Best practice in

comprehensive postabortion care

Best Practice Paper No. 3

March 2016

Version PAC-01
Published by the Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent’s
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First published 2016
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Best practice in comprehensive postabortion care i

Contents

Introduction to the RCOG Leading Safe Choices Best Practice Papers ii

Introduction 1
Management of incomplete abortion 1
Assessment 1
Management 2
Medically indicated abortion 3
Information for women in whom abortion is medically indicated 4
Assessing women for medically indicated abortion 5
Blood tests 5
Determining gestational age 6
STI screening 6
Prevention of infective complications 6
Contraception 7
Providing abortion when medically indicated 7
For pregnancies of less than 14 weeks of gestation 7
For pregnancies of 14 weeks of gestation or more 8
Cervical preparation before surgical abortion 8
Medication for pain management 8
Contraceptive provision 8
Caring for women after medically indicated abortion 9
Information to provide 9
Contraception 9
Anti-D IgG 9
Service delivery 9
Access to services 10
Information provision 10
Arrangements for the procedure 10
Evidence sources 11
Additional literature reviewed 11
Appendix: Post-abortion contraception 12

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ii Best practice in comprehensive postabortion care

Introduction to the RCOG Leading Safe Choices Best Practice Papers

Healthcare professionals providing reproductive health care have an obligation to ensure that the women and
men they treat benefit from the latest technology and evidence-based clinical practices. In support of these, and
in line with the Royal College of Obstetricians and Gynaecologists’ mandate to improve health care for women
everywhere, by setting standards for clinical practice, this Best Practice Paper sets out the essential elements of
a high-quality comprehensive postabortion care service, including induced abortion when medically indicated,
and postabortion contraception.
The best practices described are drawn from current evidence-based guidance produced by organisations such as
the World Health Organization (WHO), the Royal College of Obstetricians and Gynaecologists and Ipas.
So as to be readable and useful to staff providing health care on a daily basis, the paper has been deliberately
kept short and succinct. To this end, the primary evidence for the recommendations and the strength of that
evidence have been omitted but can be found in the original source documents. Recently published evidence has
been assessed to determine whether any of the recommendations from existing guidelines should be amended.
Recognising that different health providers may be involved at different stages of the management of women
undergoing care, this paper has been divided into sections appropriate for these stages.
The use of the clinical recommendations should be individualised to each woman, with emphasis on her
clinical needs.
While the paper may be used for reference in any country, varying legal, regulatory, policy and service-delivery
contexts may require some recommendations to be adapted to the local context. Whatever adaptations are
made, best practice should always be maintained and in this respect the RCOG is aware that some of the
recommendations made are aspirational; these are included in order to assist policy makers in moving their
services forward. This paper has been written for use in Tanzania, where abortion is only legal in order to save
the life of the mother.
For support on adapting the document while still maintaining best practice, please write to leadingsafechoices@
rcog.org.uk.
Acknowledgements
This document was developed by Anna Glasier in close consultation with David Baird, Paul Blumenthal, Sharon
Cameron, Alison Fiander, Stefan Gebhardt, Natalie Kapp, Hawa Kawawa, Judy Kluge, Patricia Lohr, Grace Magembe,
Gileard Masenga, Projestine Muganyizi, Malika Patel, Gregory Petro, Lesley Regan and Petrus Steyn. The RCOG
Best Practice Paper on Comprehensive Abortion Care from which this paper was adapted was peer reviewed by Kelly
Culwell, Kristina Gemzell-Danielsson and Angela Hyde. This Best Practice Paper on Comprehensive Postabortion Care
was peer reviewed by Daniel Grossman and Beverley Winikoff.
The Leading Safe Choices initiative
Globally, 222 million women would like to prevent or delay pregnancy but have no access to contraception.
Meeting this need would allow women to control their own fertility and reduce maternal deaths by one-third,
with lasting benefits for their families and communities.
Thanks to a three year grant, an important new initiative called Leading Safe Choices offers the RCOG a unique
opportunity to address this unmet need. Leading Safe Choices will initially pilot in Tanzania and South Africa and
focus on postpartum family planning (PPFP) in both countries, and on comprehensive abortion care in South
Africa and comprehensive postabortion care in Tanzania.
The initiative will take an integrated systems approach, working within existing health structures and with
professionals currently working in women’s health in these two countries. The pilot phase will focus on
selected high-volume maternity hospitals and midwifery units, increasing skills and improving quality in PPFP and
comprehensive abortion and postabortion care.
The programme has three broad objectives:
1 developing RCOG Best Practice Papers on PPFP and comprehensive abortion care in South Africa and on
comprehensive postabortion care in Tanzania
2 training healthcare providers and supporting the delivery of high-quality PPFP and comprehensive
abortion care in South Africa and comprehensive postabortion care in Tanzania
3 establishing a formal accreditation and certification process to:
••
recognise competence
••
raise standing within professions
••
increase the uptake and quality of service provision.
The long-term vision is to expand the Initiative across South Africa and Tanzania and to other countries,
following on from this pilot phase.

