The law and abortion

The legal criteria surrounding abortion are country‐specific. In the UK, the 1861 Offences Against the Person Act (OAPA) made having or providing an abortion a crime carrying a potential life sentence. The 1967 Abortion Act, which does not extend to Northern Ireland, did not replace the OAPA or decriminalize abortion. Rather, it defined the circumstances in which an abortion could be performed without the risk of prosecution. These include having two registered medical practitioners agree that a woman meets one of five grounds (Table 44.1). This is indicated by signing a certificate (HSA1 form), which must be retained with the woman’s clinical notes for a period of at least 3 years. In cases where an abortion is necessary as an emergency to save a woman’s life or prevent grave permanent injury, only one doctor need authorize the abortion using an HSA2 form. A notification form (HSA4) must be signed by the doctor taking responsibility for the abortion and forwarded to the Chief Medical Officer of the relevant country. In the case of surgical abortion, the HSA4 form is signed by the doctor who carried out the uterine evacuation. For medical abortion, the doctor who prescribes the medications signs the form, although nurses or midwives commonly administer the drugs. The location where abortion may be performed is also defined in the Act and is limited to NHS hospitals or premises approved by the Secretary of State for Health.

Most abortions in Britain are undertaken under grounds C or D, which state that the pregnancy has not exceeded its 24th week and where continuance of the pregnancy would involve greater risks of injury to the physical or mental health of the woman or her existing children than if the pregnancy were terminated. In determining whether these grounds are met, account may be taken of the pregnant woman’s actual or reasonably foreseeable environment. This ‘health exception’ has been very broadly interpreted by doctors in Britain, tending toward the World Health Organization definition, which states that health is not just the absence of disease but the presence of well‐being.

Since the Abortion Act does not extend to Northern Ireland, abortion there remains highly restricted. Guidance for professionals on the termination of pregnancy in Northern Ireland was published in 2016 [10], reiterating that it is only lawful to perform an abortion in order to preserve the life of the woman or if there is a risk of ‘real and serious adverse effect on her mental or physical health, which is either longer term or permanent’. The guidance is explicit in that it is not possible to create a reference list of potential circumstances in which a lawful termination could be carried out but that it is for a doctor to assess, on a case‐by‐case basis. This guidance appears to have had little effect on improving access to abortion in Northern Ireland. Almost all women needing abortion care travel to Britain or Europe and there is evidence that many obtain medications online to induce their own abortions outside the legal framework [11].

There is a conscientious objection clause within the Abortion Act that permits refusal to undertake abortions. This right is confined to participating in treatment and is excepted when an abortion is necessary to save the woman’s life or prevent grave permanent injury to her physical or mental health. The limitation of the right to direct abortion care was reaffirmed by the UK Supreme Court in December 2014. Two midwives claimed that their right was breached when asked to answer telephone calls to book women for abortions and to delegate to or supervise staff providing abortion care. The Supreme Court considered the definition of the word ‘participate’ in the Act and concluded it to be ‘taking part in a hands‐on capacity: actually performing the tasks involved in the course of treatment’. Guidance from the General Medical Council also makes clear that while an individual doctor’s personal beliefs should be respected, they must not interfere with access to information about and services for treatments to which they object [12]. A doctor with a conscientious objection to abortion is obliged to make sure a woman has enough information to arrange to see another doctor without an objection or, if it is not practical for a woman to arrange to see another doctor herself, provide or facilitate a prompt referral.

An assessment of an individual’s capacity to give valid consent is essential before any medical procedure, including abortion. Separate legislation exists in England and Wales, and Scotland regarding medical decision‐making in the absence of capacity (Mental Capacity Act 2005 and Adults with Incapacity (Scotland) Act 2000). The management of women requesting abortion who may lack capacity is discussed in detail in guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) [13]. Particular note is made of the decision‐making capacity of girls less than 16 years of age. The Abortion Act does not stipulate that a woman must be of a certain age to request abortion or require parental consent or notification. Legal precedent in England and Wales, as determined in the House of Lords ruling in the Gillick case, and legislation in Scotland (Age of Legal Capacity (Scotland) Act 1991) are similarly constructed in that following demonstration of comprehension of treatment and its consequences, individuals less than 16 years of age are able to consent for medical care. The Fraser criteria, which guides doctors asked to provide contraception to girls who refuse to involve their parents, is applicable to abortion care. The RCOG recommends that practitioners encourage a young woman to involve her parent(s) or another adult but state that this should generally not override the views of the young person.

