance. This requires that:
    • existing grounds are defined, interpreted and applied in a human rights-compliant way;
    • abortion is available when carrying a pregnancy to term would cause the woman, girl or other pregnant person substantial pain or suffering,
    • including but not limited to situations where the pregnancy is the result of rape or incest or the pregnancy is not viable;
    • abortion is available where the life and health of the woman, girl or other pregnant person is at risk;
    • health grounds reflect WHO’s definitions of health and mental health (see Glossary); and
    • there are no procedural requirements to “prove” or “establish” satisfaction of grounds, such as requiring judicial orders or police reports in cases of rape or sexual assault (for sources to support this information, refer to Web annex A: Key international human rights standards on abortion).
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Gestational age limits

Recommend against laws and other regulations that prohibit abortion based on gestational age limits. (S)
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SERVICES ACROSS THE CONTINUUM OF CARE

Provision of information on abortion care

Service Delivery

Across the continuum of abortion care:
Recommend provision of information on abortion care by community health workers, pharmacists, traditional and complementary medicine professionals, auxiliary nurses/auxiliary nurse midwives (ANMs), nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist medical practitioners. (S)
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Suggest provision of information on abortion care by pharmacy workers. (C)
Condition: In contexts where the pharmacy worker is under the direct supervision of a pharmacist and there is access or referral to appropriate health services.
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Provision of counselling

Across the continuum of abortion care:
Recommend provision of counselling by community health workers, traditional and complementary medicine professionals, auxiliary nurses/ANMs, nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist medical practitioners. (S)
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Suggest provision of counselling by pharmacy workers and pharmacists. (C)
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.
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PRE-ABORTION

Mandatory waiting periods

Recommend against mandatory waiting periods for abortion (S)
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Third-party authorization

Recommend that abortion be available on the request of the woman, girl or other pregnant person without the authorization of any other individual, body or institution. (S)
While parental or partner involvement in abortion decision-making can support and assist women, girls or other pregnant persons, this must be based on the values and preferences of the person availing of abortion and not imposed by third-party authorization requirements.
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Rh isoimmunization for abortion at gestational ages < 12 weeks

For both medical and surgical abortion at < 12 weeks: Recommend against anti-D immunoglobulin administration. (S)
Standard of care applies for anti-D administration at gestational ages ≥ 12 weeks.
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Antibiotic prophylaxis for surgical and medical abortion

For surgical abortion, regardless of the individual’s risk of pelvic inflammatory infection: Recommend appropriate prophylactic antibiotics pre- or perioperatively. (S)
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For medical abortion: Recommend against the use of prophylactic antibiotics. (S)
Lack of antibiotics should not limit access to abortion services.
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Determining gestational age of pregnancy: pre-abortion ultrasound scanning

For both medical and surgical abortion: Recommend against the use of ultrasound scanning as a prerequisite for providing abortion services.* (S)
  • Legal regulation that limits the availability of abortion by gestational age may require or result in ultrasounds being used to verify gestational age prior to abortion, even though this is not necessary from a clinical perspective. Removing legal gestational age limits on access to abortion (see Recommendation 3) should result in unnecessary pre-abortion ultrasound being avoided, and increase the availability of abortion in settings where ultrasound is difficult to access.
* On a case-by-case basis, there may be clinical reasons for using ultrasound scanning prior to abortion.
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Pain management for abortion

