Expanding health worker roles for safe abortion in the first trimester of pregnancy Summary
photo: Ipas
Safe abortion and post-abortion care in early pregnancy can be provided at the primary care level and by a range of health workers, including non-physicians. Key messages Tasks related to safe abortion care in the first trimester that can be safely and effectively provided at the primary care level by trained health workers other than specialist physicians include: vacuum aspiration to induce abortion or to manage an uncomplicated incomplete abortion or miscarriage (i.e. removal of retained products as part of basic emergency obstetric care); medical abortion with mifepristone and misoprostol (or misoprostol alone where mifepristone is not available); using misoprostol for management of uncomplicated incomplete abortion or miscarriage (i.e. removal of retained products as part of basic emergency obstetric care) for uterine size up to 13 weeks. Expansion of health worker roles must take place within overall efforts to increase access to safe abortion. It must be accompanied by appropriate mechanisms for training and ongoing monitoring and mentoring support for all cadres providing these services. NOTE All these tasks have been recommended as safe and effective in the WHO document: Safe abortion: technical and policy guidance for health systems.1 The technical guidelines on performing these tasks apply to all cadres of health workers providing such care. 1
Who is this summary for? Policy and programme decision makers.
What does this summary contain? WHO recommendations on safe, effective and feasible options for task shifting and task sharing in providing safe abortion care in the first trimester.
Why expand health worker roles? To address shortages of specialist doctors. To enable provision of care at primary care level. To facilitate access to safe and timely care for women.
Safe abortion: technical and policy guidance for health systems. Geneva: World Health Organization; 2012 (http://www.who.int/reproductivehealth/publications/unsafe_ abortion/9789241548434/en/, accessed 21 April 2016).
2 Expanding health worker roles for safe abortion in the first trimester of pregnancy
Recommendation symbols
Recommended
Recommended in specific circumstances
Recommended in the context of rigorous research
Health worker cadres Health worker type Specialist doctor Non-specialist doctor
Illustrative examples Gynaecologist, obstetrician Family doctor, general practitioner
Advanced associate and associate clinician
Assistant medical officer, clinical officer, medical licentiate practitioner, health officer, physician assistant, surgical technician, non-physician clinician, medical assistant, nurse practitioner
Midwife
Registered midwife, midwife, community midwife, nurse-midwife
Nurse
Registered nurse, clinical nurse specialist, licensed nurse, BSc nurse
Auxiliary nurse midwife (ANM) and auxiliary nurse
Auxiliary midwife, auxiliary nurse, ANMs, family welfare visitor
Doctor of complementary systems of medicine (mainly in South Asia)
Ayush doctor, Ayurvedic physician, non-allopathic physician
Pharmacist
Pharmacist, chemist, clinical pharmacist, community pharmacist
Pharmacy worker
Pharmacy assistant, pharmacy technician dispenser, pharmacist aide
Lay health worker
Community health worker, village health worker, female community health volunteer
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Recommendations Vacuum aspiration WHAT? Manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA) can be used in the first trimester for: induced abortion, and managing uncomplicated incomplete abortion/miscarriage.
WHERE? Primary care level (as an outpatient procedure)
WHO? Nurses, midwives, associate and advanced associate clinicians, non-specialist doctors and specialist doctors
Auxiliary nurses and auxiliary nurse midwives in contexts where there are established mechanisms to include them in providing basic emergency obstetric care (EmOC) and where referral systems exist. Doctors of complementary systems of medicine in contexts where these doctors are a significant part of the health workforce and where established health system mechanisms for their participation in other tasks related to maternal and reproductive health exist. NOTE Health workers who can perform a pelvic exam to diagnose and date a pregnancy can also be trained to perform vacuum aspiration. More training and experience is needed for the use of MVA at 12–14 weeks pregnancy duration as compared to the use of MVA at < 12 weeks.
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Medical abortion WHAT? In the first trimester, medical abortion (MA) is a multi-step process using two medications (mifepristone and misoprostol) or multiple doses of misoprostol alone (if mifepristone is not available). The process can be divided into the following subtasks: Determine medical eligibility for MA (i.e. assess pregnancy status and duration, rule out medical contraindications and screen for ectopic pregnancy); Manage the medications and common side-effects (i.e. administer the medications with instructions for use, provide information about managing pain and other anticipated minor side-effects, including when and how to seek emergency assistance if needed); Determine successful completion of the abortion or need for further intervention.
WHERE? Primary care level (for pregnancies up to 10 weeks, management of the medications and assessment of completeness can take place outside of the facility, including at home)
WHO? Auxiliary nurses and auxiliary nurse midwives, nurses, midwives, associate and advanced associate clinicians, non-specialist doctors and specialist doctors. Doctors of complementary systems of medicine in contexts where these doctors are a significant part of the health workforce and where established health system mechanisms for their participation in other tasks related to maternal and reproductive health exist. Pharmacists and lay health workers: Given their presence in the community and close proximity to women, further research into the effectiveness and feasibility of these providers playing a role in all of the subtasks of MA is important. NOTE One health worker can perform all of the subtasks, or different health workers can perform any of the subtasks. It is not essential that the person providing the MA should also be trained and competent in MVA provision. In case of failure of medical abortion, MVA can be made available via another trained provider or at another facility.
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Medical abortion continued ALSO: Given the nature of the MA process, women themselves have an important role to play in managing this process. Further research is needed on women self-assessing eligibility for medical abortion.