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Best practice in comprehensive postabortion care 1

Introduction
Each year, 22 million unsafe abortions are estimated to take place, resulting in approximately 47 000
deaths. Around 5 million women suffer injury as a result of complications due to unsafe abortion,
often leading to chronic disability. Safe postabortion care should be available and accessible for all
women. Comprehensive postabortion care aims to reduce deaths and injury from either incomplete
or unsafe abortion by: evacuating the uterus; treating infection; addressing physical, psychological
and family planning needs; and referring to other sexual health services as appropriate.
As with many other medical procedures, adherence to best practice standards should help to ensure
that the most effective and the safest services are delivered. This paper is therefore designed to be
used on a daily basis by healthcare workers responsible for delivering postabortion care services
including postabortion contraception.
All aspects of postabortion care should be delivered in a manner that respects women as decision
makers. Women should be provided with information and support in a sensitive manner.

Management of incomplete abortion

For women with spontaneous abortion or those whose abortion was performed unsafely, post­
abortion care can reduce the morbidity and mortality associated with complications. Management
of incomplete abortion entails evacuation of the uterus either by surgery or by medical means. The
characteristics of medical and surgical management of incomplete abortion and of abortion where
medically indicated are shown in Table 1.
For women who wish to avoid another pregnancy, contraception should be discussed and a method
provided. Women experiencing spontaneous abortion and wishing to get pregnant again are usually
advised to wait until after at least one normal menstrual period.

Assessment
Incomplete abortion should be suspected when any woman of reproductive age presents with
vaginal bleeding and/or abdominal pain after one or more missed menstrual period.

Unsafe abortion
Indications that an abortion has been attempted by unsafe methods include the presence of:
•• vaginal laceration
•• cervical injury
•• uterine enlargement equivalent to a pregnancy of more than 12 weeks of gestation
•• products of conception visible at the cervix.

Infection
It is vital to identify women who may have ongoing infection and to manage this urgently. Infection
is much more likely, and much more likely to be severe, if the abortion has been unsafe. Clinical
features suggestive of infection include:
•• temperature above 37.5 °C
•• localised or general abdominal tenderness, guarding and rebound
•• foul odour or pus visible in the cervical os
•• uterine tenderness.

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2 Best practice in comprehensive postabortion care

Features suggestive of sepsis and indicating the need for emergency action include:
•• hypotension
•• tachycardia
•• increased respiratory rate.

