Dr Ranee Thakar is the Senior Vice President for Global Health at the RCOG. On International Safe Abortion Day 2022, she writes about the need for quality abortion care for all.
Over recent years abortion has been in the international limelight. The decision by the United States Supreme Court to overturn Roe v. Wade has to date resulted in 12 out of 50 US States introducing restrictive measures, with many more likely to follow, making abortion effectively inaccessible in large parts of the country. The decision has sent shockwaves throughout the world, including healthcare providers.
It has also given renewed impetus to debates about bodily autonomy and equitable access to abortion care. This is driving and inspiring me and the RCOG to do even more to ensure that people everywhere have access to quality abortion care, grounded in clinical evidence, and provided with dignity and respect.
The new World Health Organisation (WHO) abortion guidelines are an essential resource to move towards realising this goal around the world. The guidelines have emphasised the need to move beyond a focus on safe abortion towards providing quality abortion care.
At the RCOG we are committed to supporting our Fellows, Members, trainees and other health professionals in meeting women and pregnant people’s health rights and needs. We cannot do this without addressing the barriers to quality abortion whether they are restrictive legislation, administrative barriers (such as mandatory waiting periods or third-party authorisation), lack of information, and lack of access to commodities or facilities and/or stigma.
What is quality abortion care?
As obstetricians and gynaecologists, we regularly talk about quality improvement and quality of care. The WHO, in the new guideline, has defined quality of care as including six dimensions:
- Effective, delivering health care that is adherent to an evidence base and results in improved health outcomes for individuals and communities, based on need;
- Efficient, delivering health care in a manner which optimizes resource use and avoids waste;
- Accessible, delivering health care that is timely, geographically reachable, and provided in a setting where skills and resources are appropriate to medical need;
- Acceptable/person-centred, delivering health care that takes into account the preferences and aspirations of individual service users and the cultures of their communities;
- Equitable, delivering health care that does not vary in quality because of personal characteristics such as gender, race, ethnicity, geographical location or socioeconomic status;
- Safe, delivering health care that minimizes risks and harm to service users.
In many contexts legal restrictions, administrative barriers, and/or stigma, at institutional and/or interpersonal levels, prevent healthcare workers from being able to provide some or all the six dimensions of quality abortion care.
How can we expand access to quality abortion care?
The WHO guideline includes a range of updated or additional recommendations expanding access to quality abortion care including:
- Expanding recommendations for areas of abortion care that can be provided by pharmacy workers, pharmacists, auxiliary nurses, nurses, midwives, associate/advanced associate clinicians and the pregnant woman or person themselves.
- Expanding recommendations for self-management of the medical abortion process in whole or any of the three component parts of the process including: self-assessment of eligibility (determining pregnancy duration; ruling out contraindications) , self-administration of abortion medicines outside of a health-care facility and without the direct supervision of a trained health worker, and management of the abortion.
- Telemedicine being added as a recommendation as an alternative to in-person interactions with a health worker to facilitate early medical abortions. The RCOG is developing a Best Practice Paper on telemedicine abortion to support clinicians to develop and provide quality telemedicine abortion services.
- Best practice statements on service delivery recognising there are a range of service delivery approaches that can co-exist in any context. It outlines that all service delivery approaches must include accurate information, quality medication, referral support and link to post-abortion contraception should a person want it (WHO, 2022).
Earlier this year I met with colleagues from Rwanda who are part of the RCOG Making Abortion Safe programme. In Rwanda, only medical doctors are allowed to provide abortion care and only at hospital or polyclinic level (the new WHO guidelines list all the various healthcare providers who can safely be involved in abortion care provision) As there are no doctors, hospitals or polyclinics in many rural parts of the Rwanda, many women are having to travel long distances to access routine and essential abortion care.
Not only is this inaccessible due to geographic location, it is inequitable too. It is inefficient by not utilising the local health workforce and ineffective by ignoring the evidence that abortion can be safely managed in primary health facilities. All these factors may lead to women opting for care that is potentially unsafe as people seek clandestine abortions or are forced into having abortions at later pregnancy durations. By its very nature this is a barrier to person-centred care. All these barriers are preventing people from receiving quality abortion care.
In the UK, we have made massive steps towards expanding access to quality abortion by making early medical abortion via telemedicine permanently available as of last month. There are still significant barriers to overcome, for example addressing the harassment of people outside abortion clinics around the country which some have suggested has become more adversarial this year, and the decriminalising of abortion to ensure that women are not prosecuted over a healthcare issue.
The importance of engaging others with these guidelines
These outstanding guidelines by the WHO are a fantastic starting point to begin discussions about how we can ensure we expand access to, improve and/or optimise abortion care in our day-to-day practices. But I know that there will also be resistance from some towards these guidelines. To overcome this, it is paramount to engage with health leaders and peers to address this.
There are many factors that influence acceptance and use of guidelines at individual level (clinicians and patients), meso level (organisational e.g. hospital or health centre) or macro level (health system, political context, legislation). I am not aware of any other area of medicine with so many macro level barriers to providing quality of care than abortion.
Clinicians are well placed to advocate for addressing these barriers and I know that we can rely on the commitment and drive of many of our Members, Fellows and trainees, who will be doing this within their communities, at their places of work and within their wider country contexts.
 World Health Organization. Abortion Care Guideline. Geneva: WHO; 2022. [https://www.who.int/ publications/i/item/9789240039483]
 The WHO abortion care guideline outlines the evidence for a strong recommendation for nurses and midwives effectively providing medication abortion at <12 weeks and vacuum aspiration at <14 weeks (WHO, 2022, pp. 64, 69)