Unsafe abortion occurs when a pregnancy terminated by persons lacking necessary skills: WHO

UNI Aug 10, 2018

The World Health Organization (WHO) defines unsafe abortion occurs when a pregnancy is terminated either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both.

This definition embodies concepts first outlined in a 1992 WHO Technical Consultation. Although widely used, it is inconsistently  interpreted. In this editorial we discuss its correct interpretation and operationalization. WHO’s definition of unsafe abortion was conceptualized within the framework of emerging guidelines on the management of the complications of induced abortion and was intended to be interpreted within that context. 

This linkage to technical guidelines is crucial for its correct interpretation. Nothing in  the definition predetermines who should be considered a “safe” abortion provider or what the appropriate skills or standards for performing abortions should be. Such things 
are not static; they evolve in line with evidence-based WHO recommendations.

For example, WHO guidelines now recommend mifepristone and misoprostol – or misoprostol alone if mifepristone is not available – and vacuum aspiration in lieu of the sharp curettage used formerly. They now consider induced abortions provided at the primary care level or by non-physician health-care providers as safe. The guidelines on task shifting that are being developed are expected to clarify who can safely provide an abortion under current standards.

To ensure that “unsafe abortion” is correctly interpreted, we recommend always providing an explanatory note along with the definition, as follows: “The persons, skills and medical standards considered safe in the provision of abortion are different for medical and surgical abortion and also depend on the duration of the pregnancy. What is considered ‘safe’ should be interpreted in line with current WHO technical and policy guidance.”

Although unsafe abortions are, by definition, risky, safety cannot be dichotomized because risk runs along a continuum. Risk is lowest if an evidence-based method is used to terminate an early pregnancy in a health facility; it is highest if a dangerous method, such as the use of caustic substances orally or vaginally or the insertion of sticks into the uterus, is employed clandestinely to terminate an advanced pregnancy. There is a spectrum of risk between these two extremes. Along that spectrum, for example, lie cases of self-administration of misoprostol or the use of outdated procedures, such as sharp curettage, by skilled health-care providers.

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