The World Health Organizations Safe Abortion Guidance Document We discuss the history of

the World Health Organiza-

tions (WHOs) development

of guidelines for govern-

ments on providing safe

abortion services, which

WHO published as Safe

Abortion: Technical and

Policy Guidance for Health

Systems in 2003 and up-

dated in 2012.

We show how the recog-

nition of the devastating

impact of unsafe abortion

on womens health and

survival, the impetus of

the International Confer-

ence on Population and De-

velopment and its five-year

follow-up, and WHOs pro-

gressive leadership at the

end of the century enabled

the organization to elabo-

rate guidance on providing

safe abortion services.

Guideline formulation

involved extensive review

of published evidence, an

international technical ex-

pert meeting to review the

draft document, and a pro-

tracted in-house review

by senior WHO manage-

ment. (Am J Public Health.

Published online ahead of

print February 14, 2013:

e1e3. doi:10.2105/AJPH.

2012.301204)

Paul F. A. Van Look, MD, PhD, and Jane Cottingham, MSc

FORTY-FIVE YEARS AGO, IN

1967, the World Health Assem- bly 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 frag- mentary information on inci- dence and from studies on the proportion of maternal deaths that unsafe abortion caused, the esti- mate suggested that there were at least 115 000 abortion-related deaths annually.2 However, even at the time this figure was pub- lished, reservations were expressed about its accuracy. Fol- lowing the World Health Organi- zations (WHOs) establishment of a formal database, country esti- mates of unsafe abortion (fre- quency and mortality of abortion not provided through approved facilities and/or persons3[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 sum- mary statistics. In 1993, WHO re- vised the earlier estimate of115 000 abortion-related deaths downward to 70 000 deaths annually and pro- duced regional and global esti- mates.4 Deaths owing to unsafe abortions were calculated to repre- sent 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 ac- cess 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 suf- fering associated with clandestine abortion through the provision of safe legal abortion.

THE WORLD HEALTH ORGANIZATIONS 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 back- ground of the increasingly well- documented effects of unsafe abor- tion on womens health,8 WHO formulated managerial guidelines for improving the quality and availability of abortion and care for its complications as part of a pri- mary 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. How- ever, the notion that abortion could and should be safe and that health care providers needed to be trained and equipped to pro- vide safe abortion was conspic- uously absent at this time.

Although abortion laws were being constantly revised and

made more liberal in a consider- able number of countries (par- ticularly in North America and Western and Eastern Europe), many countries still took the po- sition that abortion was unac- ceptable, and their laws reflected this, often through 19th-century colonially based legislation.10 As an intergovernmental organiza- tion, WHO had to navigate be- tween these opposing positions, and its 1995 managerial guide- lines for improving the quality and availability of abortion and care for its complications specif- ically state, National authorities are responsible for deciding whether and under what cir- cumstances to provide services for the medical termination of pregnancy. WHO takes no posi- tion 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 guide- lines,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 fur- ther. The POA, which many com- mentators have signaled as mark- ing a paradigm shift from a population-control approach to fulfilling reproductive health and rights,12 included an entire para- graph on abortion, whose final wording was the subject of long, tense negotiations between dele- gations. Governments again rec- ognized that unsafe abortion was

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a major public health concern and pledged their commitment to re- duce 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 abor- tion (emphasis added).13(para8.25)

Although by no means adequate for recognizing the extent of womens 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 and should take other measures to ensure that such abor- tion is safe and accessible. Addi- tional measures should be taken to safeguard womens health (emphasis added).14(para8.5)

It was this formulation that gave WHO a direct mandate. As the foremost international health stan- dard—setting organization, WHO had a duty to elaborate what the training and equipping of health service providers actually involved as well as the additional mea- sures to safeguard womens health. Some key nongovernmen- tal organizations started talking to WHO about how such guidance could be elaborated. In early dis- cussions, it was Ipasan interna- tional nongovernmental organiza- tion that works to increase womens ability to exercise their sexual and reproductive rights, es- pecially 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 WHOs new Director-General in 1998, WHO staff felt that the moment was ripe for the organiza- tion to elaborate and publish the guidance that health systems needed to provide safe abortion, as this would give a credibility and weight that no nongovern- mental organization could match.

