Review articleA review of evidence for safe abortion care☆
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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Cited by (42)
Interruption of pregnancy between 12 and 16 weeks of gestation: Complications depending on term and method
2022, Gynecologie Obstetrique Fertilite et SenologieA Retrospective Cost-Effectiveness Analysis of Mifepristone–Misoprostol Medical Abortions in the First Year at the Regina General Hospital
2021, Journal of Obstetrics and Gynaecology CanadaCitation Excerpt :There was a significant improvement in completion rate when using mife/miso rather than MTX/miso. Our calculated completion rate of mife/miso was 98.2%, comparable to other studies.3,5–14,16–18 Patients were more likely to choose mife/miso over MTX/miso after the addition of mife/miso to the hospital's formulary in March 2018, when it was free of charge to all WHC patients.
Medical abortion at 13 or more weeks gestation provided through telemedicine: A retrospective review of services
2021, Contraception: XCitation Excerpt :Such services offer medical abortion in early pregnancy; investigation to date has not yet focused on outcomes in pregnancies greater than 12 weeks gestation [4]. Clinical trials in hospital settings have demonstrated that medical abortion remains effective at higher gestational age ranges, with 84% to 91% expelling the fetus within 24 hours provided repeat doses of misoprostol are administered over time [11–18]. Women on Web is a nonprofit telemedicine abortion service attempting to increase abortion access to women living in countries where abortion is legally restricted [7,9,10].
A noninferiority randomized controlled trial to compare transabdominal and transvaginal sonography for eligibility assessment prior to medical abortion
2018, ContraceptionCitation Excerpt :Reliance on ultrasound is one potential barrier to increased abortion access. Guidelines from major organizations and the mifepristone prescribing information (Mifeprex; Danco Laboratories, LLC, New York, NY, USA) do not specify routine sonography as a requirement prior to medical abortion [2–9]. However, many clinic protocols still require routine sonography, and early dating sonography is commonly performed transvaginally, an examination that women may find uncomfortable; no randomized trials have assessed acceptability of transvaginal sonography (TVS) in abortion patients.
Pain management for up to 9 weeks medical abortion – An international survey among abortion providers
2018, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :This is in accordance with the reported onset of pain by most patients. The time of pain occurrence during first trimester medical abortion is poorly studied [26]. In the few studies where this information was available, 11%–40% of patients complained of abdominal pain following mifepristone administration and before misoprostol administration [27,28].
Medication abortion: Potential for improved patient access through pharmacies
2018, Journal of the American Pharmacists AssociationCitation Excerpt :Deaths attributed to clostridial infections have also been reported after vaginal delivery, cesarean section, and miscarriage, and there is no evidence of a causal link between medication abortion and infection.27,35 Administration of prophylactic antibiotics at the time of mifepristone administration is controversial, due in part to the lack of evidence that such treatment eliminates carriage of clostridial species and the potential risks associated with antimicrobials, including adverse effects and the development of antibiotic resistance.36 Medication abortion in the United States is primarily offered by clinicians who were already providing aspiration or surgical abortion.
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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.