Changes

March 2024 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

Update

Goals

To support primary health care professionals to:

• Signpost a person who is considering an abortion to an abortion care provider.
• Provide appropriate information, advice, and support to a person who is considering an abortion. 

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

NICE quality standards

Abortion care

• Healthcare commissioners and providers work together to make abortion services easy to access.
• Women who request an abortion are given a choice between medical and surgical abortion to take place up to and including 23+6 weeks gestation.
• Women who decide to go ahead with an abortion have the option to have the procedure within 1 week of assessment.
• Women having a medical abortion up to and including 9+6 weeks' gestation are given the option to take misoprostol at home.
• Women having an abortion who want contraception receive their chosen method before discharge, either at the time of their abortion or as soon as possible after expulsion of the pregnancy.
• Women having an abortion are given advice on how to access care and support after the abortion. 

[NICE, 2021]

QIPP — Options for local implementation

No QIPP indicators were found during the review of this topic.

What is an abortion?

• An abortion (or termination of pregnancy) is a procedure to end a pregnancy. 
• The legal limit for abortion in England, Scotland, and Wales is 24 weeks of pregnancy. Abortions may be performed after 24 weeks in certain circumstances, for example, if the pregnant person’s life is at risk or the child would be born severely disabled. 

[OHID, 2023]

What are the UK abortion laws?

• In England, Scotland, and Wales, abortion is lawful, provided the criteria in the Abortion Act 1967 are met. In all other circumstances, administering or procuring an abortion is a crime. In summary:
  • A pregnancy can be lawfully terminated by a registered medical practitioner in an NHS hospital or premises approved for this purpose if two medical practitioners are of the opinion, formed in good faith, that either:
    • The pregnancy has not exceeded its 24th week and the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant person or any existing children of their family.
    • The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant person.
    • Continuing the pregnancy would involve risk to the life of the pregnant person, greater than if the pregnancy were terminated.
    • There is a substantial risk that if the child were born, it would suffer from such physical or mental abnormalities as to be seriously handicapped.
  • To demonstrate that an opinion has been formed 'in good faith' does not require that the authorisation of an abortion be the right course of action, simply that the doctor has not been dishonest or negligent in forming the opinion that it is. Courts have generally considered that a doctor is acting in good faith if they have complied with accepted medical practice. 
  •  Where a doctor 'is of the opinion, formed in good faith, that the termination is immediately necessary to save the life or to prevent grave permanent injury to the physical or mental health of the pregnant person', the opinion of a second registered medical practitioner is not required. In these limited circumstances, there are no restrictions on where the procedure may be carried out.
  • Under the Abortion Act, a pregnancy may be terminated at any pregnancy duration if there is a 'substantial risk that if the child were born, it would suffer from such physical or mental abnormalities as to be seriously handicapped.'
• Under the Abortion Act, doctors have a right of conscientious objection, unless the abortion is necessary to save the pregnant person's life or prevent grave permanent injury. At the same time, the person has a right to receive objective and non-judgemental care.
  • Healthcare providers with a conscientious objection to abortion must make sure that the way they manage this does not act as a barrier to a person's access to appropriate care.
  • Healthcare providers must not express their personal beliefs (including political, religious, and moral beliefs) to the person in ways that exploit their vulnerability or could reasonably cause them distress.
• Termination of pregnancy cannot proceed without a person's consent, except when the person lacks capacity and termination is in the person's best interests. 
  • Under-16s can consent to an abortion if they are competent to do so. Those with parental responsibility for minors lacking competency can consent to treatment in their best interests on their behalf.
  • The law is clear that a decision to terminate a pregnancy rests with the person concerned and their doctor, and that the person's partner has no legal right to demand or refuse a termination. Where the pregnant person does not wish to share information with their partner, confidentiality must be maintained unless there are exceptional reasons to justify a breach.
• All people (adults and children) requesting an abortion have the right to confidentiality, as with all other medical procedures. This cannot be overridden except in exceptional circumstances.
  • People attending an abortion service are asked for their consent to share information with their own GP. However, if the person refuses to consent to sharing this information, their wishes should be respected.
  • The need for an abortion to be considered with respect to a person who lacks capacity may raise questions about their ability to consent to sexual intercourse, and may lead the doctor to believe that a serious crime has been committed. This may warrant breaching confidentiality to disclose information in order to prevent the person (and others who may be at serious risk) from further harm.
  • It is usually desirable for young people to have their parents' help and support for important and potentially life-changing decisions, such as having an abortion. Whilst young people should be encouraged to share information with their parents or legal guardians, they cannot be compelled to do so.
  • If a young person believes consultations with doctors are not confidential, they may be put off seeking help for issues related to sexual and reproductive health, with potentially serious ramifications for their long-term health.
• The age of consent in England, Scotland, and Wales is 16 years. This is the age where young people of any sex, gender, or sexual orientation can legally consent to taking part in sexual activity.  
  • As with the case of adults lacking capacity, a young person's need for an abortion may give rise to concerns about their ability to consent to sexual intercourse. In summary [RCPCH, 2022]: 
    • Children under 13 years old cannot legally consent to any sexual activity, and a safeguarding response is always required.
    • If a child or young person aged 13–15 years is deemed to have been able to, and did, agree to sexual intercourse/activity with a peer, that child or young person may not need a safeguarding referral unless there are other safeguarding concerns.
    • Sexual intercourse/activity between a person who is 18 years or older and a child or young person aged 13–15 years old often constitutes a criminal offence. The safeguarding response in this situation will depend on the circumstances but will likely result in referral to social care and the police. 
    • A child or young person aged 16 or 17 years is presumed to have the capacity to consent to sexual intercourse/activity unless there is a reason to doubt their capacity. For example, if the 16- or 17-year-old has significant learning difficulties, was/is under duress, was intoxicated, or has other vulnerabilities, this may affect their capacity to consent, regardless of whether they seem to have agreed to sexual intercourse/activity. In this situation, a safeguarding referral is appropriate.
• The use of hormonal emergency contraception or intrauterine devices does not constitute abortion.
  • A parliamentary question in 1983 clarified that the prevention of 'implantation in the womb of any fertilised ovum' does not equal the 'procuring of a miscarriage' as prohibited by the Offences Against the Person Act 1861. 'Miscarriage' should be understood as the end of an established pregnancy. This interpretation was tested and confirmed by a judicial review in 2002.

