Pre- and post-abortion counselling The provision of scientifically accurate and easy-to-understand information to all women undergoing an abortion, and non-directive voluntary counselling to women who request it, is a core element of good quality abortion services. Comprehensive contraceptive information and services should be routinely integrated with abortion and post-abortion care (15). However, counselling is more than information provision and refers to a focused, interactive process through which the woman voluntarily receives support, information and non-directive guidance from a trained person (14). It requires a much higher level of specific knowledge than providing general information about safe abortion care. Table 17 gives the recommendations.
Specialist doctors Recommended Within their typical scope of practice. No assessment of the evidence was therefore conducted. Non-specialist doctors Recommended There was no direct evidence for the safety or effectiveness of this option as compared to specialist doctors. However, it appears to be feasible in both highand low-resource settings where D&E use is common. Such doctors also routinely perform other surgical procedures like caesarean section, vacuum extraction and tubal ligation. The potential benefits of this option outweigh the harms. A specialist provider may not always be available on-site and this option may increase the ability of the health system to provide care for women needing it. Associate and advanced associate clinicians Recommended within the context of rigorous research There was no direct evidence for the safety or effectiveness. However, the potential benefits outweigh the possible harms and the option has the potential to reduce inequities in access and increase the likelihood of facilities being able to provide care in the second trimester. It is therefore important to test this option under research conditions. Doctors of complementary systems of medicine Recommended against There was no direct evidence for the safety, effectiveness or feasibility of this option. The procedure requires skills beyond what is required for vacuum aspiration in pregnancies up to 12 weeks and the procedure is usually performed at facilities where specialist or non-specialist doctors are available. Midwives, nurses, nurse-midwives, auxiliary nurse midwives, pharmacists, pharmacy workers, lay health workers Recommended against Outside of their typical scope of practice. N
Medical abortion in the first trimester Medical abortion (MA) refers to the sequential use of mifepristone followed by misoprostol or, in settings where mifepristone is not available, the use of misoprostol alone. The specific dosage, routes and regimens are different at differing pregnancy durations and are detailed in the Clinical practice handbook for safe abortion (14). MA is a process that takes place over a period of several days rather than being a discrete procedure. The process includes several components or subtasks: • assessing eligibility for MA (diagnosing and dating the pregnancy, ruling out medical contraindications, screening for possible ectopic pregnancy); • administering the medications with instructions on their appropriate use and managing the common side-effects; • assessing that the abortion process is complete and that no further intervention is required.
Auxiliary nurses (AN) and auxiliary nurse midwives (ANM) Recommended in specific circumstances We recommend this option in contexts where established mechanisms to include ANMs/ANs in providing basic emergency obstetric care or postabortion care already exist. Although there was insufficient direct research evidence for the effectiveness of this option, the benefits outweigh any possible harms. The option has also been shown to be feasible, including at scale in low-resource settings, and has the potential to decrease inequities by extending safe abortion care to rural and underserved populations. Doctors of complementary systems of medicine Recommended in specific circumstances We recommend this option in contexts with established health system mechanisms for the participation of doctors of complementary systems of medicine in other tasks related to maternal and reproductive health. There is evidence for the effectiveness of components of the task, e.g. assessing uterine size with bimanual examination as part of medical abortion provision (low certainty). These professionals perform transcervical procedures such as IUD insertion in some settings. The benefits outweigh possible harms and the option has the potential to increase equitable access to safe abortion care in regions where these professionals constitute a significant proportion of the health workforce. Pharmacists, pharmacy workers, lay health workers Recommended against Outside of their typical scope of practice. No assessment of the evidence was therefore conducted.
Specialist doctors, non-specialist doctors Recommended Within their typical scope of practice. No assessment of the evidence was therefore conducted. Associate and advanced associate clinicians Recommended There is evidence for the safety and effectiveness (moderate certainty) and for women’s satisfaction with the overall abortion experience (low certainty). This option is feasible in both high- and low-resource settings, and may decrease inequities by extending safe abortion care to underserved populations. Midwives Recommended There is evidence for the safety and effectiveness (moderate certainty) and for women’s satisfaction with the overall abortion experience (low certainty). This task is recognized as a core competency in midwifery. Women often consider care received from midwives as more supportive (moderate confidence). The option has been shown to be feasible, including in low-resource settings. Nurses Recommended There is evidence for the safety and effectiveness (low certainty) and for women’s satisfaction with this option (low certainty). Women often consider care received from nurses as more supportive (moderate confidence). The option is feasible and may decrease inequities by extending safe abortion care to underserved populations.