for surgical abortion and for prior cervical priming

For pain management for surgical abortion at any gestational age:
Recommend that pain medication should be offered routinely (e.g. non-steroidal anti-inflammatory drugs [NSAIDS]) and that it should be provided to those who want it (S)
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Recommend against the routine use of general anaesthesia (S)
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For pain management for surgical abortion at < 14 weeks:
Recommend the use of a paracervical block (S)
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Suggest that the option of combination pain management using conscious sedation plus paracervical block should be offered, where conscious sedation is available. (C)
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For pain management for cervical priming with osmotic dilators prior to surgical abortion at ≥ 14 weeks: Suggest the use of a paracervical block. (C)
For cervical priming, additional pain medication can be considered, such as the use of intravaginal gel. (See Recommendations 17–20 below on cervical priming)
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For pain management for surgical abortion at ≥ 14 weeks:
Recommend the use of a paracervical block (S)
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Suggest that the option of combination pain management using conscious sedation plus paracervical block should be offered, where conscious sedation is available (C)
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For medical abortion at any gestational age: Recommend that pain medication should be offered routinely (e.g. non-steroidal anti-inflammatory drugs [NSAIDs]) and that it should be provided for the individual to use if and when wanted. (S)
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For pain management for medical abortion at ≥ 12 weeks: Suggest consideration of additional methods to control pain or discomfort due to increased pain with increasing gestational age. Such methods include certain anti-emetics and epidural anaesthesia, where available. (C)
For medical abortion at gestational ages < 14 weeks, if NSAIDS (e.g. ibuprofen) are not available or not an option, then acetaminophen can be considered for pain control.
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Cervical priming prior to surgical abortion

at < 12 weeks

Prior to surgical abortion at < 12 weeks:
cervical priming is used: Suggest the following medication regimens:
  • Mifepristone 200 mg orally 24–48 hours prior to the procedure
  • Misoprostol 400 μg sublingually 1–2 hours prior to the procedure
  • Misoprostol 400 μg vaginally or buccally 2–3 hours prior to the procedure
(C)
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Recommend against the use of osmotic dilators for cervical priming. (S)
  • The sublingual route is more effective for misoprostol administration.
  • Appropriate pain medication should be provided.
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at ≥ 12 weeks

Prior to surgical abortion at later gestational ages:
For surgical abortion at ≥ 12 weeks: Suggest cervical priming prior to the procedure. (C)
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For surgical abortion between 12 and 19 weeks: Suggest cervical priming with medication alone (a combination of mifepristone plus misoprostol is preferred) or with an osmotic dilator plus medication (mifepristone, misoprostol, or a combination of both). (C)
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For surgical abortion between 12 and 19 weeks, when using an osmotic dilator for cervical priming: Suggest that the period between osmotic dilator placement and the procedure should not extend beyond two days. (C)
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For surgical abortion at ≥ 19 weeks: Recommend cervical priming with an osmotic dilator plus medication (mifepristone, misoprostol, or a combination of both). (S)
  • There was limited evidence for cervical priming for gestational ages between 12 and 14 weeks and therefore health workers should use clinical judgement to decide on the most convenient method for cervical priming prior to vacuum aspiration for this gestational age range.
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with medication, at any gestational age

Prior to surgical abortion at any gestational age:
Recommend cervical priming with medication by traditional and complementary medicine professionals, auxiliary nurses/ANMs, nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist medical practitioners. (S)
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Suggest cervical priming with medication by community health workers, pharmacy workers and pharmacists. (C)
  • Condition: Provision of medication for the purpose of cervical priming is part of the surgical abortion process so the health worker needs to ensure continuity of care of the woman obtaining the medicines prior to the abortion procedure.
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with osmotic dilators, at ≥ 12 weeks

Prior to dilatation and evacuation (D&E) at ≥ 12 weeks:
Recommend cervical priming with osmotic dilators by auxiliary nurses/ANMs, nurses, midwives, associate/ advanced associate clinicians, generalist medical practitioners and specialist medical practitioners. (S)
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Suggest cervical priming with osmotic dilators by traditional and complementary medicine professionals. (C)
  • Health worker ensures continuity of care from the time of cervical priming to the D&E.
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Provider restrictions

Recommend against regulation on who can provide and manage abortion that is inconsistent with WHO guidance. (S)
  • Where law or policy regulate who may provide or manage abortion, that regulation should be consistent with WHO guidance, which is presented throughout Chapter 3 of this guideline.
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Conscientious objection

