Abortion

Introduction

Induced abortion or termination of pregnancy has been carried out for thousands of years. The provision of abortion in a legal, medically supervised, and safe framework remains one of the most contentious issues in modern-day medicine. Many people have strongly held and often divergent opinions about abortion. Those who are pro-abortion maintain that they are ‘pro-choice’ and support the right of individuals to make their own decisions. They are sensitive to the difficulties of bringing an unwanted baby into the world and are aware of the impact on both the woman concerned and the society more broadly. Often, the decision to proceed with abortion is multifactorial, including socioeconomic concerns, health- or partner-related issues or fetal anomaly. Termination of pregnancy for fetal anomaly is discussed in Chapter 25 (Fetal medicine).

Those who are anti-abortion, or ‘pro-life’, argue that the fetus is more than just part of the mother. They maintain that it is a life in and of itself and should be protected, even if that means limiting the mother’s choices regarding her body.

There are many factors leading to unplanned pregnancy: contraception may have failed or perhaps was not used at all. Occasionally, intercourse without the woman’s consent has resulted in pregnancy. Of course, a woman may have an unplanned pregnancy but be pleased to be pregnant and continue the pregnancy. Another may have planned to be pregnant but then her circumstances may have changed, and she feels unable to continue. Among women attending antenatal clinics, research demonstrates that only two-thirds of women had an intended pregnancy, with the rest either ambivalent or having an unplanned pregnancy. Although abortion should not be considered as a method of contraception, contraceptive failures do occur and access to abortion allows women complete fertility regulation.

The Royal College of Obstetrics and Gynaecologists (RCOG) views abortion care as a health care need and important public health intervention. It forms a large part of the gynaecology workload in the United Kingdom, and induced abortion is one of the most common gynaecological procedures. In Britain, 1 in 3 women will have had an abortion by the age of 45 years. Although doctors may have differing degrees of involvement in abortion services, most at some point in their career will come into contact with women who are seeking abortion. Thus, doctors need to be familiar with the legal framework and options open to these women.

Worldwide Perspectives

Unintended pregnancy and abortions are experiences shared by people worldwide, irrespective of country, income, region or the legal status of abortion. It is estimated that there were 121 million unintended pregnancies worldwide each year between 2015 and 2019 and that almost two-thirds resulted in abortion. This equates to 73 million abortions per year.

Unintended pregnancy rates are higher in countries that restrict abortion access. It is estimated that the percentage of unintended pregnancies has increased over the last 3 decades from 36% (1990–1994) to 50% (2015–2019). This highlights an unmet need for contraception services.

The World Health Organization (WHO) estimates that 45% of all abortions worldwide are unsafe, with almost all of these occurring in low-income countries with the most restrictive laws. Illegal abortions are often performed in unclean environments, by persons lacking skills, or are possibly self-induced.

Unsafe abortion is a significant cause of maternal morbidity and mortality, accounting for approximately 13% of maternal deaths worldwide. In contrast, abortion performed in appropriate conditions with trained staff is a very safe procedure, with extremely low morbidity and mortality. This highlights the importance of improved access to modern contraception, post-partum contraception, and comprehensive abortion care. Strong partnerships from many sectors at a global, regional and country level are required to achieve these objectives.

United Kingdom (Uk) Legal and Ethical Issues

Great Britain (England, Scotland and Wales)

Abortion has been a criminal offence in Britain since the 19th century when legislation was passed to reduce legal access to abortion (The Offences Against the Person Act, 1861, England and Wales; Scottish Common Law). During this time, there was a rise in ‘back street’ unsafe abortions, often with use of poisonous or ineffective treatments (e.g., lead). This saw an increase in maternal deaths during 1923 to 1933, with approximately 15% attributed to illegal abortion.

In 1967, legislation was passed (The Abortion Act) to allow abortions where certain criteria were met. This was further amended in 1990 by the Human Fertilisation and Embryology Act ( Box 20.1 ).

