Adapting the WHO recommendations on health worker roles for safe abortion to a country setting: A case study from India

Abstract In 2015, the World Health Organization (WHO) published a guideline on the role of health workers in providing safe abortion and postabortion contraception, with evidence‐based recommendations on the range of providers who can perform interventions to provide safe abortion, postabortion care, and postabortion contraception. The WHO guideline is global in nature and must be contextualized to individual country settings. The present paper compares the scenario in India, including the legal and policy frameworks, with the WHO guidelines. It provides legal and policy recommendations that are needed to improve access to comprehensive abortion care in India, with a focus on expanding the provider base. The process used to develop these recommendations was a combination of empirical evidence gathering and multistakeholder consultations. An outcome of this exercise was a policy brief entitled “Improving access to comprehensive abortion care in India with focus on expanding provider base,” which is used as an advocacy tool.


| BACKGROUND
The Medical Termination of Pregnancy (MTP) Act was enacted in India in 1971 to provide the legal framework for abortion services in the country. 1 Despite this and after decades of legalization of abortion services, India has a long way to go to ensure universal access to comprehensive abortion care services. Comprehensive abortion care refers to the provision of safe, high-quality, woman-centric abortion services and includes abortion, postabortion care, and postabortion contraception.
A recent study estimated that the incidence of induced abortions in India was 15.6 million in 2015. 2 Of these, only 3.4 million (22%) took place in a facility setting using either surgical or medical methods. A substantial 73% of the total-about 11.5 million abortions-took place outside a facility using medical methods. One reason for this scenario is the lack of access to facilities registered under the MTP Act to provide abortion services-such facilities are not only fewer than required but are also inequitably distributed. 3 The other critical barrier is the shortage of trained and "certified" providers of abortion. 4 The MTP Act permits only allopathic doctors-obstetrician/gynecologists (ob/gyns) or general physicians who in India possess the Bachelor of Medicine, Bachelor of Surgery (MBBS) degree with defined experience in this field-to provide abortion services. However, data for the year 2015-2016 reported only 1292 ob/gyns in public health facilities compared with 5510 required specialists, translating to a shortfall of over 76%. 5 It is estimated that there are around 35 000 ob/gyns in the private sector but most of them are in urban areas. While there is also a shortfall in other health worker cadres, the same dataset reveals much higher availability of nurses and auxiliary nurse midwives (ANMs), both in absolute numbers and as a proportion of the total requirement in public health facilities. For example, there were over 69 000 nurses and about 220 000 ANMs posted at government-owned facilities, with a shortfall of only 20.5% and 5.3%, respectively. 5 In 2015, the World Health Organization (WHO) published the guideline "Health worker roles in providing safe abortion care and postabortion contraception" 4 (henceforth, the WHO 2015 guideline), which provides evidence-based recommendations on the range of healthcare providers who can effectively and safely perform various interventions for provision of safe abortion and postabortion care.
This guideline complements WHO's technical and policy guideline on safe abortion, 6 which describes evidence-based interventions for comprehensive abortion care along with the required legal and policy frameworks to ensure ease of access to these services for women. The WHO guideline is global in nature and must be adapted to individual country settings based on the local conditions, including the legal and policy frameworks. The aim of the present paper was to highlight the process used to develop the required legal and policy recommendations, including the challenges faced, and to share the final recommendations that emerged as the key outcome of the process.

| PROCESS USED TO DEVELOP THE RECOMMENDATIONS
A two-stage process was followed, as depicted in Figure 1. Stage one involved in-depth review and documentation of the Indian scenario, 7 including: (1) comparing health personnel cadres that are available in India, matching these with the definitions provided by WHO in its 2015 guideline (Table 1), and researching the roles they are allowed to play based on available data; (2) conducting an in-depth review of legal, policy, and other data sources (Table 2) to determine the Indian   legal and policy scenario regarding the eligibility of various health   personnel cadres to provide abortion and related services; and (3) comparing it with the WHO recommendations and mapping the gaps between the two to develop a list of potential recommendations for legal and policy changes required in India to bring the country situation on par with the WHO recommendations.
For the second stage, the review was presented to and discussed with experts at two consultative meetings; each meeting was held with a different primary purpose and methodology. The first meeting comprised a smaller group of 16 "core experts" and was an intense exercise with a two-fold purpose: (1) finalizing the gap analysis ( Figure 2) based on the desk review done by IDF; and (2) prioritizing the potential recommendations that emerged from the desk review.
This was done based on the potential impact of the recommendation on improving access to comprehensive abortion care as well as the feasibility of bringing about that legal or policy change. The second meeting comprised, in addition to the participants from the first meeting, representatives from a wider range of stakeholder groups, including legal experts and representatives from civil society and women's groups. The purpose of this group was to re-evaluate and ratify the recommendations prioritized by the first group and bring in broadbased perspectives from different stakeholders.
The recommendations finalized at the second meeting (Table 3) were translated into a policy brief 25 to be shared with the government and other advocates for improving access to comprehensive abortion care services, with special focus on expansion of the provider base. The recommendations focused primarily on task-sharing for first-trimester abortions.
It is important to note that in mapping health worker eligibility in India, the terms "partial" and "conditional" eligibility have been used.
Partial eligibility refers to contexts where the health worker is eligible F I G U R E 1 Process for developing a policy brief with legal and policy recommendations on expanding the health provider base to improve access to abortion care.
to perform the task but other conditions (such as gestational age limits) do not allow the worker to perform the task to the whole extent of WHO's technical recommendations. Similarly, conditionally permitted is used in situations where the health worker's eligibility to perform the task is limited through policy/technical guideline conditionalities, such as additional site approvals.

