by Fred Nunes
On January 15, 2026, the Government of Guyana marked the tenth anniversary of its quiet disregard of an unequivocal High Court ruling concerning mid-level health care professionals and early-term, non-surgical abortion services.
Since 1995, all duly registered mid-level health workers in Guyana have been legally authorized to provide early-term, non-surgical abortions. No additional registration is required. They need only three things: (i) access to misoprostol (Cytotec), (ii) a cooperating physician, and (iii) Form F for the submission of an anonymous report. That is all.
Yet for three decades, the Ministry of Health has waged a remarkably successful campaign of resistance against this provision. The reason is not ambiguity in the law, but a deep institutional preference for a doctor-centred, hospital-based model of care over a patient-centred, accessible public health service. Power, tradition, and professional status have been privileged above the needs of poor women, particularly those in remote and hinterland communities.
The success of this resistance is evident in the data. A 2023 survey of 518 health-care professionals found that only 16 percent knew that mid-level workers could legally provide non-surgical abortion services. Even more striking, although medication abortion has placed pharmacists at the forefront of abortion care globally, 91 percent of pharmacists in Guyana did not know that they could lawfully provide such care.
This widespread ignorance is not an individual failure. It is a systemic one. Approximately 71 percent of current health-care workers were either under ten years old in 1995 or not yet born. The Government’s failure to educate successive generations of health professionals has effectively hollowed out its own law.
The great resistance
Government resistance began almost immediately after the passage of the Medical Termination of Pregnancy (MTOP) Act. Shortly after enactment, senior Ministry of Health officials stated bluntly that “Nothing in the law requires public hospitals to provide abortions.” This astonishing position ensured that a reform intended to reduce unsafe abortion among poor women would primarily benefit private physicians and their paying clients.
That position endured for over two decades. It was not until 2016 that a Chief Medical Officer acted to introduce services within the public system. Even then, implementation was cautious and deliberately low-profile, beginning in New Amsterdam and selected regional hospitals before reaching Georgetown Public Hospital Corporation (GPHC). The delay required no legislative amendment—only individual courage.
Clause 5(1): Mid-Level Providers
One of the most innovative features of the MTOP Act was its explicit accommodation of mid-level providers in early-term, non-surgical abortion care. Clause 5(1) states that treatment for termination of a pregnancy of not more than eight weeks by any lawful method other than surgery may be “administered or supervised by a medical practitioner.”
The wording is clear. A medical practitioner may either perform the abortion or supervise its performance by another appropriately trained person. Supervision necessarily implies provision by someone other than a doctor.
This clause was grounded in legal precedent. Under the British 1967 Abortion Act, abortions were initially restricted to “registered medical practitioners.” However, as medical induction methods emerged, nurses became central to care delivery. In Royal College of Nursing v DHSS [1981], the House of Lords held that nurses acting under a doctor’s direction were acting lawfully, even without the doctor’s physical presence.
In Guyana, the driver was not professional convenience but geography and equity. The hinterland is vast, sparsely populated, and poorly served by physicians. If abortion care was to be both safe and accessible, mid-level professionals had to be empowered.
The High Court
But the Ministry rejected our interpretation and barred mid-level providers from offering abortion services. The matter was therefore taken to the High Court in 2013 with pro bono representation from Cameron and Shepherd.
In January 2016, Justice Roxane George delivered a decisive ruling. On a true construction of Section 5(1), she held that “medexes, midwives, nurses, pharmacists and any other appropriately trained and registered mid-level member of the health profession” could lawfully provide abortion care within the Act’s constraints.
That ruling should have settled the matter. It did not. Because the issue was never truly legal. Once the Court spoke, the Ministry’s duty was clear. Yet over the past decade it has neither informed doctors nor educated mid-level staff. It has not made misoprostol available in public health clinics, particularly in hinterland areas. Instead, the Ministry shifted from open legal resistance to passive administrative obstruction. Doing nothing became policy.
This inaction is not benign neglect. It is malignant indifference.
Technology and the WHO
Since 1995, abortion technology has changed dramatically. Medication abortion is now the preferred method for most women. In 2022, the World Health Organization issued its Abortion Care Guideline, recommending that mid-level providers deliver medication abortion and that care be decentralized, including through telemedicine and self-management.
Guyana’s law anticipated these recommendations by nearly three decades. Yet the Ministry of Health remains anchored to a doctor-centred, hospital-based model fundamentally at odds with WHO guidance. The difference is not technical but ethical: WHO prioritizes client-centred access, while the Ministry prioritizes professional control.
Poverty and inequality
The original impetus for law reform was poverty. In 1991, GPHC recorded 1,542 admissions for septic abortion, the third leading cause of admission. Incomplete abortion ranked eighth. The patients were overwhelmingly young and poor. Unsafe abortion was not an abstract moral issue; it was a visible humanitarian crisis.
Today, despite Guyana’s rapid economic growth, poverty persists. The World Bank estimated poverty at 48 percent in 2019; by 2024 the Inter-American Development Bank placed it at 58 percent. The offshore oil boom has bypassed the poor.
Plutarch’s warning from the first century remains apt: “An imbalance between rich and poor is the oldest and most fatal ailment of all republics.”
Yet considerations of social justice appear absent from Ministry leadership. Indigenous communities—the most marginalized populations—have not been prioritized in abortion service delivery. Access for poor women and adolescents, once central to reform, has faded from view.
From A&E to A&E
Meaningful reform requires a shift from the old A&E—Accident and Emergency—to a new A&E: Access and Education.
Under the old model, hospitals bore the cost of treating complications from unsafe abortions. Under the access model, safe public services would eliminate those admissions altogether. At GPHC, admissions for complications fell by 97 percent. Strengthened post-abortion contraception reduced unintended pregnancy by 28 percent.
Education is a longer-term investment. Health and Family Life Education (HFLE), particularly Comprehensive Sexuality Education (CSE), remain weak across the Caribbean. No country meets minimum international standards. HFLE is not examinable and is routinely dropped, despite the catastrophic consequences of failure. This reorientation would transform abortion care from an expensive, reactive, hospital-based service into a preventive, affordable, client-centred public health function.
Action is long overdue
Thirty years is a lifetime.
Progress cannot rely solely on government initiative. Advocacy and accountability are essential to democracy. Mid-level professional associations must assert their rights under the MTOP Act. Medexes, midwives, nurses, and especially pharmacists should demand access to abortion medication in district hospitals and clinics, establish cooperative links with telemedicine physicians, and obtain Form F from the Telemedicine Centre.
Beyond health professionals, where are women’s organizations, unions, political parties, teachers, students and faith leaders? Silence preserves monopoly. Democracy decays in passivity.
Nothing prevents progress more than the fear of taking the first step.
Fred Nunes, now retired, lectured at the University of the West Indies and worked with the United Nations Development Programme (UNDP), the Pan American Health Organization (PAHO) and the World Bank (IBRD). He is committed to women’s reproductive health.
SOURCE: The original, longer version of this article by Fred Nunes first appeared in Stabroek News, 12 January 2026.