Recommendations General considerations • The recommendations include tasks related to safe abortion care (including post-abortion contraception) and the management of complications of abortion (also known as post-abortion care in some settings and provided as part of emergency obstetric care). • Recommendations about who can provide care have been made only for clinical interventions that have been recommended as safe and effective according to current WHO technical guidance i.e. Safe abortion: technical and policy guidance for health systems (3). The recommendations in this guideline should be implemented in accordance with the technical standards and human rights principles as laid down in that document. • The recommendations are not targeted specifically to low-resource or low-income settings; they are intended for all settings where abortion-related care is provided. • The recommendations are intended to be implemented within the context of functioning mechanisms for referral, monitoring and supervision, as well as access to the necessary equipment and commodities. • The recommendations provide a range of options of types of health workers who can perform the specific task safely and effectively. The options are intended to be inclusive and do not imply either a preference for or an exclusion of any particular type of provider. The specific choice of health workers depends upon the needs and conditions of the local context. It is also important to note that the following assumption underlies all the options that have been recommended in this guideline: • It is assumed that any health worker discussed in this guideline has the basic training required of that type of health worker. In addition, the recommendations all assume that health workers will receive the training or information specific to the task, prior to implementation of the recommendation option. It is important to interpret all of the recommendations that follow in the context of these general considerations and assumptions.
Recommendation categories Four types of recommendations are made: Recommended The benefits of implementing this option outweigh the possible harms. This option can be implemented including at scale. For certain health worker–task combinations, the GDG decided that the option was within the typical scope of practice of the health worker. No assessment of evidence was made in such cases and this has been noted in the justification. Recommended in specific circumstances The benefits of implementing this option outweigh the possible harms in specific circumstances. The specific circumstances are outlined for each recommendation. This option can be implemented under these specific circumstances. Recommended in the context of rigorous research There are important uncertainties about this option (related to benefits, harms, acceptability and feasibility) and appropriate, well designed and rigorous research is needed to address these uncertainties. Recommended against This form of task shifting should not be implemented. For certain health worker–task combinations, the GDG decided that the option was outside the typical scope of practice of the health worker. No assessment of evidence was made in such cases and this has been noted in the justification. The explanation and justification for each recommendation is provided and the certainty of the evidence has been indicated where appropriate as follows: • High certainty: Further research is very unlikely to change our confidence in the estimate of effect. • Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. • Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. • Very low certainty: We are very uncertain about the estimate. Confidence assessments of qualitative research evidence are referred to in the following terms: • High confidence: It is highly likely that the review finding is a reasonable representation of the phenomenon of interest. • Moderate confidence: It is likely that the review finding is a reasonable representation of the phenomenon of interest. • Low confidence: It is possible that the review finding is a reasonable representation of the phenomenon of interest. • Very low confidence: It is not clear whether the review finding is a reasonable representation of the phenomenon of interest
Use of the frameworks for decision-making Draft EtD frameworks were prepared by the Steering Group and Core Evidence Team. These were reviewed by the GDG and recommendations finalized during the meeting in October 2014. In addition to the frameworks, the GDG also had access to all the evidence profiles and supplementary materials. Decisions at the GDG meeting were consensus driven. The Chair allowed for discussion of differing views on recommendation options and the final decision was based on majority opinion, provided the panel members with opposing views were willing to agree to this outcome. An option for noting dissenting opinions was available, but it did not need to be used, nor did voting need to be resorted to. Document preparation and peer review The Responsible Officer at WHO worked with a consultant to write the draft guideline. The GDG reviewed the draft and their feedback was incorporated. The guideline was also reviewed by external peer reviewers unconnected with the process of guideline development. They provided structured feedback on accuracy, presentation, implementation considerations and on the overall usefulness of the guideline. No serious factual errors affecting recommendations were noted by the peer reviewers.
