The World Health Organization’s Safe Abortion Guidance Document

Abstract

We discuss the history of the World Health Organization’s (WHO’s) development of guidelines for governments on providing safe abortion services, which WHO published as Safe Abortion: Technical and Policy Guidance for Health Systems in 2003 and updated in 2012.

We show how the recognition of the devastating impact of unsafe abortion on women’s health and survival, the impetus of the International Conference on Population and Development and its five-year follow-up, and WHO’s progressive leadership at the end of the century enabled the organization to elaborate guidance on providing safe abortion services.

Guideline formulation involved extensive review of published evidence, an international technical expert meeting to review the draft document, and a protracted in-house review by senior WHO management.

Forty-five years ago, in 1967, the World Health Assembly identified unsafe abortion as a serious public health problem for women in many countries.¹ Nevertheless, it was not until the Safe Motherhood Conference in Nairobi, Kenya in February 1987 and the publication of the first estimate of abortion-related deaths in 1989 that the extent of this public health problem was understood. Derived from fragmentary information on incidence and from studies on the proportion of maternal deaths that unsafe abortion caused, the estimate suggested that there were at least 115 000 abortion-related deaths annually.² However, even at the time this figure was published, reservations were expressed about its accuracy. Following the World Health Organization’s (WHO’s) establishment of a formal database, country estimates of unsafe abortion (“frequency and mortality of abortion not provided through approved facilities and/or persons”^3[p13]) and the associated mortality were published in 1990. Data in this first publication were presented by country, and no attempt was made to derive regional or global summary statistics. In 1993, WHO revised the earlier estimate of 115 000 abortion-related deaths downward to 70 000 deaths annually and produced regional and global estimates.⁴ Deaths owing to unsafe abortions were calculated to represent about 13% of all maternal deaths, a proportion that has remained unchanged.⁵

At the time of the Nairobi conference, Halfdan Mahler, then Director-General of WHO, highlighted the importance of access to family planning services and essential obstetric care for avoiding maternal deaths because of illegal abortion from unwanted pregnancy.⁶ Yet, for the most part, WHO ignored his call to action on unsafe abortion for some time and generally shied away from advocating intervention to prevent the unnecessary deaths and suffering associated with clandestine abortion through the provision of safe legal abortion.

THE WORLD HEALTH ORGANIZATION’S WORK ON GUIDELINES

Setting norms and standards and promoting and monitoring their implementation are core public health functions of WHO.⁷ During the 1990s, against the background of the increasingly well-documented effects of unsafe abortion on women’s health,⁸ WHO formulated managerial guidelines for improving the quality and availability of abortion and care for its complications as part of a primary health care system as well as guidelines for planning the location and content of emergency abortion care at each level of the health care system.⁹ Because of the sparse guidance relating to abortion WHO had issued up to that point, these technical and managerial guidelines were an important advance. However, the notion that abortion could and should be safe and that health care providers needed to be trained and equipped to provide safe abortion was conspicuously absent at this time.

Although abortion laws were being constantly revised and made more liberal in a considerable number of countries (particularly in North America and Western and Eastern Europe), many countries still took the position that abortion was unacceptable, and their laws reflected this, often through 19th-century colonially based legislation.¹⁰ As an intergovernmental organization, WHO had to navigate between these opposing positions, and its 1995 managerial guidelines for improving the quality and availability of abortion and care for its complications specifically state, “National authorities are responsible for deciding whether and under what circumstances to provide services for the medical termination of pregnancy. WHO takes no position on the matter” (emphasis added).^9(p7)

1994 ICPD PROGRAMME OF ACTION AND ITS FIVE-YEAR REVIEW

Shortly before the publication of the WHO managerial guidelines,⁹ the Programme of Action (POA) of the 1994 International Conference on Population and Development (ICPD), which 179 governments adopted,¹¹ laid the foundation for going much further. The POA, which many commentators have signaled as marking a “paradigm shift” from a population-control approach to fulfilling “reproductive health and rights,”¹² included an entire paragraph on abortion, whose final wording was the subject of long, tense negotiations between delegations. Governments again recognized that unsafe abortion was a major public health concern and pledged their commitment to reduce the need for abortion through expanded and improved family planning services. Yet they also agreed that “in circumstances where abortion is not against the law, such abortion should be safe. In all cases women should have access to the management of complications arising from abortion” (emphasis added).^13(para8.25) Although by no means adequate for recognizing the extent of women’s need for access to safe abortion beyond what the law allowed in many countries, this formulation opened the door to an international agreement in the five-year review of the ICPD POA in 1999 that

in circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible. Additional measures should be taken to safeguard women’s health (emphasis added).^14(para8.5)

It was this formulation that gave WHO a direct mandate. As the foremost international health standard–setting organization, WHO had a duty to elaborate what the training and equipping of health service providers actually involved as well as the “additional measures” to safeguard women’s health. Some key nongovernmental organizations started talking to WHO about how such guidance could be elaborated. In early discussions, it was Ipas—an international nongovernmental organization that works to increase women’s ability to exercise their sexual and reproductive rights, especially the right to safe abortion—that proposed to do this. But when Gro Harlem Brundtland, previous prime minister of Norway and well-known advocate of reproductive rights, was elected to become WHO’s new Director-General in 1998, WHO staff felt that the moment was ripe for the organization to elaborate and publish the guidance that health systems needed to provide safe abortion, as this would give a credibility and weight that no nongovernmental organization could match.