Recommend that access to and continuity of comprehensive abortion care be protected against barriers created by conscientious objection. (S)
  • In spite of the human rights obligation to ensure conscientious objection does not hinder access to quality abortion care, and previous WHO recommendations aimed at ensuring conscientious objection does not undermine or hinder access to abortion care, conscientious objection continues to operate as a barrier to access to quality abortion care. It is critical that States ensure compliance with regulations and design/organize health systems to ensure access to and continuity of quality abortion care. If it proves impossible to regulate conscientious objection in a way that respects, protects and fulfils abortion seekers’ rights, conscientious objection in abortion provision may become indefensible.
  • The evidence reviewed considered the impact of conscientious objection on access to and availability of abortion care and not the effectiveness of regulating conscientious objection in terms of improvements in those outcomes. However, international human rights law provides some guidance as to how States can ensure that human rights of abortion seekers are respected, protected and fulfilled (see details in main text).
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ABORTION

Methods of surgical abortion

at < 14 weeks

For surgical abortion at < 14 weeks:
Recommend vacuum aspiration (S)
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Recommend against the practice of dilatation and sharp curettage (D&C), including sharp curette checks (i.e. to “complete” the abortion) following vacuum aspiration. (S)
  • Observational studies indicate that vacuum aspiration is associated with fewer complications than D&C; however, randomized controlled trials were underpowered to detect a difference in complication rates.
  • No evidence supports the use of sharp curette checks following vacuum aspiration.
  • The quality of the evidence based on randomized controlled trials is low to moderate.
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vacuum aspiration at < 14 weeks

For surgical abortion at < 14 weeks:
Recommend vacuum aspiration by traditional and complementary medicine professionals, nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist medical practitioners. (S)
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Suggest vacuum aspiration by auxiliary nurses/ANMs. (C)
  • Condition: In contexts where established health system mechanisms involve auxiliary nurses/ANMs in providing basic emergency obstetric care, and where referral and monitoring systems are strong.
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at ≥ 14 weeks

For surgical abortion at ≥ 14 weeks: Recommend dilatation and evacuation (D&E). (S)
Vacuum aspiration can be used during a D&E (i.e. for the purpose of amniotomy or tissue removal at the end of the D&E).
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D&E at ≥ 14 weeks

For surgical abortion at ≥ 14 weeks:
Recommend D&E by generalist medical practitioners and specialist medical practitioners. (S)
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Suggest D&E by traditional and complementary medicine professionals, midwives and associate/advanced associate clinicians (C)
  • Condition: In settings where established health system mechanisms exist to include these health workers in other tasks related to maternal and reproductive health.
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Medical management of induced abortion

at < 12 weeks

For medical abortion at < 12 weeks:
Recommend the use of 200 mg mifepristone administered orally, followed 1–2 days later by 800 μg misoprostol administered vaginally, sublingually or buccally. The minimum recommended interval between use of mifepristone and misoprostol is 24 hours.* (S)
* Repeat doses of misoprostol can be considered when needed to achieve success of the abortion process. In this guideline we do not provide a
maximum number of doses of misoprostol.
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When using misoprostol alone: Recommend the use of 800 μg misoprostol administered vaginally, sublingually or buccally.* (S)
* Repeat doses of misoprostol can be considered when needed to achieve success of the abortion process. In this guideline we do not provide a
maximum number of doses of misoprostol.
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Suggest the use of a combination regimen of letrozole plus misoprostol (letrozole 10 mg orally each day for 3 days followed by misoprostol 800 μg sublingually on the fourth day) as a safe and effective option.*ǂ (C)
  • Evidence from clinical studies demonstrates that the combination regimen (Recommendation 27a) is more effective than misoprostol alone.
  • All routes are included as options for misoprostol administration, in consideration of patient and provider preference.
  • The suggested combination regimen of letrozole plus misoprostol may be safe and effective up to 14 weeks of gestation.
* Repeat doses of misoprostol can be considered when needed to achieve success of the abortion process. In this guideline we do not provide a
maximum number of doses of misoprostol.