Once initial eligibility has been assessed by an appropriate health worker and in contexts where women have a source of accurate information and access to a health-care provider should they need or want it at any stage of the process, women can: manage the mifepristone and misoprostol medication without direct supervision of a health-care provider and outside of a health-care facility; self-assess completion of the abortion process using low-sensitivity pregnancy tests and simple checklists.
Medical management of uncomplicated incomplete abortion WHAT? Management of uncomplicated incomplete abortion (i.e. removal of retained products) may be required after induced abortion or after spontaneous abortion. The medical management is identical in both cases. The procedure includes recognizing the condition, assessing uterine size and administering misoprostol in the correct dose.
WHERE? Primary care level (as an outpatient procedure)
WHO?
Auxiliary nurses and auxiliary nurse midwives, nurses, midwives, associate and advanced associate clinicians, non-specialist doctors and specialist doctors.
Doctors of complementary systems of medicine in contexts where these doctors are a significant part of the health workforce and where established health system mechanisms for their participation in other tasks related to maternal and reproductive health exist. NOTE The evacuation of retained products is a signal function of basic EmOC, thus training and implementation of these tasks can be integrated with EmOC services.
6 Expanding health worker roles for safe abortion in the first trimester of pregnancy
Providing information on safe abortion WHAT? This includes providing information on how to access safe providers, total cost of care, specifics of national laws and policies concerning conditions under which abortion is permitted, and the importance of early care seeking. Increasing health workers’ ability to provide accurate and appropriate information about safe abortion and post-abortion care ensures that women receive the information they need to obtain services and thus reduces the number of women who are at risk of unsafe abortion.
WHERE? Community level; primary care level
WHO?
Lay health workers, pharmacists, doctors of complementary systems of medicine, auxiliary nurses and auxiliary nurse midwives, nurses, midwives, associate and advanced associate clinicians, non-specialist doctors and specialist doctors.
Pharmacy workers in contexts where they are under the direct supervision of a pharmacist and where there is access to a referral linkage with a formal health system. NOTE All health workers have an obligation to ensure that scientifically correct information is provided and they should be trained to be able to fulfil this role.
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Providing pre- and post-abortion counselling WHAT? Counselling is more than providing information. It is a focused, interactive and voluntary process that allows individuals to obtain support, information and non-directive guidance from a trained person. Providing quality pre- and post-abortion counselling requires providers to have specific knowledge about safe abortion care, and this process is closely linked to the provision of the actual service.
WHERE? Wherever abortion-related services are provided
WHO?
Auxiliary nurses and auxiliary nurse midwives, nurses, midwives, associate and advanced associate clinicians, non-specialist doctors and specialist doctors.
Doctors of complementary systems of medicine in contexts where these doctors are a significant part of the health workforce and where established mechanisms for their participation in other tasks related to maternal and reproductive health exist.
Specifically trained lay health workers can play a supportive role in contexts where the provider managing the procedure is unavailable to provide counselling or the woman needs additional support.
Providing post-abortion contraception Contraception can be provided immediately post-abortion, and women should have information about and access to all contraceptive options. Technical details about the initiation of methods in the postabortion period and about the delivery of these services can be found in Safe abortion: technical and policy guidance for health systems and in the Medical eligibility criteria for contraceptive use2. A range of health workers can provide post-abortion contraception.
2
Medical eligibility criteria for contraceptive use. Geneva: World Health Organization; 2015 (http://who.int/reproductivehealth/ publications/family_planning/MEC-5/en/, accessed 21 April 2016).
8 Expanding health worker roles for safe abortion in the first trimester of pregnancy
Implementation considerations The options recommended in this brief are intended to be inclusive. They do not imply either a preference for or an exclusion of any particular type of provider. The choice of a specific health worker for a specific task will depend upon the needs and conditions of the local context. Expansion of health worker roles in abortion care should occur as part of a planned and regulated strategy including the development of mechanisms for training and ongoing monitoring. It is important to include stakeholders in the planning process and to address their concerns in order to foster trust and secure their support for complementary roles, and to create an enabling environment. Some providers may be uncomfortable shifting tasks, and some health workers may have concerns about the impact of taking on additional roles. It is also important to consider health workers’ potential needs regarding security, remuneration and non-monetary recognition of expanded roles. Legal and policy barriers to implementing these recommendations must be addressed. This could include developing mechanisms that allow selected health worker cadres to prescribe the medications used for abortion, revising regulations to allow services to be provided at primary-level facilities, or changing guidelines to permit non-physicians to provide safe abortion and post-abortion services. Health workers should be appropriately trained for their new roles using competency-based training. Including this training in pre-service curricula is important to sustain task shifting at scale and over time. Training must also promote respectful and non-judgemental care for women seeking care irrespective of the personal beliefs of the health worker. If a health worker conscientiously objects to providing abortion care, he or she must ensure that the woman is referred in a timely manner to a different provider for appropriate care.
Where can you find additional information? Health worker roles in providing safe abortion care and post-abortion contraception. PDFs for download and interactive version both available from: http://srhr.org/safeabortion/
Clinical practice handbook for safe abortion Available from: http://www.who.int/ reproductivehealth/publications/ unsafe_abortion/clinical-practice-safeabortion/en/
Safe abortion: technical and policy guidance for health systems Available from: http://www.who.int/ reproductivehealth/publications/ unsafe_abortion/9789241548434/ en/
For more information, please contact: Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, CH-1211 Geneva 27, Switzerland. E-mail: reproductivehealth@who.int www.who.int/reproductivehealth WHO/RHR/16.02 © World Health Organization 2016
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