DRAFT GUIDANCE, TECHNICAL MEETING, AND FINAL APPROVAL

As both the law and lack of appropriate services played a key role in whether women had access to safe abortions, WHO staff and partners agreed that the guidelines must include not only clinical recommendations but also guidance on how and what safe abortion services to provide as well as on how to remove the legal and policy barriers to women’s access to such services. Recommendations had to be formulated on the basis of an extensive review of evidence, for example, on safe medical methods of abortion. The WHO-based Special Programme of Research, Development, and Research Training in Human Reproduction had been contributing to an extensive body of research on abortion methods since its establishment in 1972.¹⁵

An international technical expert meeting to review the draft document that the WHO secretariat had prepared in consultation with partners, was held at WHO headquarters in Geneva in September 2000. Approximately 60 carefully chosen participants from all parts of the world with expertise in policymaking, program management and service delivery, clinical research, human rights, law, and women’s health advocacy attended. In addition to providing a forum for a critical review of the draft document, the meeting created enthusiasm among partners to promote and disseminate the guidance. This did not happen, however, for nearly three years.

Customarily, all WHO guidelines require extensive in-house review and approval. Because of the subject matter, the abortion guidance document was subjected to an exceptionally protracted process of internal review that moved up the chain of command in the organization through Brundtland’s senior policy adviser Tomris Türmen and up to Brundtland herself. At one meeting she called to discuss comments from staff in her office we found ourselves facing Chelsea Clinton, daughter of former US President Bill Clinton. Chelsea Clinton, who was spending the summer as an intern in Brundtland’s office, had been asked to read the document and assess what the reaction of the US government might be (her father had been succeeded by then by the Republican President George W. Bush). During this prolonged review process the evidence base underlying the guidance’s recommendations was never questioned. Rather, most of the concern focused on phrasing that, when taken out of context, might be interpreted as advocating liberalization of abortion laws, a situation considered unacceptable.

After a succession of revisions to the draft document, and in anticipation of senior-level approval, the first meeting to launch the WHO safe abortion guidelines was planned to take place in Addis Ababa, Ethiopia, on March 2–5, 2003 in conjunction with the regional meeting “Action to Reduce Maternal Mortality in Africa: A Regional Consultation on Unsafe Abortion.”¹⁶ When March approached, however, the final clearance had still not been given, and the department was obliged to print a limited number of provisional copies for distribution at the meeting. Only in July 2003 was final approval given and the guidance published in English.¹⁷ It was subsequently translated into other official WHO languages (French, Russian, Spanish) as well as in, among others, Azerbaijani, Bashkir, Bosnian, Polish, Portuguese, and Vietnamese by health professional organizations active in those countries.

DISSEMINATING THE GUIDANCE

In the next several years many national and international activities were undertaken to create awareness of the guidance and promote its use in developing and updating national guidelines. Ipas in particular was very committed to this work and organized several regional meetings to examine with participants how the guidance could be applied to improving safe abortion provision, even in countries with restrictive legislation. WHO, through its Department of Reproductive Health and Research, on the other hand, used the guidance in the framework of the WHO Strategic Approach to Strengthening Sexual and Reproductive Health Policies and Programmes.¹⁸ Countries using the strategic approach during this time to focus specifically on provision of safe abortion services included Moldova, Mongolia, Romania, and Vietnam. Far from there being a public outcry, as some officials had feared, distribution of the guidance was beyond expectation: some two years after its publication all 20 000 printed copies had been sold or distributed and more than 5000 copies had been downloaded from the department’s Web site.

UPDATING THE GUIDANCE

To ensure that guidelines remain relevant and current, WHO internal regulations require they be regularly reviewed and, where necessary, updated. In 2008, WHO commenced a review and revision of the safe abortion guidance. The chapter “Clinical Care for Women Undergoing Abortion” was updated on the basis of recent or newly prepared systematic reviews, most of which were subsequently published in the Cochrane Database of Systematic Reviews. WHO also reviewed and updated other sections to include the latest global estimates of unsafe abortion, new information on service delivery, and new developments in international, regional, and national human rights law. At a WHO-convened meeting in Geneva in August 2010, 30 international experts in clinical practice and research, policymaking and program management, health advocacy, human rights, and law reviewed the revised guidelines and underlying evidence and finalized the draft recommendations.

The approval process for the second edition was somewhat less protracted. As with the first edition, most of the concern focused on chapter 4 “Legal and Policy Considerations,” with a suggestion at one point to publish it separately. However, department staff argued successfully against this proposition, as this would have destroyed the essence of the technical and policy guidance. The overall structure of the second edition thus remains the same as that of the first edition.

The government of the Netherlands together with the department organized the official launch of the new edition and scheduled it to take place in conjunction with the World Health Assembly in May 2012. Like the original 2003 edition, the new edition of the guidance had not been fully approved at that time and was printed in limited quantity as a draft. In-house approval followed shortly afterward, and the new edition appeared on the department’s Web site the following month. An English version of the guidelines has been printed,¹⁹ and French, Russian, and Spanish editions will follow.

CONCLUSIONS

When we started working at WHO in the 1980s, it seemed impossible that the organization would publish guidance for governments on how to provide safe abortion services. However, the recognition of the devastating impact of unsafe abortion on women’s health and survival, the impetus of the International Conference on Population and Development and its five-year follow-up, and the progressive leadership at WHO at the end of the century opened up windows of opportunity for WHO to address the issue of women’s access to safe abortion. In this, several European governments—in particular those of the Netherlands, the United Kingdom, and Scandinavian countries—along with health professional organizations and others who believed that WHO should and would provide leadership in this critical area of women’s health and rights supported the organization. The recent tribute in the Lancet provides evidence that the WHO guidance is living up to this role: “WHO’s new guidelines on safe abortions, published in July this year, should form an essential part of each country’s plan to reduce maternal deaths.”^20(p1791)