Management
The management of an incomplete abortion will depend on the woman’s condition, whether infection
is present, the gestation of the pregnancy and on the skills of available personnel and the facilities
and equipment available. When uterine evacuation is an emergency (the woman is shocked, bleeding
heavily or has severe infection), if there are personnel available who have the skills to undertake
manual vacuum aspiration (MVA) (and who do the procedure often enough to maintain these skills)
and if the appropriate equipment is available then undertaking MVA may be a better option than
using misoprostol because the uterus will be emptied more quickly. If there is no provider skilled at
MVA then it will be safer to use misoprostol to empty the uterus. The dose of misoprostol depends
on the gestation and on the route of administration (oral, buccal, vaginal, etc). If a woman is bleeding
heavily then misoprostol may be less well absorbed if given vaginally than, for example, buccally.
If there is no suspicion of infection and uterine size is less than 14 weeks
••uterine evacuation with vacuum aspiration:
•• antibiotic prophylaxis should be given before surgical evacuation – 200 mg doxycycline
within 2 hours before the procedure (with or without 200 mg doxycycline after the
procedure) or a single dose of 500 mg azithromycin within 2 hours before the procedure
(NB. If antibiotics are not available, the procedure should not be delayed.)
OR
••
misoprostol 600 micrograms orally or 400 micrograms sublingually.
If there is no suspicion of infection and uterine size is 14 weeks or larger
••evacuation using vacuum aspiration and blunt forceps if necessary (provided that the clinician
has been trained to use them):
•• antibiotic prophylaxis should be given before surgical evacuation – 200 mg doxycycline
within 2 hours before the procedure (with or without 200 mg doxycycline after the
procedure) or a single dose of 500 mg azithromycin within 2 hours before the procedure
(NB. If antibiotics are not available, the procedure should not be delayed.)
OR
••
misoprostol:
••
14–28 weeks: 200 micrograms administered vaginally, sublingually or buccally at least 6-hourly
(maximum four doses)
••
28+ weeks: 25 micrograms vaginally 6-hourly or 25 micrograms orally 2-hourly
••
14+ weeks if the woman has had a previous caesarean section: 25 micrograms vaginally
6-hourly or 25 micrograms orally 2-hourly.

If infection is present the uterus should be evacuated urgently

••start broad-spectrum antibiotics orally immediately if infection is mild but intravenously if
infection is moderate or severe
••transfer to a unit with the facilities for undertaking surgical evacuation if it cannot be done in
the facility to which the woman presents

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Best practice in comprehensive postabortion care 3

••ifspecialist
the woman is in septic shock, start IV fluids (normal saline or Hartmann’s). Transfer to a
unit for surgical uterine evacuation. Administer broad-spectrum antibiotics (such as
a combination of ampicillin 0.5–1 g 6-hourly, metronidazole 500 mg 8-hourly and gentamicin
120 mg daily) intravenously prior to transfer if available.
If the skills necessary for urgent surgical uterine evacuation are not available, misoprostol can be used:
•• <14 weeks: misoprostol 600 micrograms orally or 400 micrograms sublingually
•• 14–28 weeks: At least 200 micrograms administered vaginally, sublingually or buccally at least
6-hourly
•• 28+ weeks: 25 micrograms vaginally 6-hourly or 25 micrograms orally 2-hourly.

Information to provide after the abortion

Before leaving the facility, women should receive instructions about how to care for themselves
after they go home, including:
•• how much bleeding to expect
•• how to recognise potential complications
•• how and where to seek help if required
•• women who want to try to conceive again are usually advised to wait until after having at least
one normal menstrual period, longer if chronic health problems (e.g. anaemia) require treatment.

Contraception
Before they leave the healthcare facility, all women should receive contraceptive information and,
if desired, the contraceptive method of their choice. If the chosen method is not available, they
should be referred to a service where the method can be provided.
Women should be advised of the greater effectiveness of long-acting reversible methods of contra­
ception (LARC: implants and intrauterine devices (IUDs)) and, unless they have a clear preference for
another effective method (such as pills or injectables), encouraged to choose an IUD or an implant.
IUD insertion or female sterilisation should be delayed until the woman’s health is restored and any
infection is resolved. Interim contraception should be provided using the most effective acceptable
method until an IUD can be inserted or sterilisation performed.

Anti-D IgG
If available, anti-D IgG should be given, by injection into the deltoid muscle, to all RhD-negative
women within 72 hours following abortion occurring after 12 weeks of gestation.

