World Health Organization · 2nd edition, 2024 (second printing with updated Recommendation 22 remarks) · 214 pages
Evidence-based recommendations for comprehensive abortion care across law, clinical services and service delivery for policy-makers and health workers
- Issuer
- World Health Organization
- Edition
- 2nd edition, 2024 (second printing with updated Recommendation 22 remarks)
- Audience
- National and subnational policy-makers, SRH programme managers, NGOs, civil society, professional societies, health workers (all cadres), stakeholders in sexual and reproductive health and rights
- Evidence
- GRADE-rated systematic reviews with Evidence-to-Decision frameworks using WHO-INTEGRATE methodology; innovative approach integrating human rights protection into health outcomes for law and policy recommendations; 54 recommendations (new and updated) and best practice statements
- Reviewed
- 14 Oct 2026 · GMJ
What this guideline says
GMJ summary
This second edition consolidates all WHO recommendations on comprehensive abortion care, integrating law and policy, clinical services and service delivery domains. The guideline contains 54 recommendations and best practice statements covering the continuum from information provision through medical and surgical abortion to post-abortion contraception. Core recommendations include decriminalization of abortion, removal of gestational age limits, provision of abortion on request without third-party authorization, and expansion of health worker roles including self-management approaches.
Medical abortion with mifepristone 200 mg plus misoprostol 800 μg is recommended for pregnancies under 12 weeks, with a new suggestion for letrozole 10 mg daily for 3 days plus misoprostol 800 μg as an alternative regimen. Vacuum aspiration is recommended over sharp curettage for surgical abortion under 14 weeks. Pain management with NSAIDs is recommended routinely, with paracervical block for surgical procedures. The guideline emphasizes quality of care—effective, efficient, accessible, acceptable, equitable and safe—delivered without discrimination.
Service delivery innovations include telemedicine for medical abortion, self-management of the abortion process in whole or part before 12 weeks, and task-sharing to community health workers and mid-level providers. Post-abortion contraception can be initiated immediately, including hormonal methods with medical abortion and IUDs after surgical abortion. The enabling environment requires human rights-compliant laws, accessible information, and well-functioning health systems integrated within universal health coverage and primary health care.
Key points
For clinicians — doses and thresholds as stated in the guideline
- For medical abortion <12 weeks: mifepristone 200 mg orally followed 24–48 hours later by misoprostol 800 μg vaginally, sublingually or buccally; or misoprostol 800 μg alone by same routes
- New alternative regimen <12 weeks: letrozole 10 mg orally daily for 3 days, then misoprostol 800 μg sublingually on day 4
- For medical abortion ≥12 weeks: mifepristone 200 mg orally followed 24–48 hours later by misoprostol 400 μg every 3 hours vaginally, sublingually or buccally
- For surgical abortion <14 weeks: vacuum aspiration recommended; dilatation and sharp curettage not recommended
- Pain management: NSAIDs offered routinely; paracervical block recommended for surgical abortion at any gestational age; conscious sedation plus paracervical block suggested as an option where available
- Anti-D immunoglobulin recommended against for abortion <12 weeks; prophylactic antibiotics recommended for surgical abortion, not for medical abortion
- Ultrasound scanning not required as prerequisite for abortion; gestational age can be determined by last menstrual period or clinical examination
- Self-management of medical abortion <12 weeks recommended for all three components: self-assessment of eligibility, self-administration of medicines, and self-assessment of success
Recommended medication regimens for medical abortion by gestational age
Table extracted from the guideline
| Gestational age | Recommended regimen | Alternative regimen | Remarks |
|---|---|---|---|
| <12 weeks | Mifepristone 200 mg orally, then 24–48 hours later misoprostol 800 μg vaginally/sublingually/buccally | Misoprostol 800 μg alone vaginally/sublingually/buccally; OR Letrozole 10 mg orally daily × 3 days, then misoprostol 800 μg sublingually | Combination regimen more effective than misoprostol alone; repeat misoprostol doses can be considered |
| ≥12 weeks | Mifepristone 200 mg orally, then 24–48 hours later misoprostol 400 μg every 3 hours vaginally/sublingually/buccally | Misoprostol 400 μg every 3 hours alone vaginally/sublingually/buccally | Vaginal route most effective; reduce misoprostol dose beyond 24 weeks; caution with prior uterine incision |
| Missed abortion <14 weeks | Mifepristone 200 mg orally, then misoprostol 800 μg any route | Misoprostol 800 μg alone any route | Repeat misoprostol at ≥9 weeks more efficacious |
| IUFD ≥14–≤28 weeks | Mifepristone 200 mg orally, then 24–48 hours later misoprostol 400 μg every 4–6 hours sublingually/vaginally | Misoprostol 400 μg every 4–6 hours alone sublingually/vaginally | Reduce dose beyond 28 weeks |
Source: World Health Organization, Abortion care guideline, 2nd edition. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- Second edition updates the 2012 Safe abortion guidance, 2015 Health worker roles guidance, and 2018 Medical management of abortion guidance
- New recommendation on letrozole plus misoprostol combination regimen as alternative for medical abortion <12 weeks
- New recommendations on pain management specifying paracervical block and conscious sedation options by gestational age
- New recommendation on cervical priming for surgical abortion ≥12 weeks with detailed osmotic dilator guidance
- New recommendation on telemedicine as alternative to in-person interactions for medical abortion services
- Expanded self-management recommendations to include all three components of medical abortion process
- Seven separate law and policy recommendations developed from previous composite recommendation
- Updated remarks for Recommendation 22 on conscientious objection in this second edition printing
- Removal of requirement for 'close medical supervision' for abortion medicines, aligned with 2019 WHO Essential Medicines List revision
- Recommendation against anti-D immunoglobulin for abortion <12 weeks gestational age
From the guideline
Verbatim