ǂ Further evidence is needed to determine the safety, effectiveness and acceptability of the letrozole plus misoprostol combination regimen at later
gestational ages, especially in comparison with that of the mifepristone plus misoprostol combination regimen (the available evidence focused on
comparison with the use of misoprostol alone).
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at < 12 weeks* in whole or in part (i.e. performing all or some of the subtasks)

For medical abortion at < 12 weeks: Recommend medical management by self (see Recommendation 50), community health workers, pharmacy workers, pharmacists, traditional and complementary medicine professionals, auxiliary nurses/ANMs, nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist medical practitioners. (S)
* Available evidence for the independent provision of medical abortion by non-physicians is for pregnancy durations up to 10 weeks (70 days).

ǂ For this recommendation, the medical abortion regimens covered in the available evidence were mifepristone plus misoprostol, or misoprostol alone
(the regimen using letrozole was not included).
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at ≥ 12 weeks

For medical abortion at ≥ 12 weeks:
Suggest the use of 200 mg mifepristone administered orally, followed 1–2 days later by repeat doses of 400 μg misoprostol administered vaginally, sublingually or buccally every 3 hours.* The minimum recommended interval between use of mifepristone and misoprostol is 24 hours. (C)
* Misoprostol can be repeated at the noted interval as needed to achieve success of the abortion process. Providers should use caution and clinical
judgement to decide the maximum number of doses of misoprostol in pregnant individuals with prior uterine incision. Uterine rupture is a rare
complication; clinical judgement and health system preparedness for emergency management of uterine rupture must be considered with later
gestational age.
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When using misoprostol alone: Suggest the use of repeat doses of 400 μg misoprostol administered vaginally, sublingually or buccally every 3 hours.* (C)
  • The combination regimen (Recommendation 29a) is more effective than use of misoprostol alone.
  • Evidence suggests that the vaginal route is the most effective. Consideration for patient and provider preference suggests the inclusion of all routes.
  • Pregnancy tissue should be treated in the same way as other biological material unless the individual expresses a desire for it to be managed otherwise.
* Misoprostol can be repeated at the noted interval as needed to achieve success of the abortion process. Providers should use caution and clinical
judgement to decide the maximum number of doses of misoprostol in pregnant individuals with prior uterine incision. Uterine rupture is a rare
complication; clinical judgement and health system preparedness for emergency management of uterine rupture must be considered with later
gestational age.
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For medical abortion at ≥ 12 weeks:
Recommend medical management by generalist medical practitioners and specialist medical practitioners. (S)
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Suggest medical management by traditional and complementary medicine professionals, auxiliary nurses/ ANMs, nurses, midwives and associate/advanced associate clinicians. (C)
  • Condition: In contexts where established and easy access to appropriate surgical backup and proper infrastructure is available to address incomplete abortion or other complications.
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Missed abortion

Medical management at < 14 weeks

For missed abortion at < 14 weeks, for individuals preferring medical management: Recommend the use of combination mifepristone plus misoprostol over misoprostol alone.
  • Recommended regimen: 200 mg mifepristone administered orally, followed by 800 μg misoprostol administered by any route (buccal, vaginal or sublingual).*
  • Alternative regimen: 800 μg misoprostol administered by any route (buccal, vaginal or sublingual).ǂ
(S)
  • The decision about the mode of management (expectant, medical or surgical) of missed abortion should be based on the individual’s clinical condition and preference for treatment.
  • Expectant management can be offered as an option on the condition that the woman, girl or other pregnant person is informed of the longer time for expulsion of the pregnancy tissue and the increased risk of incomplete emptying of the uterus.
  • Pregnancy tissue should be treated in the same way as other biological material unless the individual expresses a desire for it to be managed otherwise.
* The minimum recommended interval between use of mifepristone and misoprostol is 24 hours.