Medically indicated abortion

Abortion is legal in Tanzania if continuation of the pregnancy risks the life of the mother. This
decision is usually made by an obstetrician and gynaecologist but all healthcare workers who
provide antenatal care should be aware of the circumstances in which induced abortion may be
medically indicated in order to save a mother’s life. Healthcare workers at all levels should know
where to refer pregnant women in whom abortion may be medically indicated and should be aware
of the need to refer rapidly.
If abortion is medically indicated, it should be done safely. As with many other medical procedures,
adherence to best practice standards should ensure the most effective and the safest services.
Women should be provided with information and support in a sensitive manner.

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Information for women in whom abortion is

medically indicated
All women in whom abortion is medically indicated should be informed about their pregnancy
options and the following information should be provided:

••the choice of abortion method available (if appropriate) and the advantages of each (see Table 1)
••what will be done during and after the abortion
••symptoms likely to be experienced both during and following the abortion (e.g. menstrual-like
cramps, pain and bleeding)
••the range of emotions commonly experienced after having an abortion
••how long the abortion is likely to take
••what pain management will be made available
••the risks and complications associated with the abortion method
••follow-up care, including contraceptive advice and provision
••other services that are available, such as sexually transmitted infection (STI) testing and
support for women experiencing sexual coercion or domestic violence
••the care that is required for the pregnancy-related condition that necessitated the abortion
••whether or not it is advisable for her to get pregnant again in the future and, if so, when
••follow-up care including contraceptive advice and provision – this is particularly important if
further pregnancies are contraindicated.

Table 1  Characteristics of abortion procedures and medical and surgical management of incomplete abortion;
adapted from WHO (2014) Clinical Practice Handbook for Safe Abortion
Medical management Surgical management
• has a higher risk of incomplete or failed abortion • quick procedure
• avoids surgery • an intrauterine pregnancy is verified by evaluation
• mimics miscarriage of aspirated products of conception and a molar
• controlled by the woman pregnancy may be seen
• takes time (hours to days) to complete abortion, • takes place in a healthcare facility
and the timing may not be predictable • sterilisation of the woman or placement of an
• women experience bleeding and cramping, and intrauterine device (IUD) may be performed at
potentially some other side effects (nausea, the same time as the procedure
vomiting) • requires instrumentation of the uterus
• products of conception may be passed at home • small risk of uterine or cervical injury
• may require more clinic visits than surgical • timing of abortion is controlled by the facility and
management healthcare provider
May be preferable in the following situations: May be necessary in the following situation:
• for severely obese women • if there are contraindications to medical
• if the woman has uterine malformations or management of incomplete abortion or to
fibroids, or has had previous cervical surgery medical abortion
• if the woman wants to avoid surgical intervention
• if a pelvic examination is not feasible or is unwanted
Information about the side effects of abortion should emphasise the overall safety of the procedure
and should be discussed in a way that women can understand. The information should be given in
a non-judgemental and supportive way.

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Best practice in comprehensive postabortion care 5

The consultation should include the following information:

1 That abortion is a safe procedure for which major complications and mortality are rare at
all gestations.
2 For women in whom abortion is medically indicated, the earlier in pregnancy an abortion is
undertaken, the safer it is likely to be.
3 That surgical and medical methods of abortion carry a small risk of failure to end the
pregnancy (1 or 2 per 100 procedures).
4 That there is a small risk (less than 2 in 100 for surgical abortion, and 5 in 100 for medical
abortion using mifepristone and misoprostol and around 15 in 100 using misoprostol alone)
of the need for further intervention to complete the procedure, i.e. surgical intervention
following medical abortion or re-evacuation following surgical abortion.
5 That the following complications may occur:
•• severe bleeding requiring transfusion – the risk is lower for first-trimester abortions (less
than 1 in 1000), rising to around 4 in 1000 at gestations beyond 20 weeks
•• uterine rupture in association with second-trimester medical abortion at late gestations –
the risk is less than 1 in 1000.
For surgical abortions only:
•• cervical trauma – the risk of damage is no greater than 1 in 100 and is lower for first-
trimester abortions; trauma is less likely if cervical preparation is undertaken in line with
best practice
•• uterine perforation – the risk is in the order of 1–4 in 1000 and is lower for first-
trimester abortions.
6 That should one of these complications occur, further treatment (e.g. blood transfusion,
laparoscopy, laparotomy or hysterectomy) may be required.
7 That infection of varying degrees of severity is unlikely, but may occur after medical or surgical
abortion and is usually caused by pre-existing infection.
There are a number of myths about the consequences of abortion. If she expresses concern, the
woman can be reassured that there are no proven associations between induced abortion and
subsequent ectopic pregnancy, placenta praevia, infertility, risk of breast cancer or psychological
problems.
Women for whom abortion is medically indicated may wish to get pregnant again as soon as
possible. They are usually advised to wait until after at least one normal menstrual period but
women with chronic medical conditions that require treatment (e.g. anaemia) or women who
undergo induced abortion at late gestation should wait longer. There may be some women for
whom another pregnancy would be an unacceptable risk to health.