Medications that are used in the abortion process are the prostaglandin analogue misoprostol and mifepristone, an anti-progestogen. Prior to 2017, misoprostol had to be administered within a National Health Service (NHS) hospital or approved clinic. A women’s place of ordinary residence was approved for home misoprostol use up to 9 ⁺⁶ weeks’ gestation in Scotland in 2017, followed by England and Wales in 2018. This allows women the option of having their medical abortion at home, where they can be as comfortable as possible. Safety data and qualitative research supported this change, which reduces repeat clinic appointments, time away from work, childcare issues and risk of symptoms on their way home from clinic after taking the medication.

Further amendments were made in 2020 to ensure that essential abortion services continued during the COVID-19 pandemic. In March 2020, England, then Scotland and Wales, approved the use of home mifepristone and telemedicine to avoid women attending hospital/clinics due to the risks associated with COVID-19 spread.

There are also attempts in Britain to decriminalise abortion care (to bring Britain in line with Northern Ireland) and introduce buffer zones around abortion clinics to stop anti-abortion protests outside clinics.

The 1967 Abortion Act, as amended in 1990, states that abortion can be performed if two doctors agree that the pregnancy can be terminated on one or more grounds (see Box 20.1 ). Most abortions (98%) are carried out under Clause C of the Abortion Act, where two doctors agree that continuing the pregnancy would carry greater risk to the physical or mental health of the woman than abortion. A smaller number of abortions (1%) are carried out to protect the health of existing children. Clauses C and D carry an upper gestational limit of 24 weeks.

Current methods of inducing abortion are now so safe that it is safer for the woman to have an early abortion than to continue to term and give birth. Of course, that does not mean that abortion should be recommended for all women. However, a clinician may positively consider a request for an abortion when a woman feels that her health or well-being (or that of her children) will be adversely affected by continuing the pregnancy.

Although this provision is uncommonly used, the Abortion Act also allows abortion to be performed in an emergency situation upon the single signature of the doctor performing the procedure. Such an emergency abortion can be carried out either to save the life of the pregnant woman or to prevent grave permanent injury to the physical or mental health of the pregnant woman.

Northern Ireland

Abortion was decriminalised in Northern Ireland in 2019, meaning that now it is seen as a health care rather than a criminal matter. Prior to this, the 1861 Offences Against the Person Act was in place, limiting abortion to the most exceptional cases (rape or fatal fetal anomaly were not included). This meant that in 2018, approximately 1000 women travelled to Britain for an abortion, often self-funded. Others purchased abortion pills online illegally.

In June 2018, the UK Supreme Court found this to be in breach of the European Convention of Human Rights. In July 2019, the UK Parliament voted in favour of an amendment to a parliamentary bill.

The relevant section of the Northern Ireland (Executive Formation etc.) Act 2019 came into force in October 2019, with 2 key components.

• 1

  Decriminalise abortion and a moratorium on abortion-related criminal prosecutions from that date.

• 2

  Place the UK Government under a duty to bring forward regulations and introduce a new legal framework for abortion by 31 March 2020.

The regulations are detailed in Box 20.2 .

UK Perspectives

The Abortion Act was passed in 1967, after which there was a rapid rise in the number of abortions carried out in England, Wales and Scotland due to the legal framework and increased reporting.

In 2019, just over 207,000 abortions took place in England and Wales, with a further 13,583 in Scotla­nd. Women of all reproductive ages have abortions, although the highest rate is among women aged 20 to 24 years, with the largest increase seen recently in women over 35 years. Most terminations (80%) are carried out before 10 weeks of pregnancy, with only 8% performed above 13 weeks of gestation. In Britain, 1 in 13 pregnant women have conceived within 1 year of a previous birth. This suggests an unmet contraception need for women following pregnancy, particularly following childbirth. Deprivation is associated with increased abortion prevalence.

Personal Beliefs

The Abortion Act 1967 allows doctors the legal and professional right to opt out of participating in abortion care. However, guidance from the General Medical Council in the United Kingdom advises that if a doctor is unable to make a referral for abortion, then a timely referral of the woman to a colleague who does not hold similar views is obligatory. Direct self-referrals to abortion clinics are now favoured to avoid untimely delays.

However, every doctor has an obligation to treat in an emergency situation. Therefore, it is essential that abortion care is embedded in undergraduate and post-graduate education.

