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Safe Abortion: Technical and Policy Guidance for Health Systems. 2nd edition. Geneva: World Health Organization; 2012.

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Safe Abortion: Technical and Policy Guidance for Health Systems. 2nd edition.

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Process of guideline development

Background

Safe abortion: technical and policy guidance for health systems was published by the World Health Organization (WHO) in 2003 (2) as the first global guidance for abortion-related care and policy issues. Since that time, the guidance has been translated into French, Russian, Spanish and various non-official United Nations (UN) languages and has been widely used by governments, nongovernmental organizations (NGOs), providers of women's health services, and women's health and human rights advocates.

Since publication of the guidance in 2003, a considerable amount of new data have been produced and published, relating to epidemiological, clinical, service delivery, legal and human rights aspects of providing safe abortion care. Therefore, preparation for this revision of the guidance included extensive literature review and updating of recommendations related to service delivery, legal and policy issues, and the conduct of new systematic reviews and updates of outdated systematic reviews to provide the evidence for recommendations related to clinical questions prioritized by an international panel of experts. The substantial revisions in this update reflect changes in methods of abortion and related care, service delivery as it applies to the availability and use of new methods, and application of human rights for policy-making and legislation related to abortion, among other topics. Recommendations in the 2003 guidance for which there was no new evidence remain unchanged.

Additionally, in parallel with the revision of the guidance, a companion document entitled Clinical practice handbook for safe abortion care has been developed for providers of abortion services, with additional information on the details of implementing the clinical care recommendations of the guidance document.

Methods

This document was prepared according to the WHO standards and requirements for guideline development. In summary, this process included: identification of priority questions and outcomes; evidence retrieval, assessment and synthesis; formulation of recommendations; and planning for dissemination, implementation, impact evaluation and updating. The identification of priority questions for recommendations was initiated by professional staff from the WHO Department of Reproductive Health and Research (WHO Secretariat), who drafted a list of questions and outcomes related to provision of safe abortion care in light of new data since the initial publication of the guidance in 2003 (2), as well as in response to solicited feedback from its users.

A global panel of international stakeholders, including health-service providers, health programme managers, researchers, methodologists, human rights lawyers, and women's health and human rights advocates, was established to review and prioritize the draft questions and outcomes, which included clinical, technical and programmatic topics. This initial consultation was conducted electronically, and all responses were reviewed by members of the WHO Secretariat. Questions and outcomes rated as critical were included in the scope of this document, for evidence grading using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, and the development of recommendations. The list of final questions considered for GRADE tables and outcomes is presented in Annex 2.

Cochrane systematic reviews of randomized clinical trials were the primary source of evidence for the recommendations. Based on the list of priority questions, identified as described above, the relevant Cochrane systematic reviews (314) were identified and conducted or updated using their specific, standard search strategies. Additionally, three systematic reviews were conducted outside of the Cochrane Database of Systematic Reviews and were published in peer-reviewed journals (1517). The search strategies and the specific criteria for including and excluding trials identified by the search are provided in the corresponding systematic reviews. The available evidence was appraised and graded following the GRADE approach (1822), reflecting the priority comparisons and outcomes; comparisons and outcomes not relevant to the recommendation were excluded. As a result, evidence profiles (GRADE tables) were prepared (available from http://apps.who.int/iris/bitstream/10665/75840/1/WHO_RHR_12.10_eng.pdf) - date accessed 14 February 2013. Standardized criteria for grading the evidence using GRADE are presented in Annex 3. For each selected comparison, data for available priority outcomes have been assessed and presented in the evidence profiles (if data for priority outcomes were not available in specific comparisons, they were omitted in the GRADE tables). Based on the evidence profiles, recommendations were drafted by the WHO Secretariat.

For Chapter 3 on establishing and strengthening safe abortion services, two issues were identified (indicators of safe abortion and competencies for providing safe abortion) for which recent WHO guidance was already available. Therefore, the steps taken to address the topics in Chapter 3 were to adopt and reference recent WHO guidance, and to conduct an extensive literature review of the issues presented for the existing recommendations from the first edition of the document, while updating the references.

For Chapter 4 on legal and policy considerations, WHO contracted the Programme on International Reproductive and Sexual Health Law in the Faculty of Law at the University of Toronto, Toronto, Canada, to assist the revision, including proposing changes to the existing content, based on international and regional human rights treaty provisions and the work of international and regional human rights bodies. Staff at the programme also produced a series of research briefs providing human rights and legal research and analysis on selected issues of particular concern (for example, elaboration of the health indication for safe abortion, conscientious objection, and legal and regulatory barriers).

In order to review the draft recommendations and the supporting evidence, a technical consultation was organized at WHO headquarters in Geneva, Switzerland. The members of a guidelines development group – a subset of the international panel that participated in the initial online consultation and other experts – were invited to participate in this consultation (see Annex 4 for a list of participants and their affiliations). Draft recommendations, revised chapters and supporting documents were shared with the participants before the consultation for their review.