Assessing women for medically indicated abortion

If abortion is medically indicated to save a mother’s life, it may be an emergency as her condition is
likely to worsen the longer that pregnancy continues. It is important to make sure that gestation
is correctly assessed and that any ongoing infection is excluded or properly managed.

Blood tests
Pre-abortion assessment may include determination of Rhesus blood status if testing is available.

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6 Best practice in comprehensive postabortion care

Where clinically indicated, pre-abortion assessment may also include measurement of haemo­
globin concentration.

Determining gestational age

It is not necessary to determine the exact gestational age but rather to make sure that the gestation
falls within the range of eligibility for a particular method of inducing abortion. The date of onset
of the last menstrual period, bimanual pelvic examination, abdominal examination and recognition
of symptoms of pregnancy are usually adequate after a positive pregnancy test. Table 2 shows
gestation in both weeks and days of amenorrhoea.

Table 2  Weeks of gestation in terms of days since the last menstrual period (LMP); reproduced from
RCOG (2011) The Care of Women Requesting Induced Abortion, Evidence-based Clinical Guideline Number 7
Completed
0 1 2 3 4 5 6 7 8 9 10 11 12
weeks
Days since
0–6 7–13 14–20 21–27 28–34 35–41 42–48 49–55 56–62 63–69 70–76 77–83 84–90
LMP

Completed
13 14 15 16 17 18 19 20 21 22 23 24
weeks
Days since
91–97 98–104 105–111 112–118 119–125 126–132 133–139 140–146 147–153 154–160 161–167 168–174
LMP

Routine pre-abortion ultrasound scanning is unnecessary but, if available, may be useful if there are
concerns about complications, e.g. ectopic pregnancy.

STI screening
It is best practice to undertake a risk assessment for STIs for all women (e.g. HIV, chlamydia,
gonorrhoea, syphilis), and to screen for them if appropriate and available but this should be done
without delaying the abortion.
The partners of women who test positive for STIs should be informed and advised about treatment.
Ideally, a system for partner notification and follow-up or referral should be in place.
Services should make available information about the prevention of STIs, and offer condoms for STI
prevention to all women undergoing abortion.

Prevention of infective complications

Routine use of antibiotics at the time of surgical abortion is best practice as it reduces the risk of
infection after the abortion. However, abortion should not be delayed if antibiotics are not available.
The following regimens are recommended for perisurgical abortion antibiotic prophylaxis:
••200 mg doxycycline within 2 hours before the procedure
OR
••500 mg azithromycin within 2 hours before the procedure.

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Best practice in comprehensive postabortion care 7

Contraception
Effective methods of contraception should be discussed with women at the initial assessment
and a plan agreed, and documented, for contraception after the abortion. Before they leave the
healthcare facility, all women should receive the contraceptive method of their choice. If the chosen
method is not available, they should be referred to a service where the method can be provided.
Women should be advised of the greater effectiveness of implants and IUDs (long-acting reversible
(LARC) methods)) and encouraged to choose them unless they have a clear preference for another
effective method. Immediately after surgical abortion is an optimal time for insertion of an IUD
(and is safe after both first- and second-trimester surgical abortions). Contraceptive implants can
be provided at any time once the abortion procedure has started.