ǂ If using the alternative regimen (misoprostol alone), it should be noted that at gestational ages ≥ 9 weeks, evidence shows that repeat
dosing of misoprostol is more efficacious to achieve success of the abortion process. In this guideline we do not provide a maximum number
of doses of misoprostol.
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Intrauterine fetal demise

Medical management at ≥ 14 to ≤ 28 weeks

For medical management of IUFD at ≥ 14 to ≤ 28 weeks: Suggest the use of combination mifepristone plus misoprostol over misoprostol alone.
  • Suggested regimen: 200 mg mifepristone administered orally, followed 1–2 days later by repeat doses of 400 μg misoprostol administered sublingually or vaginally every 4–6 hours.* The minimum recommended interval between use of mifepristone and misoprostol is 24 hours.
  • Alternative regimen: repeat doses of 400 μg misoprostol administered sublingually or vaginally every 4–6 hours.*
(C)
  • Evidence from clinical studies indicates that the combination regimen is more effective than the use of misoprostol alone.
  • Pregnancy tissue should be treated in the same way as other biological material unless the individual expresses a desire for it to be managed otherwise.
* Misoprostol can be repeated at the noted interval as needed to achieve success of the abortion process. Providers should use caution and clinical
judgement to decide the maximum number of doses of misoprostol in pregnant individuals with prior uterine incision. Uterine rupture is a rare complication; clinical judgement and health system preparedness for emergency management of uterine rupture must be considered with later
gestational age.
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Medical management at ≥ 14 to ≤ 28 weeks

For IUFD at ≥ 14 to ≤ 28 weeks:
Recommend medical management by generalist medical practitioners and specialist medical practitioners. (S)
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Suggest medical management by traditional and complementary medicine professionals, auxiliary nurses/ ANMs, nurses, midwives and associate/advanced associate clinicians. (C)
  • Condition: In contexts where established and easy access to appropriate surgical backup and proper infrastructure is available to address incomplete abortion or other complications.
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POST-ABORTION

Follow-up care or additional services

Following uncomplicated surgical abortion or medical abortion: Recommend that there is no medical need for a routine follow-up visit. However, information should be provided about the availability of additional services if they are needed or desired. (S)
  • Women, girls and other pregnant persons must be adequately informed about symptoms of ongoing pregnancy (which may or may not indicate failure of the abortion) and other medical reasons to return for follow-up, such as prolonged heavy bleeding, no bleeding at all with medical management of abortion, pain not relieved by medication, or fever.
  • The quality of the evidence was low (observational studies and indirect evidence).
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Incomplete abortion

For incomplete abortion at < 14 weeks, recommend either vacuum aspiration or medical management. (S)
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For the medical management of incomplete abortion at < 14 weeks uterine size: Suggest the use of 600 μg misoprostol administered orally or 400 μg misoprostol administered sublingually. (C)
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For the medical management of incomplete abortion at ≥ 14 weeks uterine size: Suggest the use of repeat doses of 400 μg misoprostol administered sublingually, vaginally or buccally every 3 hours.* (C)
  • The decision about the mode of management of incomplete abortion should be based on the individual’s clinical condition and preference for treatment.
  • Expectant management of incomplete abortion can be as effective as misoprostol; it can be offered as an option on the condition that the woman, girl or other pregnant person is informed of the longer time for expulsion of the pregnancy tissue and the increased risk of incomplete emptying of the uterus.
  • Recommendation 35 was extrapolated from research conducted in women with reported spontaneous abortion.
* Misoprostol can be repeated at the noted interval as needed to achieve success of the abortion process. At gestational ages ≥ 14 weeks, providers
should use caution and clinical judgement to decide the maximum number of doses of misoprostol in pregnant individuals with prior uterine incision.
Uterine rupture is a rare complication; clinical judgement and health system preparedness for emergency management of uterine rupture must be
considered with advanced gestational age.
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Medical management with misoprostol at < 14 weeks

For uncomplicated incomplete abortion at < 14 weeks: Recommend medical management with misoprostol by community health workers, pharmacy workers, pharmacists, traditional and complementary medicine professionals, auxiliary nurses/ANMs, nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist medical practitioners. (S)
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Vacuum aspiration at < 14 weeks

