Expanding health worker roles and decentralizing safe abortion and postabortion care: Experiences in diverse settings

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The recommendations in the guideline are based on the premise that while task-sharing may be a necessary strategy to overcome an absolute or relative shortage of physicians, it is entirely appropriate to include a wider range of cadres of health workers in safe abortion care because there is ample evidence that they can provide care as safely and effectively as physician providers, and in many cases may be preferred by women. [1][2][3] Translating the guideline recommendations into national programs requires thoughtful consideration of the country's unique legal and health systems, and political, social, and cultural contexts. As a follow- Ghana is an example from sub-Saharan Africa and one of collaboration between the Ministry of Health and international nongovernmental organizations. 6 It is also an illustration of building upon task-sharing precedent in other areas of reproductive and sexual health care.
Awareness of the critical care gap when there is a shortage of available specialized physicians underpinned support for task-sharing in general. To fill this gap, midwives and other nonphysician health workers were trained to be able to take on specific tasks. Abortion care was eventually included on this list. Although the initial guidelines offered a highly medicalized service, the introduction of mifepristone into public facilities has simplified service delivery. Although nonspecialist physicians are now permitted to be involved in care and the services can be delivered at the primary level, there remains resistance to further demedicalization and task-sharing. However, recent evidence of the effectiveness of nurse-led service delivery and a more general movement to (re) include midwives into maternal and sexual and reproductive health care are promising. 7 Midwives' prominent role in sexual and reproductive health care in Sweden has been in place for decades. In this context, and with the introduction of medical abortion, this health worker cadre became the natural choice for involvement in service delivery. The authors of the article in this Supplement outline why they believe task-sharing was possible in the context of Sweden and highlight how, despite midwives' lack of explicit responsibility for abortion care in Sweden, they have had a dominant role. 8 Several of the research studies that have been conducted with midwives in Sweden have been used to support the introduction of medical abortion and task-sharing with midwives elsewhere in the world. 9,10 Like Sweden, Tunisia has produced important research on the efficacy of a medical abortion service delivered by midwives. Midwives had been responsible for various aspects of sexual and reproductive health for many decades, becoming involved in the delivery of medical abortion when it was introduced in the country in 2001. However, as the political and social environment of the country has become more conservative, barriers to access to safe abortion have been increasing, largely related to provider attitudes. 11 An additional paper presents an analysis of the cross-cutting themes and lessons learned across the six case study contexts. 12 The author asks: What features do these six contexts share that have enabled the implementation of task-sharing in abortion care? The strategies highlighted in this article are informative for programs wishing to implement task-sharing in abortion care in their contexts.
In addition to the country case studies, a paper from India describes a participatory process of mapping country gaps, both in the availability of a healthcare workforce and in task-sharing policies/guidelines or practice in place. 13 The exercise allows stakeholders to assess where they may need to invest energies to successfully bring the distribution of tasks among health workers in line with the WHO recommendations.
These case studies and the articles can serve as a valuable tool to facilitate knowledge translation and bridge the gap between the WHO recommendations and their transformation into country implementation.

AUTHOR CONTRIBUTIONS
AS and BG co-wrote the Editorial.