Declarations of interest were obtained from the participants in the technical consultation using a standard WHO form prior to their participation in the meeting. These declarations were reviewed by the WHO Secretariat and, when necessary, by the WHO Office of the Legal Counsel before the consultation. Two consultation participants (Dr Laura Castleman and Dr Helena von Hertzen) declared that they were employed by organizations that have or might appear to have commercial conflicts of interest. For recommendations that were directly relevant to their organizations' work, they left the room during final recommendation making. No other participants declared any conflicts or potential conflicts of interest.

Decision-making during the technical consultation

For each recommendation, the participants in the technical consultation discussed the draft text prepared by the WHO Secretariat, with the aim of reaching consensus. Consensus was defined as agreement by the majority of participants, with no one strongly disagreeing. No strong disagreements occurred during the consultation and, therefore, an alternative system, such as voting, was not necessary. In addition to the scientific evidence and its quality, applicability issues, costs and other expert opinions were considered while formulating the final recommendations.

The strength of the recommendations was determined through the assessment of each intervention on the basis of: (i) desirable and undesirable effects; (ii) the quality of available evidence; (iii) values and preferences related to interventions in different settings; (iv) the cost of options available to health-care workers in different settings; and (v) the perceived likelihood of changing the recommendation due to further research. In general, a strong recommendation with moderate- or high-quality evidence indicates that further research should not be considered a priority. The full text of the recommendations from the technical consultation is found in Annex 5.

Topics not identified as the subject of a new systematic review for which WHO recommendations already existed were presented at the technical consultation, for group discussion. Those recommendations found by the group to be relevant and current were endorsed and adopted. These topics included: indicators of safe abortion; contraceptive use following abortion; and the recommendations surrounding establishing and strengthening abortion services, including competencies for providing abortion care, found in Chapter 3.

Document preparation and peer review

A preliminary document, containing the draft recommendations, was prepared and made available to the participants in the technical consultation three weeks before the meeting. The draft recommendations were amended during the meeting, based on the discussions. After the meeting, the draft document was revised by the WHO Secretariat. The revised version was sent electronically to all participants, for their approval and comments. Primary reviewers for each chapter were identified based on their fields of expertise. Finally, the whole document was sent for external critical appraisal and peer review. During this process of review, important suggestions were incorporated into the document; however, the WHO Secretariat refrained from making major changes in the scoping (e.g. further expansion of the guidance scoping) or in the recommendations agreed upon during the consultation.

Dissemination of the guidance document

As with the first edition of the guidance document, dissemination will be undertaken through distribution of the print version, and a series of regional workshops will be organized on applying the WHO Strategic Approach to strengthening sexual and reproductive health policies and programmes (23) to the issue of unsafe abortion. The aim of the workshops will be to develop proposals based on the guidance that can strengthen safe abortion care within sexual and reproductive health programmes. The workshops will include preselected country teams with representatives from ministries/departments of health, including a variety of health-service providers and programme managers, and representatives from NGOs, professional associations and UN organizations.

Assessing the impact of published guidelines is a challenging task. In an attempt to do so, we plan to monitor the number of requests from countries for assistance in implementation of the guidelines, direct follow-up in countries applying the Strategic Approach, and the number of countries that modify their national abortion programme monitoring to reflect the indicators for safe abortion provided in Table 3.2 (page 75) of this document. Additionally, we will continue to monitor the number of downloads of the document, as well as the number of hard copies of the guidance requested and distributed.

Updating the guidelines

The WHO Secretariat anticipates that these guidelines will be reviewed again four years following their publication, to assess whether revision is necessary, based upon newly available evidence and feedback from users.

References

1.
Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. 3rd ed. Geneva: World Health Organization; 2011.
2.
Safe abortion: technical and policy guidance for health systems. Geneva: World Health Organization; 2003.
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Guyatt GH, et al. What is “quality of evidence” and why is it important to clinicians? British Medical Journal. 2008;336:995–998. [PMC free article: PMC2364804] [PubMed: 18456631]
21.
Guyatt GH, et al. Going from evidence to recommendations. British Medical Journal. 2008;336:1049–1051. [PMC free article: PMC2376019] [PubMed: 18467413]
22.
Schünemann HJ, et al. Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. British Medical Journal. 2008;336:1106–1110. [PMC free article: PMC2386626] [PubMed: 18483053]
23.
The WHO Strategic Approach to strengthening sexual and reproductive health policies and programmes. Geneva: World Health Organization; 2007.
Copyright © 2012, World Health Organization.

All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: tni.ohw@sredrokoob). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press through the WHO web site (http://www.who.int/about/licensing/copyright_form/en/index.html).

Bookshelf ID: NBK138184

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