Unsafe abortion occurs when a pregnancy is terminated either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. Safe abortions are those performed in accordance with WHO guidelines and standards, thus ensuring that the risk of severe complications is minimal. The rate of unsafe abortions is higher where access to effective contraception and safe abortion care is limited or unavailable.
Life-threatening complications that may result from unsafe abortion include haemorrhage, infection, and injury to the genital tract and internal organs. In addition to the deaths and disabilities caused by unsafe abortion, there are major social and financial costs to women, families, communities and health systems. Almost every abortion-related death and disability could be prevented through sexuality education, use of effective contraception, provision of safe and legal induced abortion, and timely care for complications.
The overall vision of this initiative is a comprehensive approach to maternal mortality reduction through health systems strengthening, with a specific focus on maternal mortality and morbidity caused by complications due to unsafe abortion. HRP coordinates implementation and monitoring through a technical working group that brings together all three levels of WHO. This initiative includes ten countries across four WHO regions and six departments at WHO headquarters.
Strengthened policy and regulatory environment for essential sexual and reproductive health services
National guidelines aligned with WHO recommendations
National guidelines related to post-abortion care and family planning were revised in Sierra Leone. National standards and guidelines on the prevention of unsafe abortion and post-abortion care were updated and put into practice in the Lao People’s Democratic Republic. In collaboration with the WHO Regional Office for Africa, 11 African countries (Angola, Burundi, Ethiopia, Gabon, Guinea-Bissau, Lesotho, Liberia, Madagascar, Mali, Niger and Zimbabwe) have been supported through building their national capacity to review and update national guidelines, and to develop national scorecards to monitor implementation.
Sierra Leone has revised its national model list of essential medicines to include Misoprostol for post-abortion care. Revisions to align national lists with the WHO Model List of Essential Medicines have been initiated in Benin, Lao People’s Democratic Republic, Pakistan, and Rwanda.
Integrating comprehensive abortion care and family planning competencies in educational programmes
As a response to requests received from many WHO country offices, HRP has initiated a comprehensive abortion care and family planning toolkit for health workforce strengthening. The toolkit: outlines comprehensive abortion care and family planning competencies; suggests competency-based curricula guidance; provides guidance on implementation, monitoring, and evaluation of competency-based education; and includes a checklist to facilitate the understanding of the roles, rights and responsibilities of health workers involved in comprehensive abortion care and family planning services.
To help strengthen the capacity and quality of education programmes, several countries (Benin, Nepal, Pakistan, Rwanda) have assessed their national curricula for the training of medical doctors, midwives, and nurses. Based on the findings, WHO country offices have collaborated with national education institutions to introduce comprehensive abortion care and family planning competencies into existing medical, nursing and midwifery pre-service curricula; to equip skills labs; and to enhance the capacity of faculty members.
To address misconceptions, myths and stigmatizing attitudes towards abortion care in the WHO Eastern Mediterranean Region, an online course on Islamic considerations with regards to sexual and reproductive health and rights, including family planning and comprehensive abortion care, was pilot tested and finalized.
Improving systematic monitoring and evaluation of abortion related indicators
As a contribution to the “Harmonized Health Facility Assessment”, a list of core abortion care indicators was developed to measure service availability, readiness, and quality of care. These indicators have been piloted in Pakistan and Burkina Faso, and are currently being tested in Rwanda, Uganda, and Zambia. Questionnaires were also developed for the population-based “World Health Survey Plus”, so that it includes measures of core indicators of abortion incidence and safety, abortion-related decision making, quality of care, health system support for access to care, and the level of awareness of the legal status of abortion.
Several countries (Benin, Burkina Faso, India, Lao People’s Democratic Republic, Pakistan, Rwanda, Sierra Leone, South Africa) have successfully included comprehensive abortion care and family planning indicators in their national health management information systems. HRP has been supporting these efforts and has facilitated learning between regions based on these countries’ experiences.
Strengthening access to quality-assured essential SRH medicines and health products
Based on essential medicine assessments conducted in 2020, five countries (Afghanistan, Iraq, Lebanon, Morocco, and Pakistan) have been supported to address the gaps identified. Three countries (Libya, occupied Palestinian territory, including east Jerusalem, and Somalia) began their assessments in 2021, and occupied Palestinian territory, including east Jerusalem and Somalia have already disseminated their findings to national policy-makers, programme managers and other stakeholders.
Incorporating CAC services in national basic health service packages
In collaboration with the WHO Health Governance and Financing Department, HRP included questions related to abortion in the current round of the “Global Health Technology Assessment and Health Benefit Package Survey”; results will be available in early 2022.
Results from a multi-country research study led by HRP with partners in 17 countries shed light on the severity of abortion-related complications and their clinical management. Published in BMJ Global Health, results from the facility-based study across 11 sub-Saharan African countries and six Latin American and Caribbean countries also highlight women’s experiences of post-abortion care. Researchers in the 17 countries collected data from more than 20,000 women presenting at over 200 health facilities with an abortion-related complication. Their signs and symptoms were classified into one of five categories, based on severity: deaths, near misses, potentially life-threatening complications, moderate complications, and mild complications. The majority of women in the study suffered a mild to moderate complication. However, twice as many women in the African sites than in the Latin America and Caribbean sites had a potentially life-threating complication, or nearly died.
Read the HRP project brief: https://www.who.int/publications/m/item/who-multi-country-survey-on-abortion-(whomcs-a)
There are growing concerns about the negative health impact of substandard and falsified medicines (also known as “out of specification” drugs), particularly in low- and middle-income countries – including several medicines on the WHO Model List of Essential Medicines, such as misoprostol. In 2021, HRP collaborated with the WHO Access to Medicines and Health Products division to publish a Medical Product Alert for a falsified CYTOTEC (misoprostol) product reported at wholesale and patient level in Cameroon, the Democratic Republic of Congo, Ghana and Nigeria.