DRAFT GUIDANCE, TECHNICAL MEETING, AND FINAL APPROVAL

As the law and lack of appro- priate 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 rec- ommendations but also guidance on how and what safe abortion services to provide as well as on how to remove the legal and pol- icy barriers to womens 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 Re- search Training in Human Repro- duction had been contributing to an extensive body of research on abortion methods since its estab- lishment in 1972.15

An international technical ex- pert meeting to review the draft document that the WHO secre- tariat had prepared in consultation with partners, was held at WHO headquarters in Geneva in Sep- tember 2000. Approximately 60 carefully chosen participants from all parts of the world with exper- tise in policymaking, program management and service delivery, clinical research, human rights, law, and womens health advocacy attended. In addition to providing a forum for a critical review of the

draft document, the meeting cre- ated enthusiasm among partners to promote and disseminate the guidance. This did not happen, however, for nearly three years.

Customarily, all WHO guide- lines require extensive in-house review and approval. Because of the subject matter, the abortion guidance document was sub- jected to an exceptionally pro- tracted process of internal review that moved up the chain of com- mand in the organization through Brundtlands senior policy ad- viser Tomris Trmen and up to Brundtland herself. At one meet- ing she called to discuss com- ments 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 Brundt- lands office, had been asked to read the document and assess what the reaction of the US gov- ernment 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 guidances re- commendations was never ques- tioned. Rather, most of the con- cern focused on phrasing that, when taken out of context, might be interpreted as advocating lib- eralization of abortion laws, a sit- uation considered unacceptable.

After a succession of revisions to the draft document, and in anticipation of , 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 Re- duce Maternal Mortality in Africa: A Regional Consultation on Un- safe 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 provi- sional 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, Portu- guese, 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 aware- ness of the guidance and promote its use in developing and updating national guidelines. Ipas in particu- lar was very committed to this work and organized several regional meetings to examine with partici- pants how the guidance could be applied to improving safe abortion provision, even in countries with restrictive legislation. WHO, through its Department of Repro- ductive Health and Research, on the other hand, used the guidance in the framework of the WHO Strategic Approach to Strengthening Sexual and Reproductive Health Pol- icies 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 expecta- tion: some two years after its pub- lication all 20 000 printed copies had been sold or distributed and more than 5000 copies had been downloaded from the departments Web site.

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UPDATING THE GUIDANCE

To ensure that guidelines remain relevant and current, WHO internal regulations require they be regu- larly reviewed and, where neces- sary, 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 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 ser- vice delivery, and new develop- ments in international, regional, and national human rights law. At a WHO-convened meeting in Ge- neva in August 2010, 30 interna- tional experts in clinical practice and research, policymaking and pro- gram management, health advo- cacy, 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 edi- tion, most of the concern focused on chapter 4 Legal and Policy Considerations, with a suggestion at one point to publish it sepa- rately. However, department staff argued successfully against this proposition, as this would have destroyed the essence of the tech- nical and policy guidance. The overall structure of the second edition thus remains the same as that of the first edition.

The government of the Nether- lands together with the depart- ment 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 ap- proved at that time and was printed in limited quantity as a draft. In-house approval fol- lowed shortly afterward, and the new edition appeared on the de- partments 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 im- possible that the organization would publish guidance for governments on how to provide safe abortion ser- vices. However, the recognition of the devastating impact of unsafe abortion on womens health and survival, the impetus of the Interna- tional Conference on Population and Development and its up, and the progressive leader- ship at WHO at the end of the century opened up windows of op- portunity for WHO to address the issue of womens access to safe abortion. In this, several European governmentsin particular those of the Netherlands, the United King- dom, and Scandinavian countries along with health professional organizations and others who be- lieved that WHO should and would provide leadership in this critical area of womens health and rights sup- ported the organization. The recent tribute in the Lancet provides evi- dence that the WHO guidance is living up to this role: WHOs new guidelines on safe abortions, pub- lished in July this year, should form an essential part of each countrys plan to reduce maternal deaths.20(p1791) j

About the Authors Paul F. A. Van Look is a consultant in sexual and reproductive health based in

Val-dIlliez, Switzerland, and Jane Cottingham is a consultant in sexual and reproductive health and rights based in Geneva, Switzerland.

At the time when the first edition of the WHO Safe Abortion Guidance document was being conceptualized and formulated by the World Health Organizations Department of Reproductive Health and Research, P. F. A. Van Look was the Departments Director and J. Cottingham was the Coordinator of the Departments Team on Gender, Reproductive Rights, Sexual Health and Adolescence. Both J. Cottingham and P. F. A. Van Look also participated in a consultant capacity in the development of the updated, second edition of the document. Correspondence should be sent to Paul

F. A. Van Look, Consultant in Sexual and Reproductive Health, Route des Crosets 48, CasePostale51,CH-1873Val-dIlliez,Valais, Switzerland (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the Reprints link.

This commentary was accepted December 20, 2012.

Contributors The authors contributed equally to the writing of this commentary.

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