Assessment of confidence in the evidence The certainty (i.e. the extent to which one can be confident that an estimate of the effect or association is correct) of the benefits and harms outcomes was assessed using the GRADE approach. Five criteria – study limitations, consistency of effect, imprecision, indirectness and publication bias – were used to assess the certainty for each outcome. Evidence was downgraded by one level for serious and by two levels for very serious limitations. Assessments were made independently by two GRADE methodologists. Confidence in findings from the reviews of qualitative studies was assessed with the CERQual tool, utilizing an approach similar to GRADE. Each review finding was assessed on four factors: • the methodological limitations of the individual qualitative studies contributing to the review finding, assessed using an appropriate qualitative critical appraisal tool; • the relevance of a review finding, assessed by the extent to which the supporting evidence is applicable to the context specified in the review question; • the coherence of each review finding, assessed by the extent to which the review finding was based on data that were similar across multiple individual studies and/or incorporated convincing explanations for any variations; • the adequacy of data supporting the review finding, assessed by determining the degree of richness and/or scope, as well as the quantity of data supporting a review finding. An overall judgment of the confidence in each review finding was made, based on all of the above. Where existing systematic reviews were used, confidence assessments as reported in the original reviews were used. Assessing the confidence in each finding was not possible for the case study synthesis given that these findings were based on a wide range of evidence types. Moving from evidence to recommendations In order to follow a systematic process that explicitly considers the various factors that inform decisions on recommendations, the Evidence to Decision (EtD) frameworks developed by the DECIDE collaboration were used.2 One framework was prepared for each question using a pre-set template. All systematically synthesized evidence as well as additional information was summarized into the following sections: • Background information: – This section contains information about the PICO, the context and general information about the task. • Benefits and harms: – The section contains the Summary of Findings (SoF) tables on safety, effectiveness and satisfaction, a narrative description of the included studies, and relevant additional contextual information. • Acceptability: – This section contains the summary of key findings from qualitative studies regarding the extent to which a task-shifting intervention is considered to be reasonable among women potentially or actually receiving abortion care and among health workers potentially or actually delivering this care. Acceptability to women was prior.
Scoping and formulation of the guideline questions
The initial list of tasks and health worker types to be considered for the guideline was developed on the basis of input and insights gained from previous technical consultations and regional meetings on safe abortion in Riga, Latvia (May 2012), Addis Ababa, Ethiopia (September 2012), Kathmandu, Nepal (September 2012), and Nairobi, Kenya (November 2012). Additionally, an online questionnaire was sent to a purposively selected group of approximately 90 knowledgeable individuals to help define some of the relevant health worker categories, country-level practices and health worker roles. Responses were received from 35 people many of whom provided further input on national policies relating to health worker roles. The preliminary list was finalized in consultation with the GDG. Formulation of questions Agreed on questions on health worker–task combinations were formulated in PICO (population, intervention, comparator, outcome) format. The prioritized outcomes were as follows: • Benefits and harms: – safety: serious adverse events, complications (specific to the task); – effectiveness (specific to the task); – satisfaction of women receiving care with the overall services/health worker providing the care. • Acceptability: – findings reported in qualitative research regarding the extent to which a task-shifting intervention is considered to be reasonable or adequate among women potentially or actually receiving abortion care, and among health workers potentially or actually delivering this care. • Feasibility: – findings from qualitative studies on factors affecting implementation of task-shifting programmes at scale.
Doctor of complementary systems of medicine For the purpose of this guideline, this refers to a professional of traditional and complementary systems of medicine (non-allopathic physician) whose training includes a 4- or 5-year university degree that teaches the study of human anatomy, physiology, management of normal labour and the pharmacology of modern medicines used in obstetrics and gynaecology, in addition to their systems of medicine. For the purpose of this guideline, these doctors are included with reference to the provision of elements of abortion-related care as per conventional medical practice. Ayush doctor, Ayurvedic physician, non-allopathic physician Pharmacist For the purpose of this guideline, this refers to a health practitioner who dispenses medicinal products. A pharmacist can counsel on the proper use and adverse effects of drugs and medicines following prescriptions issued by medical doctors/health professionals. Education includes university-level training in theoretical and practical pharmacy, pharmaceutical chemistry or a related field. Pharmacist (USA), chemist (United Kingdom and the Commonwealth), clinical pharmacist, community pharmacist Pharmacy worker For the purpose of this guideline, this refers to technicians and assistants who perform a variety of tasks associated with dispensing medicinal products under the guidance of a pharmacist. They inventory, prepare and store medications and other pharmaceutical compounds and supplies, and may dispense medicines and drugs to clients and instruct on their use as prescribed by health professionals. Technicians typically receive 2–3 years training in a pharmaceutical school, with an award not equivalent to a university degree. Assistants have usually been through 2–3 years of secondary school with a subsequent period of on-the-job training or apprenticeship. Pharmacy assistant, pharmacy technician dispenser, pharmacist aide, dispensary assistant Lay health worker For the purpose of this guideline, this refers to a person who performs functions related to health-care delivery/ information provision and was trained in some way in the context of the task, but has received no formal professional or paraprofessional certificate or tertiary education degree. Community health worker, village health worker, female community health volunteer