Providing abortion when medically indicated

The most appropriate abortion methods/regimens (surgical or medical) should be determined and
discussed with the woman (see Table 1).
Dilatation and sharp curettage (D&C) is an obsolete method of surgical abortion and should be
replaced by vacuum aspiration and/or medical methods.

For pregnancies of less than 14 weeks of gestation

Surgical abortion
Either manual or electric vacuum aspiration:
•• There is no lower limit of gestation for surgical abortion.
•• It is best practice to inspect aspirated tissue at all gestations to confirm complete evacuation;
this is essential following vacuum aspiration before 7 weeks of gestation.
•• During vacuum aspiration, the uterus should be emptied using the suction cannula and forceps
(if required) only. The procedure should not be routinely completed by sharp curettage.
•• Use of medications containing either oxytocin or ergometrine are not recommended
for prophylaxis to prevent excessive bleeding either at the time of vacuum aspiration or
afterwards.
•• Sharp curettage should not be performed.
OR
Medical abortion
••Ifit mifepristone is available, it is best practice to use it in combination with misoprostol as
shortens the induction–abortion interval, reduces side effects and decreases the rate
of ongoing pregnancy; mifepristone 200 mg should be administered orally 24–48 hours
before misoprostol.
•• Misoprostol 800 micrograms given by the vaginal, buccal or sublingual route, followed by
misoprostol 400 micrograms every 3 hours until abortion occurs.

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8 Best practice in comprehensive postabortion care

For pregnancies of 14 weeks of gestation or more

Surgical abortion
Surgical abortion can be performed by trained providers using:
•• vacuum aspiration using large bore cannulae
•• dilatation and evacuation (D&E).
OR
Medical abortion
••misoprostol 800 micrograms followed by misoprostol 400 micrograms every 3 hours until
abortion occurs.

Cervical preparation before surgical abortion

Cervical preparation should be used for all women with a pregnancy over 14 weeks. Suitable
preparations include:
•• osmotic dilators 12–24 hours before the procedure
OR

••misoprostol 400 micrograms vaginally, sublingually or buccally 3 hours before the procedure.

Cervical preparation may be considered for women before 14 weeks if there is a high risk for
cervical injury or uterine perforation. The following regimen is recommended:
•• misoprostol 400 micrograms administered vaginally or buccally 3 hours before the procedure
or sublingually 2 hours before the procedure.

Medication for pain management

For both medical and surgical abortions, analgesia (pain relief) should always be offered and
provided without delay, if requested.
•• In most cases, analgesics (e.g. nonsteroidal anti-inflammatory drugs (NSAIDS)), local
anaesthesia and/or conscious sedation supplemented by verbal reassurance are sufficient.
•• The need for pain management increases with gestational age and narcotic analgesia may
be required.
•• Prophylactic NSAIDs may reduce the need for narcotic analgesia during MVA.
•• Prophylactic paracetamol (oral or rectal) is ineffective in reducing pain during both surgical and
medical abortion.
Local anaesthesia, such as lidocaine, will alleviate discomfort from mechanical cervical dilatation
and uterine evacuation during surgical abortion and should be routinely offered if available.
General anaesthesia is not recommended for routine abortion procedures, as it has been associated
with higher rates of complications than analgesia and local anaesthesia.

Contraceptive provision
If a woman has chosen a contraceptive method that can be provided as part of or during the
abortion procedure (e.g. IUD insertion once vacuum aspiration is completed), it is important to

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Best practice in comprehensive postabortion care 9

be sure that this has been done. IUDs can be inserted at the time of the abortion in both the first
and second trimesters. Contraceptive implants can be inserted at any time once the abortion
procedure has started.

Caring for women after medically indicated abortion

Healthcare staff involved in this aspect of providing abortion where medically indicated should
ensure that the woman leaves the service knowing what to expect following the procedure and
where to get help if necessary. They should also ensure that every woman is able to leave with
a method of family planning to start immediately. Women should be informed of the superior
effectiveness of IUDs and implants in preventing unplanned pregnancy.

