Explained: WHO's Latest Guidelines Could Help Prevent More Than 25 Million Unsafe Abortions

Globally, around 73 million induced abortions take place each year. While almost half of all abortions are unsafe, a staggering 97% of these happen in developing countries. Between 4.2% to 13.2% of all maternal deaths are attributed to unsafe abortions worldwide. This equates to between over 13,000 and nearly 39,000 lives lost annually, due to the failure to provide safe abortions, according to the WHO guidelines.

Over half (53.8%) of all unsafe abortions occur in Asia (mostly in south and central Asia). This is followed by eastern and western Africa (24.8%), Latin America and the Caribbean (19.5%). In 14 developing countries with unsafe abortions caused by high restrictions, 40% of women who have an abortion develop complications that require medical attention and about 6.9 million women are treated annually for such complications.

India reported more than 33,000 abortions in November 2021, as per Health Management Information System (HMIS) data presented in the Lok Sabha in December 2021. In October 2021, it reported more than 44,000 abortions. With 8,902 cases in November 2021, Maharashtra leads in abortion cases in the country, followed by Assam (3,190), West Bengal (2,374) and Karnataka (2,120).

As per available data from the National Family Health Survey (NFHS), 2015-16, only 20% of abortions take place in public sector facilities and 52% in private. Morever, only 53% of abortions were performed by registered medical doctors while the rest were done by midwives and auxiliary nurses.

Highlights of the New Guidelines

WHO's guidelines include recommendations that delve into law and policy, clinical services and health-care delivery during the pre-abortion, abortion and post-abortion phases.

Firstly, the guidelines recommend the complete decriminalisation of abortion. This includes removing abortion from all penal/criminal laws (does not apply to other crimes such as murder, manslaughter, etc) and ensuring that there are no penalties against those having, assisting with or providing information about abortion.

While most countries allow abortion under select circumstances, more than 20 countries such as Eqypt, Iraq, Philippines, Laos, Dominican Republic, Haiti, etc have prohibited it. In India, although abortion is legal, the amended laws still do not give women complete agency over their reproductive choices.

India amended its abortion laws in March 2021. The Medical Termination of Pregnancy (MTP Amendment) Act, 2021, raised gestation limits from the previous limit of 20 weeks to 24 weeks but only for select categories of pregnant women such as rape or incest survivors. However, this termination would need the approval of two registered doctors. When it comes to penal sanctions, Section 312 of the Indian Penal Code (IPC) clearly mentions that a woman is liable to punishment if she causes to miscarry (the act of causing miscarriage must be voluntary and must not be done in good faith) the foetus.

Further, in the pre-abortion phase, the guidelines recommend against mandatory waiting periods before receiving a requested abortion and also recommends that abortion be available on the request of the woman, girl or pregnant person without the authorisation of any person or institution.

Next, the guidelines related to pain management for surgical abortion <14 weeks recommend the use of paracervical block. This is an anaesthetic procedure where an injection is administered around the cervix area for pain reduction.

The use of telemedicine as an alternative to in-person interactions with a health worker has also been highlighted. This includes counselling related to the abortion process, active facilitation of the administration of medicines and follow-up post abortion care.

In 2015, 15.6 million abortions were administered in India. Of these, 73% were conducted outside health facilities, according to a study in The Lancet. "With limited mobility, increased reports of intimate partner violence, changes in living patterns of migrants, delays in accessing contraception and safe abortion care, and potential changes to decisions about parenting, there is an increased need for safe abortion services in India due to the pandemic," according to a study published in the National Center for Biotechnology Information (NCBI).

Countries such as England, France, Scotland, New Zealand and Pakistan permit at-home abortions with guidance from a medical professional over the internet or phone to ensure access to safe, legal abortion, and/or post-abortion care. The Telemedicine Practice Guidelines for India published on March 25, 2020 do not specifically include abortion services, the study mentions.

Lastly, when it comes to self-management approaches for post-abortion contraception, WHO recommends the use of self-administration of injectable contraception during this period. It also recommends that over the counter oral contraceptive pills (OCPs) and emergency OCPs should be made available without a doctor's prescription.