For uncomplicated incomplete abortion at < 14 weeks:
Recommend vacuum aspiration by traditional and complementary medicine professionals, nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist medical practitioners. (S)
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Suggest vacuum aspiration by auxiliary nurses/ANMs. (C)
Condition: In contexts where established health system mechanisms involve auxiliary nurses/ANMs in providing basic emergency obstetric
care, and where referral and monitoring systems are strong.
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Management of non-life-threatening complications

Infection

For non-life-threatening post-abortion infection: Recommend initial management by traditional and complementary medicine professionals, auxiliary nurses/ANMs, nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist
medical practitioners.* (S)
* For the pharmacists, pharmacy workers and community health workers, it is important that they are equipped with the knowledge to recognize signs
and symptoms of this complication.
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Haemorrhage

For non-life-threatening post-abortion haemorrhage: Recommend initial management by traditional and complementary medicine professionals, auxiliary nurses/ANMs, nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist
medical practitioners.* (S)
* For the pharmacists, pharmacy workers and community health workers, it is important that they are equipped with the knowledge to recognize signs
and symptoms of this complication.
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Timing of post-abortion contraception

Medical eligibility criteria (MEC) for contraceptive use

The following contraceptive methods may be started immediately (MEC Category 1 – no restrictions) after a surgical or medical abortion (first and second trimester, and also after a septic abortion): combined hormonal contraceptives (CHCs), progesterone-only contraceptives (POCs) and barrier methods (condoms, spermicide, diaphragm, cap – note: The diaphragm and cap are unsuitable until 6 weeks after second-trimester abortion).

Intrauterine devices (IUDs) may be started immediately after a first-trimester surgical or medical abortion (MEC Category 1 – no restrictions) or after second-trimester abortion (MEC Category 2 – the advantages generally outweigh the risks), but should not be started immediately after septic abortion (MEC Category 4 – insertion of an IUD may substantially worsen the condition).

Fertility-awareness-based (FAB) methods: Symptom-based methods should only be started after abortion with “caution” (special counselling may be needed to ensure correct use of the method in this circumstance) and the use of calendar-based methods should be delayed (until the condition is evaluated; alternative temporary methods of contraception should be offered). (GPS)
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Contraception and surgical abortion

For individuals undergoing surgical abortion and wishing to use contraception: Recommend the option of initiating the contraception at the time of surgical abortion. (S)
The quality of evidence based on randomized controlled trials was very low.
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Contraception and medical abortion

For individuals undergoing medical abortion with the combination mifepristone and misoprostol regimen or with
misoprostol alone:
For those who choose to use hormonal contraception (pills, patch, ring, implant or injections): Suggest that they be given the option of starting hormonal contraception immediately after the first pill of the medical abortion regimen. (C)
  • This recommendation applies to the combination mifepristone plus misoprostol regimen and the use of misoprostol alone. The letrozole plus misoprostol combination regimen is not mentioned here because the included studies informing these recommendations did not assess this regimen.
  • Immediate initiation of intramuscular depot medroxyprogesterone acetate (DMPA) is associated with a slight decrease in the effectiveness of medical abortion regimens. However, immediate initiation of DMPA should still be offered as an available contraceptive method after an abortion.
  • Indirect evidence was used as a basis for decision-making on initiation of hormonal contraception as an option for individuals undergoing medical abortion with misoprostol alone.
  • No data were available on the use of combined hormonal contraception (pills or injections) by those undergoing medical abortion.
  • Individuals who choose to initiate the contraceptive ring should be instructed to check for expulsion of the ring in the event of heavy bleeding during the medical abortion process.
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For those who choose to have an IUD inserted: Suggest IUD placement at the time that success of the abortion procedure is determined. (C)
This recommendation applies to the combination mifepristone plus misoprostol regimen and the use of misoprostol alone. The letrozole plus misoprostol combination regimen is not mentioned here because the included studies informing these recommendations did not assess this regimen.
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Intrauterine devices (IUDs)