Information to provide
Before leaving the facility, women should receive instructions about how to care for themselves
after they go home, including:
•• how much bleeding to expect in the next few days and weeks
•• how to recognise potential complications, including signs of ongoing pregnancy
•• when to resume normal activities (including sexual intercourse)
•• how and where to seek help if required

••whether or not they can get pregnant again and when to start trying.
Contraception
Before they leave the healthcare facility, women for whom contraception is indicated should receive
appropriate information and, if desired, the contraceptive method of their choice. If the chosen
method is not available, they should be referred to a service where the method can be provided.
Women should be advised of the greater effectiveness and duration of LARC methods (implants
and IUDs) and encouraged to choose them unless they have a clear preference for another
effective method.
Sterilisation can be safely performed at the time of induced abortion although it can be more likely
than interval sterilisation to be associated with regret.
Failure rates for sterilisation are slightly higher if it is performed at the same time as the abortion.

Anti-D IgG
If available, anti-D IgG should be given by injection into the deltoid muscle to all RhD-negative
women within 72 hours following abortion for gestations longer than 12 weeks.

Service delivery
The provision of a safe and effective comprehensive postabortion care service, and of safe induced
abortion when medically indicated, depends on everyone involved in the service ensuring that
everything is done to meet the need. It is not enough for doctors and nurses to have clinical skills
for postabortion care if the facilities and tools that they need are not reliably available and if the
service is not organised in a way that ensures safe and effective comprehensive postabortion care

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10 Best practice in comprehensive postabortion care

and induced abortion care when medically indicated. Best practices for service delivery are
listed below.

Access to services
1 Abortion services must be available to the fullest extent that the law allows. Healthcare
providers should know what the law does allow in their country and be clear about the
circumstances for which abortion is legal.
2 Safe abortion is legal in Tanzania to save the life of the woman.
3 Healthcare providers must know the process required for induced abortion to be approved,
which, in Tanzania, requires the agreement of two physicians.
4 Abortion is safer the sooner it is done. Services should provide the abortion at the earliest
possible gestation and as close to home as possible.
5 All healthcare providers should be trained to provide comprehensive postabortion care, and
induced abortion when medically indicated, in line with their skills and licences. This can help
spread the workload and improve the skills of all providers of women’s health care, thereby
increasing the safety of all abortion and postabortion care.
6 Integrating postabortion, and abortion where medically indicated, services into overall
maternal/women’s health care minimises the stigma associated with abortion care for both
women and providers.
7 In settings where women with incomplete abortion are likely to present but where there
is no provision for emergency or specialist care, there must be robust and timely pathways
for referral.

Information provision
1 There should be local arrangements in place for providing information to women and
healthcare professionals on routes of access to postabortion care and to induced abortion
when medically indicated.
2 Services should ensure that written, objective, evidence-guided information is available in a
way that is understandable to women presenting for postabortion care and to women for
whom induced abortion is medically indicated. Information should be available in a variety of
languages and formats.
3 Women for whom induced abortion is medically indicated should have access to objective
information and, if required, counselling and decision-making support about their
pregnancy options.
4 Information for women and providers should emphasise the need for confidentiality and be
sensitive to the woman’s need for privacy.

Arrangements for the procedure

1 In order to minimise delay, service arrangements should be such that postabortion care, and
induced abortion when medically indicated, can be provided as soon as possible, ideally on the
same day as the assessment.
2 A system should be in place to ensure that the required documentation is completed
accurately and soon after the procedure.

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3 The setting for postabortion care, as well as for induced abortion when medically indicated,
including the consultation room, the procedure room and the recovery room, should respect
the need for women’s privacy and dignity.

Evidence sources
World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems. 2nd ed. Geneva:
WHO; 2012 [www.who.int/reproductivehealth/publications/unsafe_abortion/9789241548434/en/].
World Health Organization. Clinical Practice Handbook for Safe Abortion. Geneva: WHO; 2014 [www.who.
int/reproductivehealth/publications/unsafe_abortion/clinical-practice-safe-abortion/en/].
Royal College of Obstetricians and Gynaecologists. The Care of Women Requesting Induced Abortion.
Evidence-based Guideline Number 7. London: RCOG; 2011 [www.rcog.org.uk/en/guidelines-research-
services/guidelines/the-care-of-women-requesting-induced-abortion].

