Elsevier

Contraception

Volume 88, Issue 3, September 2013, Pages 350-363
Contraception

Review article
A review of evidence for safe abortion care

https://doi.org/10.1016/j.contraception.2012.10.027Get rights and content

Abstract

Background

The provision of safe abortion services to women who need them has the potential to drastically reduce or eliminate maternal deaths due to unsafe abortion. The World Health Organization recently updated its evidence-based guidance for safe and effective clinical practices using data from systematic reviews of the literature.

Materials and Methods

Systematic reviews pertaining to the evidence for safe abortion services, from pre-abortion care, medical and surgical methods of abortion and post-abortion care were evaluated for relevant outcomes, primarily those relating to safety, effectiveness and women's preference.

Results

Sixteen systematic reviews were identified and evaluated. The available evidence does not support the use of pre-abortion ultrasound to increase safety. Routine use of cervical preparation with osmotic dilators, mifepristone or misoprostol after 14 weeks gestation reduces complications; at early gestational ages, surgical abortions have very few complications. Prophylactic antibiotics result in lower rates of post-surgical abortion infection. Pain medication such as non-steroidal anti-inflammatories should be offered to women undergoing abortion procedures; acetaminophen, however, is not effective in reducing pain. Women who are eligible should be offered a choice between surgical (vacuum aspiration or dilation and evacuation) and medical methods (mifepristone and misoprostol) of abortion when possible. Modern methods of contraception can be safely initiated immediately following abortion procedures.

Conclusions

Evidence-based guidelines assist health care providers and policymakers to utilize the best data available to provide safe abortion care and prevent the millions of deaths and disabilities that result from unsafe abortion.

Introduction

Globally, unsafe abortion is a frequent and preventable cause of maternal mortality and morbidity. Each year, unsafe abortion results in the death of an estimated 47,000 women and disabilities for an additional five million women worldwide [1]. Almost every death and disability could have been prevented through the provision of safe induced abortion services. To improve the quality of and access to safe services, the World Health Organization (WHO) published the first evidence-based global guidance document for policymakers, program managers and providers of abortion in 2003 [2]. Given the popularity of this document, and the ongoing need for guidance where evidence continually becomes available, this document has recently been revised. This article presents summaries of the evidence reviewed for the recommendations made in the new WHO guidelines for safe abortion care.

The evidence presented here is divided into three distinct areas of abortion services: (1) pre-abortion care (including evidence for use of ultrasound, cervical preparation, antibiotic use, and pain management); (2) methods of medical and surgical abortion at varying gestational ages; and (3) post-abortion care and follow-up (including post-abortion contraception and treatment of incomplete abortion). The evidence summary presented on each topic is intended to provide the available data, their limitations and clinical circumstances in which they apply.

Section snippets

Materials and methods

The evidence presented was collected as part of a standardized WHO process for guideline development. This process includes the following steps: identification of priority questions and outcomes; evidence retrieval, assessment and synthesis; formulation of recommendations; and planning for dissemination, implementation, impact evaluation and updating. The priority questions were determined by identifying those topics for which new data were available or for which feedback to WHO had indicated

Background

Ultrasound assessment before an abortion has been recommended in some guidelines, although there is little evidence to support its use [5]. While ultrasound can be useful for confirming intrauterine pregnancy and gestational age or assessing for pregnancy-related abnormalities, it can also be costly and increase training and maintenance requirements in already under-resourced settings. In addition, if ultrasound training or equipment are inadequate its use can introduce error to gestational age

Discussion

The new WHO clinical guidelines on safe abortion are a tool for clinicians who wish to provide safe abortion based on the best available evidence. These clinical recommendations are meant to be adapted to the local context by program managers and health professionals. Their applicability will depend on larger issues of trained providers and the availability of services and medications (such as mifepristone) within each setting.

The evidence for the WHO recommendations was based on systematic

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    The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the World Health Organization or Ipas.

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