For intrauterine devices (IUDs):
Recommend insertion/removal by auxiliary nurse midwives, nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist medical practitioners. (S)
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Suggest insertion/removal by traditional and complementary medicine professionals (TCMPs) and auxiliary nurses (ANs). (C)
  • Condition (TCMPs): In contexts with established health system mechanisms for the participation of these professionals in other tasks related to maternal and reproductive health.
  • Condition (ANs): In the context of rigorous research.
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Contraceptive implants

For contraceptive implants:
Recommend insertion/removal by nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist medical practitioners. (S)
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Suggest insertion/removal by community health workers (CHWs), traditional and complementary medicine professionals (TCMPs), auxiliary nurses (ANs)/ANMs. (C)
  • Condition (CHWs): In the context of rigorous research.
  • Condition (TCMPs): In contexts with established health system mechanisms for the participation of these professionals in other tasks related to maternal and reproductive health and where training in implant removal is given along with training in insertion.
  • Condition (ANs/ANMs): In the context of targeted monitoring and evaluation.
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Injectable contraceptives

For injectable contraceptives (initiation and continuation): Recommend administration by self (see Recommendation 51), community health workers, pharmacy workers, pharmacists, traditional and complementary medicine professionals, auxiliary nurses/ANMs, nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist medical practitioners. (S)
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Tubal ligation

For tubal ligation:
Recommend tubal ligation by associate/advanced associate clinicians, generalist medical practitioners and specialist medical practitioners. (S)
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Suggest tubal ligation by nurses and midwives. (C)
Condition: In the context of rigorous research.
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SERVICE-DELIVERY OPTIONS AND SELF-MANAGEMENT APPROACHES

Telemedicine approaches to delivering medical abortion care

Recommend the option of telemedicine as an alternative to in-person interactions with the health worker to deliver medical abortion services in whole or in part. (S)
  • The above recommendation applies to assessment of eligibility for medical abortion, counselling and/or instruction relating to the abortion process, providing instruction for and active facilitation of the administration of medicines, and follow-up post-abortion care, all through telemedicine.
  • Hotlines, digital apps or one-way modes of communication (e.g. reminder text messages) that simply provide information were not included in the review of evidence for this recommendation.
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Service-delivery approaches for provision of information, counselling and medical abortion

Best Practice Statement on service delivery

Part 1. There is no single recommended approach to providing abortion services. The choice of specific health worker(s) (from among the recommended options) or management by the individual themself, and the location of service provision (from among the recommended options) will depend on the values and preferences of the woman, girl or other pregnant person, available resources, and the national and local context. A plurality of service-delivery approaches can co-exist within any given context.

Part 2. Given that service-delivery approaches can be diverse, it is important to ensure that for the individual seeking care, the range of service-delivery options taken together will provide:
  • access to scientifically accurate, understandable information at all stages;
  • access to quality-assured medicines (including those for pain management);
  • back-up referral support if desired or needed;
  • linkages to an appropriate choice of contraceptive services for those who want post-abortion contraception.
(GPS)
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Self-management of medical abortion at < 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.
(S)
  • 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 selfmanagement within the regulatory framework of the health system.
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Self-management approaches for post-abortion contraception

Injectable contraception (initiation and continuation)

Recommend the option of self-administration of injectable contraception in the post-abortion period. (S)
The administration of an injectable contraceptive involves using a syringe and may be intramuscular or subcutaneous. Compact pre-filled autodisable devices have been developed to facilitate the self-administration process.
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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. (S)
1226065

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. (S)
1226065

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. (GPS)
1226065

Recommendation Grading

Overview

Title

Abortion Care

Authoring Organization

World Health Organization

Publication Month/Year

March 7, 2022

Last Updated Month/Year

April 1, 2024

Document Type

Guideline

Country of Publication

US

Inclusion Criteria

Female, Adolescent, Adult

Health Care Settings

Ambulatory, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Management

Diseases/Conditions (MeSH)

D000028 - Abortion, Induced, D037881 - Aborted Fetus

Keywords

abortion, induced abortion, medication abortion, medical abortion, Procedural abortion