World Health Organization Advocates for Expansion in the Role of Health Workforce to Prevent Unsafe Abortions.

Abstract

DEAR EDITOR, An abortion is considered unsafe when it is performed either by individuals who do not possess the necessary skills or is executed in such an environment which does not comply with recommended minimal medical standards, or both.[1] In-fact, the recent estimates suggest that almost 22 million unsafe abortions are being performed every year on a global scale, a major proportion of which is contributed by low and middle income nations.[1,2] Further, close to 5 million women every year are hospitalized due to unsafe abortion in developing nations and another 3 million women are devoid of desired medical attention following unsafe abortion.[1] It is very important to understand that any unsafe abortion is the outcome of unsuitable situations before, during or after an abortion (viz. availability/acceptance of contraceptives, nil or poor preabortion advice, septic environment, induction by an untrained individual or by an object/medication with no subsequent follow-up care, etc.).[1,2] A wide range of adverse effects, including complications, impact on women's ability to conceive, deaths of thousands of women (among adolescent girls/women who are either unmarried, or less educated, or belong to the lower socioeconomic class and resides in rural settings) and augmented financial burden on the individual or the health care delivery system have been reported.[1,3,4] Even though, multiple factors (like prevailing stigma in society, restrictive laws, dissent from health care providers, limited availability of health services, expensive nature, requirements of third-party authorization/unnecessary tests, etc.), have prevented access of women to safe abortion services, the lack of trained providers remains the critical barrier among all.[1,5,6] In-fact, it has been estimated that there will be a dearth of almost 13 million skilled health care workers by the year 2035, with a great disparity within the nations itself (shortage being more in rural areas and in the public sector).[5,7] This has been indirectly attributed to the current strategy of provision of safe abortion services through gynaecologists alone in most of the settings, despite the presence of the infrastructure and resources at the primary level of health care.[7] In order to address the issue of shortage of trained health providers in extending safe abortion services, the World Health Organization (WHO) has released a new set of guidelines to ensure that different activities are shared appropriately among the available health workforce.[5] Further, it has been emphasized that it is high time to move beyond specialists and enable the involvement of a wide range of health workers (like practitioners, nurses, midwives, auxiliaries, etc.) in safe abortion care so that the ultimate goal of providing equitable and timely health care to all sections of community can be achieved.[5] This strategy is indispensable in settings with an enormous shortage of skilled workers, and is of great importance even in developed nations to address sub-national imbalances.[5,7] However, the key perquisite for the success is to ensure task-specific competency-based training of health workers and the presence of a clear mechanism to enable monitoring, mentoring and support to health workers taking on these additional roles.[7,8,9] The WHO has stressed that abortion and postabortion care, especially in the first trimester (interventions like vacuum aspiration or drug induced medical abortion) can be easily delivered through the trained health worker like associate clinicians, midwives, nurses, etc.[7] These trained workforce members can even assist the specialist in the assessment of the gestational age of women, providing information on the appropriate use of drugs, and insertion of intrauterine devices.[1,5] Similarly, for providing care in the later stages of pregnancy, these nonphysician health workers can play supportive roles by assisting in cervical priming before dilatation and evacuation or in extending care throughout the process of abortion.[5,7] At the same time, it has been envisaged that as women themselves can manage their own health care, they should be empowered and equally involved in task sharing, provided they have access to appropriate information and to back-up health care.[1,5,6] To conclude, despite the existence of safe and effective primary health care level interventions, most of the women from developing nations have no access to them, placing their lives unnecessarily at risk. Hence, by ensuring the involvement of different cadres of health workforce it will not only help specialists in reducing their workload, but will even enhance the accessibility of women towards safe abortion and postabortion care.