What is abortion? Induced abortion (sometimes known as termination of pregnancy –TOP) is a procedure undertaken to intentionally end a pregnancy by expulsion or removal of the fetus. Abortion is one of the most commonly undertaken gynaecological procedures.
Global overview: The estimated absolute number of abortions worldwide in 2008 was 43.8 million, although obtaining accurate global abortion data is difficult as procedures are often under reported in countries where restrictive laws apply and even in liberal countries data must be retrieved from multiple sources. The subject of abortion often courts controversy and ethical and political debate. Although abortion is legal in most of countries including the UK, it is still outlawed or severely restricted in many regions worldwide. Restricting or banning abortion does not reduce the abortion rate in these countries, but instead women may seek this procedure from illegal and unsafe providers; self-induce abortion; or be forced to travel to a different country (with more liberal laws) to access a service. It is estimated that there are 47,000 deaths worldwide each year from unsafe abortion. Most of these occur in developing countries. In contrast, legal abortion performed by competent individuals in sterile facilities is a safe procedure with a low incidence of morbidity and mortality.
Legal issues
Most countries will allow abortion to save a women’s life, although the uncertainty professionals face in some countries when determining who meets these criteria were illustrated in a high-profile case in The Republic of Ireland in
2012.
Therefore, new abortion legislation was introduced in Ireland in 2013. In
the USA and Australia abortion are legal however each state or territory will have
its own laws governing the procedure. In other countries such as Malta and many
parts of Latin America abortion is criminalized in most circumstances.
In Great Britain (England, Scotland and Wales but not Northern Ireland)
abortion is governed by the Abortion Act 1967 (amended in 1990 by the Human
Fertilization and Embryology Act) which allows abortion up to 24 weeks’
gestation if certain criteria are met (Box 27.1), and abortion over 24 weeks’
gestation in exceptional circumstances (e.g. to save the woman’s life, or for
severe fetal anomalies). Any treatment for the termination of pregnancy can only
be carried out in an NHS hospital or in a place approved for the purpose by the
Secretary of State, and after 24 weeks, only in an NHS hospital (except in an
emergency).
The majority of abortions in Britain (over 95%) are undertaken under Ground C.
In Britain prior to an abortion, two doctors must complete a “Grounds for
carrying out an abortion” form (e.g. HSA1 in England or Certificate A in
Scotland), and following the procedure an “Abortion Notification form” must be
sent to the Chief Medical Officer (CMO).
Although part of the United Kingdom, the Abortion Act of 1967 does not extend
to Northern Ireland, where abortions are governed by the Offences Against the
Person Act 1861. This Act effectively outlaws abortion in all but exceptional
cases. On average five women a day travel from Northern Ireland to mainland
Britain to obtain an abortion (at their own expense).
Role of health care professionals
Doctors are responsible for completing the legal documents, prescribing any drugs required for the procedure and taking overall responsibility for the abortion process in Great Britain and most other countries.
Nurses and midwives can administer the drugs required for an abortion at any gestation once they have been prescribed by a doctor, but in Britain, and the majority of developed countries they cannot perform surgical abortions. There is growing support however to expand the role of midlevel health care providers (nurse practitioners, midwives, physicians assistants, etc.) in abortion care. In South Africa nurse practitioners and physician’s assistants have been able to provide first-trimester abortion services since 1997. More recently (2013), the state of California in the USA passed legislation to allow trained mid-level healthcare workers to provide first trimester aspiration abortions. As evidence grows that abortion is safe when undertaken by these competent providers, their role is likely to expand in many countries.
Conscientious objection
The Abortion Act contains a conscientious objection clause Health practitioners can refuse to participate in abortion treatment if it conflicts with their moral or religious beliefs.
Doctors who have a conscientious objection to abortion must tell women of their right to see another doctor. This clause does not apply when treatment is required in an emergency
situation, e.g. to save life or prevent grave permanent injury to the woman’s physical or mental health.
Referral and service providers
Referral
Women often seek advice and referral from their primary care provider (GP or
practice nurse) or community reproductive health clinic in the event of an
unplanned pregnancy. Alternatively, some abortion services will accept self-referrals. Many abortion providers have close links with other services, e.g. addictions services or the Looked After Accommodated Children (LAAC) team to allow swift access to the service and minimize delays, particularly in the most vulnerable groups of women. National standards exist regarding referral timeframes for abortion. The RCOG recommends that women are offered an assessment appointment within 5 working days of referral as the earlier in pregnancy an abortion is performed the safer it is.