| Documents generated through the process
Papers documenting the in-depth analysis were also developed. The documents, "Expanding Provider Base for Safe Abortion in India: Policy Gaps" 7 (which describes the situation analysis of India's legal and policy scenario concerning the eligibility of health worker cadres to perform various abortion-related tasks, with detailed references to the various documents reviewed), and "Expanding Provider Base for Safe Abortion in India: Policy Actions" 26 (which is a more concise and easy-to-read version of the Indian policy analysis document), along with the final policy brief 25 are available in the public domain and can be used by advocates working to make legal and policy changes in the abortion context, health and human rights experts, law and policy makers working on abortion-related issues, as well as academics and researchers studying the abortion scenario in other countries.

| CHALLENGES AND LESSONS LEARNED FROM THE PROCESS
While the process of comparing the national scenario with the global guideline and drawing recommendations should have been a relatively straightforward process, we faced several challenges, both expected and unexpected.
The purpose of the exercise was to develop recommendations and ensure that they are acceptable to a wide range of stakeholders, including those who have a role to play in implementing the recommended changes, such as the different cadres of health service providers. To achieve this we included varied stakeholders in our consultative meetings, including ob/gyn specialists, AYUSH (Ayurveda, yoga, naturopathy, Unani, Siddha, or homoeopathy) doctors, nurses, government decision makers, public health experts, researchers, legal experts, advocacy experts, civil society leaders, and representatives of multilateral organizations. There were many advantages to following this inclusive process, which: (1) ensured ownership of the process and the finalized recommendations by representatives of key stakeholder groups; (2) enabled sharing of varied perspectives on the issues, making the recommendations balanced and well-thought through; (3) provided inputs on the need and feasibility of the changes recommended by the people who were engaged, in one way or another, with abortion care; and (4) initiated discussions on comprehensive abortion care-related issues with and between the different stakeholders, both within and beyond the meetings, which will be required to bring the recommended legal and policy changes to fruition.
The challenge in engaging with such a large group was merging the divergent opinions into a common consensus. The following management steps and tools were used to arrive at a consensus: (1)    did not specify the health worker cadre(s) they were meant for. In the initial desk review, this lack of information was interpreted as lack of eligibility of that cadre to perform the tasks and subtasks.
While in most cases the experts agreed with this assessment, in a few cases the experts opined that in situations where cadres are not specified, it can be considered that they are permitted to provide the service. For example, the law (MTP Act) permits only allopathic (MBBS) doctors with a qualification and/or experience in ob/gyn to conduct abortions. The initial review interpreted this to mean that nonphysician cadres were not permitted to perform even the related subtasks, such as cervical dilation (using osmotic dilators or medications) prior to a dilatation and evacuation. The experts, however, felt that the law was applicable to the actual provision of abortion, that is, the evacuation process only, and that in a facility setting the law did not restrict other cadres from performing the preparatory subtasks. They argued that a relatively restrictive inter-  From a feasibility and impact viewpoint, the experts recommended initiating the change with permitting these additional cadres to provide abortion using medical methods only; permission to use vacuum aspiration for abortion may be added later. b Misoprostol for management of incomplete abortion is discussed in the documents only in cases of failed MMA. Even in this, it is restricted to specific cases where the gestational sac is visible on an ultrasound but is not viable. c While the Rules of the MTP Act mention 7 weeks as the maximum gestation until which MMA can be used to induce abortion, the permission by the DCGI for using the mifepristone plus misoprostol combi-pack for abortion is until 9 weeks of gestation. to perform these tasks should be revised. They also felt that interpretation of the Act should be more expansive than restrictive, as that may be the first step toward expanding the provider base for comprehensive abortion care. In contrast, the legal experts felt that a more restrictive interpretation should be adopted (as done by IDF in the initial background note and accepted by the first group of experts) to safeguard the interests of the providers. Should an issue arise regarding "mismanagement" of a case involving nonphysician health personnel, the health personnel might be found at fault. As such a case has never arisen, there is no precedent set in court to give a sense of which way the judgment would go.

| DISCUSSION
The process used a combination of empirical evidence gathering and