Assessment for abortion

The assessment of a woman requesting induced abortion is focused on confirming that she is sure of her decision and providing sensitive decision‐making support if needed, determining gestational age, identifying any contraindications that will restrict a choice of abortion method or anaesthesia, and determining whether treatment needs to be performed in a hospital setting or with cross‐specialty liaison. There is strong evidence supporting a lower risk of complications for abortions undertaken at earlier gestations. Services therefore need to be organized to minimize delay. The assessment also provides an opportunity to discuss and plan for initiation of a contraceptive method, should a woman choose to use one after the abortion, and to screen for genital tract infections that increase the risk of infective complications.

Most women requesting abortion will have decided to have a termination of pregnancy before coming to a healthcare provider for assistance [14]. Compulsory counselling is not recommended as it delays treatment unnecessarily and may be viewed as intrusive by a woman who is certain of her decision. A non‐judgemental interaction with a provider, an explanation of treatment options and risks, and prompt referral for treatment summarizes the expectations of most women once the decision to have an abortion has been made. For the small proportion of women for whom the decision is not straightforward, healthcare providers can assist with non‐directive decision‐making support or arrange for counselling. Either option may be assisted by the use of a tool, such as that created by the Family Planning Association (www.fpa.org.uk), which provides information about abortion, adoption and parenting and a list of considerations when deciding between them. Practitioners and women can be reassured that whether an unintended pregnancy is continued or terminated, the mental health outcomes will be the same [15]. The development of psychological problems after an abortion or a birth is most reliably predicted by a history of mental health problems. Referral pathways to therapeutic counselling should be in place for those situations regardless of the outcome of the pregnancy.

The clinical history should include relevant medical conditions, obstetric and gynaecologic history including prior ectopic pregnancy and sexually transmitted infections, allergies, medications, and recreational drug or alcohol use or abuse. It is important to explore any history of pain or bleeding in the current pregnancy as this may affect the decision to utilize ultrasound for gestational age determination and pregnancy location. There should be routine enquiry about intimate partner violence with appropriate support and information provided.

Most abortions can be safely carried out in day‐case units or freestanding clinics. Indications for treatment in hospital include conditions that necessitate prolonged or intensive monitoring, such as severe cardiopulmonary disease, and those which place the woman at high risk of haemorrhage such as placenta praevia in women with prior caesarean deliveries, or coagulopathy. Some conditions, such as obesity or uterine anomalies including large fibroids, can make surgical abortion more challenging so prior knowledge of them is useful for procedure planning.

Establishing gestational age is important because it is the primary determinant of the way in which a medical or surgical abortion will be performed. Limits on gestational age are also integral to most abortion laws, including in Britain. The duration of the pregnancy is often determined by abdominal or vaginal ultrasound, as relevant to the anticipated gestation, where it is readily available. However, this should not be a barrier to service delivery as there is no evidence that the routine use of ultrasound for this purpose improves either the safety or effectiveness of abortion procedures [16]. Last menstrual period (LMP) and a bimanual pelvic examination are sufficient in most cases with selective use of ultrasound where there is a discrepancy between LMP and uterine size or a concern for an ectopic pregnancy. Ultrasound is also often used to determine placental location in the second trimester in women with prior caesarean deliveries. It is important that a scan is undertaken in a sensitive setting and manner with a chaperone if the woman wishes to have one present. She should be advised that it is not necessary for her to watch the ultrasound examination in progress but she may be allowed to do so if this is her preference. It is useful to ask whether or not she wishes to be informed of any findings, such as multiple gestations.

Physical examination can be tailored to the anticipated treatment and the woman’s medical history. Observations and height and weight (to determine body mass index) are routine, with cardiac, pulmonary, abdominal, pelvic or other examinations undertaken as needed. Blood testing is typically limited to determination of rhesus (D) antigen status. The risk of iso‐immunization in the early first trimester appears negligible [17], but most services offer anti‐D immunoglobulin to rhesus‐negative women regardless of gestational age. Testing for haemoglobin is performed when there is a concern for anaemia and, often, if significant blood loss is anticipated, although data to support this practice are limited [18].

Ovulation can resume within 2 weeks of an abortion and many women will resume sexual activity during this time. Therefore, a woman who wishes to use a contraceptive method should initiate it as soon as possible after the procedure. This is facilitated by discussing contraception during the abortion assessment and providing a method at the time of treatment. Initiation of any hormonal method including the contraceptive implant, or insertion of intrauterine contraception (IUC) can occur immediately following completion of an uncomplicated surgical abortion at any gestation [19]. The risk of IUC expulsion may be increased slightly with immediate insertion after second‐trimester surgical abortion but is far lower than the risk of not returning at all for insertion at a separate visit. Similarly, women may start any hormonal contraceptive method at the time of a medical abortion. IUC may be inserted once the gestational sac is confirmed as expelled, which is typically by ultrasound 1–2 weeks after taking the medications. Depending on the type used, a cervical cap or diaphragm will require refitting after second‐trimester abortion. Condoms (male and female) can be used at any time after abortion and women may be offered emergency contraception (levonorgestrel or ulipristal acetate) to have in advance of need.