[BMA, 2023]

What methods of abortion are available?

• There are two methods of abortion: medical and surgical [RCOG, 2022a] [WHO, 2022; OHID, 2023].
  • Medical abortion is the use of medications (mifepristone followed by misoprostol) to end a pregnancy. 
    • The medications are usually taken 24–48 hours apart.
    • Most people will pass the pregnancy within 4–6 hours of taking misoprostol, but some people will need to take extra doses of misoprostol until the pregnancy passes (more common after 10 weeks of pregnancy).
    • Occasionally, the pregnancy does not pass, and surgery is needed to complete the procedure. For more information, see the section on Complications and risks.
  • Surgical abortion is the use of transcervical procedures to end a pregnancy, including manual vacuum aspiration (MVA), electric vacuum aspiration (EVA), and dilatation and evacuation (D&E).
    • Vacuum aspiration uses a vacuum source to evacuate the contents of the uterus — with MVA, the vacuum is created using a hand-operated plastic syringe; with EVA, the vacuum is created using an electric vacuum pump. 
    • D&E involves dilation of the cervix followed by surgical evacuation of the contents of the uterus.
    • Surgical abortion may be done with local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation, or general anaesthesia.
• The choice of abortion method will depend on the stage of pregnancy and the pregnant person's circumstances and preferences.
  • See Table 1 for similarities and differences between medical and surgical abortion.

Table 1: Similarities and differences between medical and surgical abortion.