“Between 4.7% and 13.2% of all maternal deaths are attributed to unsafe abortions, which equates to between 13 865 and 38 940 deaths caused annually by the failure to provide safe abortion.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As editor of GMJ and a WHO consultant, I see this consolidated guideline as directly relevant to ongoing health system reforms across Georgia and the South Caucasus. While our region has made progress—Georgia does not criminalize abortion within legal timeframes and has integrated family planning into the UHC programme since 2013—significant implementation gaps remain, particularly in rural and mountainous areas where access to trained providers and quality-assured medicines is limited. The recommendation I would most stress to Georgian clinicians is the evidence against requiring routine ultrasound before abortion, which adds unnecessary cost and delay without improving safety, and the expansion of medical abortion provision to mid-level providers including nurses and midwives who already provide maternal health services in our primary care network. A realistic caveat for our context is that the self-management and telemedicine recommendations, while promising for addressing geographic barriers, will require careful adaptation to ensure uninterrupted access to quality-assured mifepristone—currently imported and not consistently available outside Tbilisi—and robust referral pathways for the small proportion of cases requiring facility-based management of complications, which our regional health infrastructure in some areas may not yet adequately support.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 14 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia’s 2007 Healthcare Code permits abortion on request up to 12 weeks and on medical/social grounds up to later gestational ages, placing it among countries with relatively liberal legal frameworks in the region. However, implementation challenges remain: availability is concentrated in Tbilisi and regional centres, financial barriers exist despite official fee schedules, and conscientious objection by providers can delay access. The guideline’s emphasis on integrating abortion care into primary health care and the State Programme for Universal Health Coverage is directly relevant to Georgia’s ongoing UHC reforms. Task-sharing recommendations align with Georgia’s mid-level provider workforce (feldshers, midwives), while telemedicine recommendations offer solutions for rural areas in mountainous regions. The decriminalization recommendation has limited direct applicability as Georgia does not criminalize abortion within legal timeframes, but the guidance on ensuring access without mandatory waiting periods, third-party authorization and gestational limits can inform policy review. Regional disparities in contraceptive access make the post-abortion contraception recommendations particularly relevant. National adaptation would need to address existing conscientious objection practices, strengthen supply chains for quality-assured mifepristone and misoprostol beyond major cities, and develop competency-based training for expanded provider roles within the existing health workforce regulatory framework.
Questions this guideline answers
Quick answers
Which health workers can provide medical abortion according to the guideline?
For medical abortion <12 weeks, the guideline recommends provision by self-management, community health workers, pharmacy workers, pharmacists, traditional and complementary medicine professionals, auxiliary nurses/ANMs, nurses, midwives, associate/advanced associate clinicians, generalist medical practitioners and specialist medical practitioners. For ≥12 weeks, generalist and specialist medical practitioners are recommended, with suggestion for other mid-level providers where appropriate surgical backup is available.
Is ultrasound required before abortion?
No. The guideline recommends against ultrasound scanning as a prerequisite for abortion services. Gestational age can be determined by last menstrual period in women with regular cycles, or by clinical examination. Ultrasound may be used on a case-by-case basis when there are specific clinical indications, but should not be a routine requirement that delays or prevents access to care.
Can women self-manage medical abortion at home?
Yes, for pregnancies <12 weeks. The guideline recommends self-management of medical abortion in whole or in part, including self-assessment of eligibility, self-administration of medicines outside a health facility without direct supervision, and self-assessment of success. However, self-managing individuals must have access to accurate information, quality-assured medicines, support from trained health workers if needed, and access to referral services for complications.
What pain management is recommended for surgical abortion?
NSAIDs should be offered routinely and provided to those who want them at any gestational age. For surgical abortion <14 weeks, paracervical block is recommended, with the option of combination pain management using conscious sedation plus paracervical block where conscious sedation is available. For ≥14 weeks, paracervical block is recommended, with the same option for combined conscious sedation plus paracervical block. General anaesthesia is recommended against for routine use.
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- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 2nd edition, 2024 (second printing with updated Recommendation 22 remarks)
- Replaces
- Safe abortion: technical and policy guidance for health systems, 2nd edition (2012); Health worker roles in providing safe abortion care and post-abortion contraception (2015); Medical management of abortion (2018)
- Status
- Current
- Published
- 2025-08-25
- Languages
- English (original)
- Scope
- Comprehensive abortion care including information provision, induced abortion (medical and surgical methods), management of pregnancy loss (missed abortion, IUFD, incomplete abortion), post-abortion care and post-abortion contraception; law and policy framework, clinical services and service delivery across continuum of care
- Audience
- National and subnational policy-makers, SRH programme managers, NGOs, civil society, professional societies, health workers (all cadres), stakeholders in sexual and reproductive health and rights
- Pages
- 214
- Licence
- CC BY-NC-SA 3.0 IGO
- ISBN
- 978-92-4-010420-4
- Evidence
- GRADE-rated systematic reviews with Evidence-to-Decision frameworks using WHO-INTEGRATE methodology; innovative approach integrating human rights protection into health outcomes for law and policy recommendations; 54 recommendations (new and updated) and best practice statements
- Next review
- Not specified
- Record history
- Created 14 Oct 2026 · updated 14 Oct 2026 · next check Apr 2027
World Health Organization. Abortion care guideline, 2nd edition. Geneva: World Health Organization; 2024. Licence: CC BY-NC-SA 3.0 IGO.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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