Screening for Chlamydia trachomatis and Neisseria gonorrhoeae is helpful because they increase the risk of post‐abortion upper genital tract infection and its long‐term sequelae of tubal factor infertility and ectopic pregnancy. The role of bacterial vaginosis (BV) in post‐abortion infection is less clear and screening would be atypical. Rates of post‐abortion upper genital tract infection vary widely but when objective criteria are used it is diagnosed in less than 1% of cases, regardless of abortion method and gestation.

Prophylactic antibiotics before first‐trimester surgical abortion reduces the risk of infection by 41% (95% CI 25–54%) [20]. Evidence is limited in the context of second‐trimester surgical abortion but it is reasonable to expect a similar impact on the reduction of infection. Universal prophylaxis before surgical abortion is standard but the evidence is poor for an optimal regimen. Recommendations vary from a single dose or short (3‐day) course of doxycycline to presumptive treatment of Chlamydia and BV. The benefit of antibiotic prophylaxis with medical abortion is less clear. There have been no randomized controlled trials of antibiotic prophylaxis with medical abortion. Very rare deaths have been reported due primarily to Clostridium species. One before‐and‐after study of 227 823 women in the USA showed a 93% reduction in serious infection when two simultaneous changes were made: implementation of a routine 7‐day course of doxycycline and a switch from the vaginal to buccal route of misoprostol [21]. As with surgical abortion, the RCOG recommends presumptive treatment of Chlamydia and BV at the time of medical abortion, but gives it a ‘C’ rating due to the limitations of existing studies.

Opportunistic screening for sexually transmitted infections (STIs), including HIV, also allows for active follow‐up and partner notification and treatment. Screening for infections such as syphilis, hepatitis B and hepatitis C may occur on a selective basis, influenced by sexual health risk assessment and population disease prevalence. Cervical screening is not essential to abortion care but is an opportunity to check that screening is up to date and, where it is not, offering a cervical smear. For all tests it is important to ensure that the result can be communicated to the woman and appropriate action taken on any abnormal result.

Choice of method

Choice is an integral part of abortion care. Provision of information, along with decision‐making support if needed, are essential to helping a woman select an abortion method that is right for her and which will optimize her abortion experience. In both the first and second trimesters, presuming no contraindications, abortion may be performed surgically or by the administration of abortifacient medications (Fig. 44.1). Both methods can be used in the case of multiple gestations. Some women prefer surgical abortion because it is predictable and quick, can be performed with a general or local anaesthetic or sedation, and has a low risk of complications. Others prefer medical abortion because it does not involve surgical instrumentation or anaesthesia and is perceived as more natural, like a miscarriage. In addition, medical abortion at a gestation of 70 days or less may be managed safely and effectively by the woman in the privacy of her own home which is preferred by many to care in a clinical setting.

Trials comparing medical and surgical abortion have been challenging to undertake because many women have an a priori preference for a method and refuse randomization. In the few studies available, some of which have included preference arms, acceptability with medical abortion has been found to be lower than with surgical abortion mainly due to greater pain and prolonged or heavier bleeding with medical abortion [22–25]. However, acceptability and satisfaction with either method is greatest when women are able to receive the type of abortion they want. Services with appropriately trained providers should therefore make both methods available at all gestational ages for which abortion is offered. If a service can only offer one method, referral pathways into other providers should be in place.

Information provided to a woman during the decision‐making process should include which abortion methods and pain management options are available to her; what will be done before, during and after the procedure including any tests or examinations; what she is likely to experience (e.g. pain and bleeding, side effects, complications); where the procedure will occur; and how long the process is likely to take, including the need for any follow‐up. Women undergoing medical abortion in the second trimester should be advised of the variable duration of the induction and possible need for overnight stay. Surgical abortion in the second trimester may require cervical preparation up to 24 hours before the evacuation so women need to be prepared for a procedure over 2 days although admission is not required.

Other aspects of care which may be important to address are whether her partner or another support person may be present during treatment and whether she may see the fetus or need to dispose of the products of conception after the abortion herself (i.e. with medical abortion at home). The World Health Organization’s Clinical Practice Handbook for Safe Abortion (www.who.int/reproductivehealth/publications/en/) includes charts comparing the characteristics of various methods.