How common is abortion?

• Abortion is a common procedure worldwide, with 6 out of 10 unintended pregnancies and 3 out of 10 of all pregnancies ending in induced abortion [WHO, 2022].
  • In 2021, according to the Office for Health Improvement and Disparities (OHID) [OHID, 2023]: 
    • There were 214,869 abortions in England and Wales, the highest number since the Abortion Act was introduced.
    • Most of the abortions (214,256) were to residents of England and Wales, representing an age-standardized abortion rate of 18.6 per 1000 residents aged 15–44 years. 
    • The abortion rate was highest for people aged 22 years (31 per 1000 people), but the largest increases in abortion rates by age were in people aged 30–34 years (from 17.2 per 1000 in 2011 to 22.1 per 1000 in 2021). 
    • Medical abortions accounted for 87% of total abortions in 2021, an increase of 2% from 2020. 
    • Most of the abortions in England and Wales (99%) were funded by the NHS.

What are the complications and risks of an abortion?

• Abortion is a safe procedure when it is carried out in line with clinical best practice (that is, with a method appropriate to the pregnancy duration and by a person with the necessary skills).
  
  • Unsafe abortion is a leading cause of mortality and morbidity in pregnant people worldwide. Between 4.7 and 13.2% of deaths in pregnant people are attributed to unsafe abortions. This equates to between 13,865 and 38,940 lives lost annually, with many more people experiencing serious morbidities, due to the failure to provide safe abortion [WHO, 2021; RCOG, 2022a].
• When abortion is safe, major complications and mortality are rare at all pregnancy duration [RCOG, 2011] [RCOG, 2022a] [WHO, 2022]. 
  • Abortions are safest when carried out as early as possible in pregnancy. Delaying an abortion will increase the risk of complications, although the overall risk is low. 
  • See Table 2 for possible complications and risks of medical and surgical abortion.
• Abortion is not associated with an increased risk of [NICE, 2019]:
  • Infertility.
  • Breast cancer [American Cancer Society, 2014].
  • Mental health issues [Academy of Medical Royal College, 2011].
• The most common emotion after an abortion is relief. However, it is common to feel a range of emotions after an abortion. 

Table 2: Complications and risks of medical and surgical abortion.

How can a person access abortion services?

• Abortions can only be carried out in an NHS hospital or premises approved for this purpose.
  • To access abortion services, the pregnant person can self-refer directly to an abortion care provider or be referred by a GP, sexual health clinic, or specialist clinic (such as Brook service).
  • Information on local abortion care providers is available from:
    • British Pregnancy Advisory Service (BPAS)
    • MSI Reproductive Choices UK
    • National Unplanned Pregnancy Advisory Service (NUPAS)
  • Abortions are usually free of charge on the NHS.
  • People can also access abortion services privately. Costs for private abortions vary depending on the stage of pregnancy and the method used to carry out the procedure. 

Scenario: Management

From age 16 years onwards (Female).

A full literature search was not requested as this CKS topic is primarily based on the National Institute for Health and Care Excellence (NICE) guidelines Abortion care.

Unrestricted - November 2023

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• exp abortion/, abortion$.tw,

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• Health Protection Agency
• World Health Organization
• National Guidelines Clearinghouse
• Guidelines International Network
• TRIP database
• GAIN
• NHS Scotland National Patient Pathways
• New Zealand Guidelines Group
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• University of Michigan Medical School
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• Patient UK Guideline links
• UK Ambulance Service Clinical Practice Guidelines
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work(occupational health practice)

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

• Bandolier
• Drug & amp; Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

• Department of Health
• Health Management Information Consortium(HMIC)

• Healthtalkonline
• BMJ - Patient Journeys
• Patient.co.uk - Patient Support Groups

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary(BNF)
• electronic Medicines Compendium(eMC)
• European Medicines Agency(EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency(MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

• Animal studies
• Original research is not written in English

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

None.