Abortion providers
Abortions may be provided within the public sector (e.g. NHS), or by independent or charitable organizations. These services may fall within the remit of hospital gynaecology departments although increasingly community based SRH services are responsible for providing abortion. The type and location of abortion services is largely determined by the country in which the service is located and its governing legislation. In Scotland, 98% of abortions are provided
within the public sector (NHS), whereas in England although 97% of procedures
are funded by the NHS, only 35% of these are undertaken in NHS hospitals, the
remainder being undertaken in the independent sector, e.g. Marie Stopes
International (MSI) or British Pregnancy Advisory Service (BPAS). An
alternative to attending a service is to access medical abortion via a web-based
service. Women on Web (WoW) enables women to access a medical
consultation via an interactive web-based questionnaire and to receive the drugs
required for medical abortion via postal mail. In countries where abortion is
illegal or highly restricted, or the drugs for medical abortion are not available,
this service can offer an alternative to unsafe abortion.
Pre-abortion assessment
Pre-abortion discussion: Not all women considering an abortion have an
unplanned or even unwanted pregnancy. Changes in a women’s health or
socioeconomic circumstances can result in women seeking an abortion for a
planned and much wanted pregnancy.Equally, not all women attending an assessment
clinic will decide on an abortion and it is important to discuss all the available
choices during this initial consultation in a non-directional manner, including
offering support which may be appropriate (e.g. department of social work). This
will enable the woman to make an informed decision. There are three main
options available to women with an unintended pregnancy. Women
may need time to consider these options before making a decision or may choose
to access more formal counselling services. This should be facilitated in a timely
manner.
Pre-abortion counselling: In some countries counselling is mandatory prior to
having an abortion. An example is Texas in the USA, where from late 2013,
women must receive state-directed counselling that includes information
designed to discourage proceeding with an abortion and then wait 24 hours
before the procedure is provided. The introduction of mandatory independent
counselling in the UK was also debated recently but has not been introduced.
Many view these developments as impeding access to safe and timely abortion
access for women.
Investigations: Most women will undergo an ultrasound scan as part of their initial
assessment; however RCOG guidance does not recommend this as a prerequisite
to abortion although there should be access to it if required. Provision of STI
screening varies by service. A risk assessment and consideration of the local
prevalence of STI’s such as gonorrhoea is useful when planning abortion service
protocols.
Contraception: Future contraception should be discussed before the procedure
and a plan made for commencing the chosen method post-abortion.
Abortion procedures
Abortion may be undertaken using medical or surgical methods at all gestations
up to 24 weeks. The choice of method will depend on patient preference, local
availability and the gestation of the pregnancy.
- Medical abortion
Since medical methods of abortion were licensed for use in the UK in 1991, an
increasing number of abortions are being performed medically. The proportion
of medical abortions trebled in the last decade in England and Wales, and in
2013, over 78% of procedures were performed medically in Scotland.
Drug information
Medical abortion employs the use of 2 drugs ; an antiprogesterone
(mifepristone), followed 24–72 hours (usually 48 hours) later by a prostaglandin
(e.g. misoprostol). In the UK the prostaglandin gemeprost is licensed for
abortion procedures however it is expensive and requires storage below minus
10°C, so conventionally misoprostol is used although this is out with product
licence. Many of the medical regimens used for abortion are unlicensed for such
use however these drugs can be used out with licence in the UK as long as the
woman is aware that it is being used for an unlicensed indication.
Route of administration
Misoprostol can be administered orally, vaginally, sublingually or bucally;
however, after 49 days, vaginal misoprostol is more effective than the oral route.
Sublingual or buccal routes of misoprostol administration are associated with
more adverse effects than vaginal routes (e.g. headache) and are associated with
an unpleasant taste in the mouth.
Place of abortion
Although the medication for abortion must be administered in licensed premises
in Great Britain, there is no restriction on where the actual abortion takes place.
Many services now offer early discharge home for abortions at gestations up to
63 days. The woman leaves the hospital following administration of misoprostol
and completes the procedure at home. Adequate support and rigorous follow-up
arrangements must be made for these women.
Surgical abortion
Vacuum aspiration can be performed up to 16 weeks’ gestation with the
following caveats:
- Below 7 weeks the failure rate is higher than at later gestations and a
rigorous protocol should be followed including inspection of the aspirated
tissue and further evaluation (e.g. serum βHCG) if the products are not
identified. - Between 14 and 16 weeks large bore cannulae must be used, which may not
be readily available in Great Britain. Only experienced clinicians should be
undertaking procedures at this gestation. - Cervical preparation should be considered in all women undergoing
surgical abortion to reduce the risk of uterine perforation or cervical trauma.
