Remarks:

• There was more evidence for self-management of medical abortion (with either of the regimens) for pregnancies before 10 weeks of gestation.
• This recommendation applies to the combination regimen of mifepristone plus misoprostol, and the use of misoprostol alone. The included studies informing these recommendations did not assess the letrozole plus misoprostol regimen.
• All individuals engaging in self-management of medical abortion must also have access to accurate information, quality-assured medicines including for pain management, the support of trained health workers and access to a health-care facility and to referral services if they need or desire it.
• Restrictions on prescribing and dispensing authority for abortion medicines may need to be modified or other mechanisms put in place for self-management within the regulatory framework of the health system.

Implementation considerations

• Every individual must have access to accurate information about the self-management process as well as other options available within their local context, to enable informed decision making on whether to selfmanage all or parts of the process.
• Self-assessment of eligibility includes the assessment of pregnancy duration based on LMP. Paper or digital tools to assist recall and calculate duration or checklists may assist in the self-assessment of eligibility. When menstrual cycles are irregular or women have other concerns, she should be encouraged to seek support from a trained health worker where possible.
• Self-administration of medicines and management of the medical abortion process involves taking all or some of the abortion medicines without the direct supervision of a health worker. It is important that all sources from which medicines are procured provide quality-assured medicines.
• Women should also have information about pain during the process and should be able to obtain medicines for pain management.
• Women should also have information about the requirements of managing abortion-related bleeding at home, and should have access/referral to emergency care if this becomes necessary.
• Self-assessment of the success of abortion can be done using check lists of signs and symptoms. Other tools (e.g. low-sensitivity pregnancy tests), if available, may be used to assist the woman in self-assessing completion. Low-sensitivity urine pregnancy tests are different from ordinary pregnancy tests. The use of a high-sensitivity pregnancy test (a multi-level pregnancy test [MLPT]) alone or in conjunction with checklists has been shown to have a higher sensitivity for detecting successful abortion. Access should be available to a health worker or health-care facility to confirm the success of abortion or to manage side-effects or complications.
• As part of the enabling environment, health workers and managers should recognize self-management as a legitimate pathway to abortion care, and should work to adapt health systems to facilitate and support women in their self-management of abortion – for example, by adapting clinical protocols used at their facility.
• Mechanisms need to be established to ensure access or referrals to post-abortion contraception services and provision of contraception for women who want them.
• While self-management can support efficiencies within health systems in the long term, it should not mean that the burden of the cost of health services is simply transferred from the provider or facility to the woman herself.

KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO SELF-MANAGEMENT APPROACHES

• Sexual and reproductive health (SRH) care must be available, accessible, acceptable and of good quality.
• States must ensure availability of a wide range of modern, safe and affordable contraceptive methods.
• States must ensure adequate access to essential medicines in an affordable and nondiscriminatory manner.
• States must respect autonomous decision-making, non-discrimination and equality. This means that States should repeal or reform laws and policies that nullify or impair the ability of certain individuals and groups to realize their right to SRH, including the criminalization of abortion or restrictive abortion laws.
• States must make accurate, evidence-based abortion information available to individuals on a confidential basis
• States must take steps to reduce maternal mortality and morbidity.
• In line with human rights requirements, self-management of abortion should not be criminalized. Criminalization of self-management of abortion may result in delays in or barriers to seeking assistance or post-abortion care where needed. Self-management of medical abortion should be available as an option on the basis of clinical appropriateness. It should not be restricted for non-clinical reasons such as age.