Remarks:

• Evidence from clinical studies demonstrates that the combination regimen (Recommendation 27a) is more effective than misoprostol alone.
• All routes are included as options for misoprostol administration, in consideration of patient and provider preference.
• The suggested combination regimen of letrozole plus misoprostol may be safe and effective up to 14 weeks of gestation. * Repeat doses of misoprostol can be considered when needed to achieve success of the abortion process. In this guideline we do not provide a maximum number of doses of misoprostol.

Implementation considerations

• It is not essential that the person providing the medical abortion should also be trained and competent in vacuum aspiration provision.
• Restrictions on prescribing and dispensing authority for some categories of health workers may need to be modified within the regulatory framework of the health system or other mechanisms put in place to allow these providers to make the medicines available to abortion seekers.
• Privacy should be ensured in all settings, in particular in places where a private space may be challenging (e.g. pharmacies).
• Support tools can be used to assess eligibility and outcome (e.g. high-sensitivity pregnancy tests, checklists).
• A range of service-delivery models exist to facilitate the medical abortion process, such as telemedicine or community outreach (see section 3.6.1).
• Mechanisms to ensure access to quality medicines need to be set up. Development of tools like point-ofcare tests to assess quality could support both the pharmacy worker and the individual.
• It is important to note that as with all other medicines, pharmacy workers should dispense mifepristone and misoprostol as indicated by prescription.
• The person undergoing medical abortion should have access/referral to emergency care in case this becomes necessary.
• As part of the enabling environment, health workers should recognize self-management as a legitimate pathway to abortion care and to adapt health systems to facilitate and support women in their selfmanagement of abortion, e.g. adapting clinical protocols.
• Mechanisms need to be established to ensure access or referrals to post-abortion contraception services and provision of contraceptives for women who want them.

KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO MEDICAL ABORTION

• Everyone has a right to privacy and confidentiality in sexual and reproductive health (SRH) care.
• Abortion regulation should be human rights and evidence based.
• States must ensure adequate access to essential medicines in an affordable and nondiscriminatory manner.
• Everyone has the right to scientific progress and right to health, which requires the availability and accessibility, acceptability, and quality of medical abortion. This means that States should ensure access to abortion medicines, and that evidence-based standards and guidelines for the provision and delivery of SRH services, are (i) in place and (ii) routinely updated to incorporate medical advancements.