Vacuum aspiration involves evacuation of the uterus using a cannula attached to
a vacuum source. The vacuum is either generated using an electrical (EVA) or
manual source (MVA).
MVA employs a hand-held syringe or aspirator which is connected to a cannula
and used to create a vacuum manually . This technique is
growing in popularity in Great Britain. It is often performed with a local
anaesthetic, and safety, efficacy and levels of satisfaction are similar to EVA.
Surgeons report more procedural difficulties using MVA over 9 weeks’
gestation, so for this reason many services offer EVA at later gestations. The
maximum cannula diameter available for MVA is 12 mm.
Feticide
To negate the risk of a live birth, feticide (e.g. via ultrasound guided intracardiac
potassium chloride injection) should be performed before medical abortion after
21 weeks 6 days’ gestation.
Analgesia and anaesthesia
Surgical abortion can be performed under local (para-or intracervical)
anaesthetic, conscious sedation or general anaesthetic. Intracervical block has
less risk of vascular injection than paracervical block and is safe and effective. MVA is traditionally performed under local anaesthetic whereas
EVA often employs general anaesthesia in Great Britain. Analgesia is routinely
offered during both medical and surgical abortion e.g. non-steroidal anti-inflammatory drugs (NSAIDs). Medical abortion at later gestations may require
the use of narcotic analgesia.
Risks, complications and adverse effects
Overall abortion is a safe procedure with a low risk of major complications and
extremely low risk of mortality in the UK. The risks increase with
increasing gestation hence the importance of early access and minimizing the
delays to abortion services.
Post-abortion infection: there are several strategies used to prevent
complications from infection. Screening is important as it
provides an opportunity to treat the partner of an infected woman thus
preventing re-infection. Peri-abortion antibiotic prophylaxis should be
provided for women undergoing medical or surgical abortion and should
utilize drugs which are effective against C. trachomatis and anaerobes
Breast cancer: there is no association between abortion and an increase in
breast cancer risk
Future reproductive outcomes: abortion is not associated with subsequent
infertility, placenta praevia or ectopic pregnancy however there is some
evidence to suggest an association with a small increased risk of future
preterm delivery. The evidence is insufficient to demonstrate causality
Psychological sequelae: women may experience a range of emotions
around the time of an unplanned pregnancy. Those with pre-existing mental
health problems may experience further problems whether they continue
with the pregnancy or have an abortion. There is no evidence that
proceeding with an abortion negatively impacts on psychological wellbeing
any more than continuing with the pregnancy and having the baby
Disposal of fetal tissue
Fetal tissue should be disposed of with sensitivity and dignity in accordance with
National legislation and local policy. Recent guidance from the Scottish Government advises that a minimum standard is collective disposal of pregnancy tissue in a crematorium. Women should be informed of the options available for fetal disposal and their wishes met wherever possible Options generally include cremation or burial, but women can make their own arrangements. Conversely, some women do not wish to participate in a detailed dialogue regarding disposal
of fetal tissue and this decision should also be respected.
Post-abortion care and follow-up
Although routine follow-up after abortion is not required, a review to exclude a continuing pregnancy may be required with medical abortion, particularly if this has taken place at home and there is uncertainty as to whether the products of conception (POC) have passed. Confirmation may be by means of a follow-up ultrasound scan, or alternatively
by urine HCG testing (patient self-testing at home) with telephone review.
Contraception
Immediate provision of all methods of contraception should be available in
abortion services. The efficacy of the LARC methods should be emphasized.
Ideally all methods should be initiated on the day of the surgical procedure or the
second part of the medical procedure. In this instance, the methods will be
immediately effective. If the POP, a combined hormonal method, progestogen
only injection or implant are initiated more than 5 days after the abortion, then
additional precautions will be required (e.g. barrier methods or abstinence). The
starting regimens for each method are detailed in the relevant chapters. There is
an increased incidence of regret if sterilization is undertaken at the time of an
abortion therefore it is advisable to delay this procedure for at least 6 weeks. In
order to avoid a further unplanned pregnancy during this time, consideration
should be given to provision of a bridging method of contraception until the time
should be given to provision of a bridging method of contraception until the time
of the procedure. It is suggested that an intrauterine method (Cu-IUD or LNGIUS) is inserted at the time of surgical abortion or immediately following the
second part of medical abortion or within 48 hours of these procedures.
Otherwise, practice has been to delay insertion for a further 4 weeks. There is
not however any evidence that insertion of an intrauterine device between 48
hours and 4 weeks post abortion increase the risk of perforation and it can be
undertaken by an experienced clinician once the procedure has been confirmed
complete. Again, if there is any delay initiating one of these methods, a bridging
method should be initiated in the interim.
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