Additional literature reviewed

Conde-Agudelo A, Belizan JM, Breman R, Brockman SC, Rosas-Bermudez A. Effect of the interpregnancy
interval after an abortion on maternal and perinatal health in Latin America. Int J Gynaecol Obstet 2005;89
Suppl 1:S34–40.
Mark AG , Edelman A, Borgatta L. Second-trimester postabortion care for ruptured membranes, fetal
demise, and incomplete abortion. Int J Gynaecol Obstet 2015;129:98–103.
Love ER, Bhattacharya S, Smith NC, Bhattacharya S. Effect of interpregnancy interval on outcomes
of pregnancy after miscarriage: retrospective analysis of hospital episode statistics in Scotland. BMJ
2010;341:c3967.
Passini R Jr, Cecatti JG, Lajos JG, Tedesco RP, Nomura ML, Dias TZ, et al., for the Brazilian Multicentre
Study on Preterm Birth study group. Brazilian Multicentre Study on Preterm Birth (EMIP): prevalence and
factors associated with spontaneous preterm birth. PLoS One 2014;9):e109069.
The United Republic of Tanzania. Standard Treatment Guidelines and Essential Medicines List. 4th edition.
Ministry of Health and Social Welfare; 2013 [www.who.int/selection_medicines/country_lists/Tanzania_
STG_052013.pdf].
World Health Organization. Report of a WHO Technical Consultation on Birth Spacing. Geneva: WHO; 2005
[www.who.int/maternal_child_adolescent/documents/birth_spacing05/en].

Royal College of Obstetricians and Gynaecologists Best Practice Paper No. 3

12 Best practice in comprehensive postabortion care

Appendix:
3.3 Post-abortion contraception
Post-abortion contraception *
(Adapted from World Health Organization (2014) Clinical Practice Handbook for Safe Abortion)

Generally, almost all methods of contraception can be initiated immediately following

a surgical or medical abortion. Immediate start of contraception after surgical abortion
refers to the same day as the procedure, and for medical abortion refers to the day the
first pill of a medical abortion regimen is taken. As with the initiation of any method of
contraception, the woman’s medical eligibility for a method should be verified.

Post-abortion medical eligibility recommendations for hormonal

contraceptives, intrauterine devices and barrier contraceptive methods

POST-ABORTION FIRST SECOND IMMEDIATE

CONDITION TRIMESTER TRIMESTER POST-SEPTIC ABORTION

COC 1 1 1

CIC 1 1 1

Patch & vaginal ring 1 1 1

POP 1 1 1

DMPA, NET-EN 1 1 1

LNG/ENG implants 1 1 1

Copper-bearing IUD 1 2 4

LNG-releasing IUD 1 2 4

Condom 1 1 1

Spermicide 1 1 1

Diaphragm 1 1 1

CIC, combined injectable contraceptive; COC, combined oral contraceptive; DMPA/NET-EN, progestogen-only
injectables: depot medroxyprogesterone acetate/norethisterone enantate; IUD, intrauterine device; LNG/ENG,
progestogen-only implants: levonorgestrel/etonorgestrel; POP, progestogen-only pill.

Definition of categories
1: a condition for which there is no restriction for 3: a condition where the theoretical or proven
the use of the contraceptive method. risks usually outweigh the advantages of using
2: a condition where the advantages of using the the method.
method generally outweigh the theoretical or 4: a condition that represents an unacceptable
proven risks. health risk if the contraceptive method is used.

*
Based on Medical eligibility criteria for contraceptive use, 4th ed. Geneva: World Health Organization; 2009.

58Contraception for women

Section 3 Post-abortion on antiretroviral therapy for HIV
There are potential drug interactions between some antiretroviral drugs and hormonal contraception.
However, WHO has reviewed the data and concluded that the benefits of using hormonal contraception
outweigh the risks (2015 MEC, Category 2).

Best Practice Paper No. 3 Royal College of Obstetricians and Gynaecologists