Often, conscience is not black and white and should be visualised on a spectrum with conscientious objection and conscientious commitment at opposing ends. In practice, this allows doctors to set the limits on what they opt in and out off. It is recognised that these limits can change over time. However, it is important that conscientious objection does not lead to conscientious obstruction, whether that be overtly (e.g., providing false information), or delaying referral in subtle ways (e.g., being judgemental), or stating one’s moral objection to abortion.

It is important to be open and honest with colleagues about conscience to ensure a supportive work environment and optimal patient care.

Consultation and Counselling Before Abortion

When a woman is considering abortion, it is important that she is able to weigh the practical and emotional aspects of her decision to ensure that the best choice is made in her circumstances. The National Institute for Health and Care Excellence (NICE) guideline on abortion care recommends that the initial assessment should be available within 1 week of the request to avoid any unnecessary delays. The abortion should be provided within 1 week of the assessment if required. There is no compulsory time period for reflection prior to abortion. It is important to meet the needs of the local populations, and assessments may need to be carried out by telephone or video call if appropriate (as occurred during the COVID-19 pandemic).

The woman will require sympathetic but non-directional support so that she is able to explore her own feelings and to make her own informed decision. Many women with an unplanned pregnancy will make their decision within a few days of knowing that they are pregnant. Other women may remain undecided for some time. It is important that the decision to abort or continue the pregnancy is made freely by the woman and that she is not coerced by another party, for example, a parent or partner. For this reason, it is imperative to speak to the woman alone at some point during the consultation.

Psychological problems and rates of depression are not increased after abortion when compared with background population risk, but some women may experience coping problems and distress. The assessment process can help to identify these women and ensure that appropriate support is offered both before and after the abortion. Box 20.3 outlines risk factors for emotional problems.

Women who blame themselves for the pregnancy and subsequent abortion can struggle to come to terms with their decision. It can help to identify what went wrong that led to the pregnancy. Jointly agreeing on a contraceptive plan with the woman can return a sense of control to her and give her something positive for the future to take from the experience.

Clinicians are used to taking a structured gynaecological and sexual history, collecting factual inform­ation, such as date of last menstrual period. However, clinicians should also help the woman to express her emotional needs by using some basic counselling techniques:

• Ask open-ended questions, for example, ‘How did you feel about the pregnancy?’ rather than ‘Were you upset when you found out?’

• Actively listen to the woman, for example, show interest in her views, and show understanding.

• Reassure her that her feelings are normal, for example, saying ‘I understand that you are finding this difficult to talk about’.

• Encourage questions, for example, say ‘What would you like to ask me about your choices?’, rather than ‘Any questions?’

Some women need practical information to make their choice, such as details about maternity leave, housing rights and so forth, or information about adoption. Timely referral to a social worker should be available.

Pre-abortion Investigations

Once the woman has decided to proceed to abortion, there are a number of investigations which are usually performed to ensure that the abortion is as safe as possible:

• Blood tests: Rhesus status should be established for those over 10 ⁺⁰ weeks proceeding with either medical or surgical abortion. Anti-D immunoglobulin is not recommended for those opting for a medical abortion who are 10 ⁺⁰ weeks or less but can be considered with surgical abortions if rhesus negative. If required, the dose for anti-D immunoglobulin is 250 international units (IU) if <20 weeks and 500 IU if >20 weeks.

  Human immunodeficiency virus (HIV) and syphilis testing should be offered to all women. Other blood-borne virus (BBV) testing and haemoglobinopathy screening can be performed if indicated.

  Haemoglobin measurement is no longer routine unless symptomatic of anaemia, for example, dizziness, shortness of breath.

• Estimation of gestation : This can be performed by history, clinical examination or ultrasound. RCOG and NICE guidance state that routine ultrasound scanning to confirm gestation is not required. This supports the use of telemedicine. However, it is essential to provide when gestation is unclear, when ectopic pregnancy is suspected, or if requested by the person.

  Some women will not make the decision until they know the gestation of the pregnancy, that is, they may decide to abort an early pregnancy but would not wish to undergo a later abortion. Occasionally, women may request a scan photograph as a memento of the pregnancy. Ultrasound will sometimes show a non-viable pregnancy, which will then relieve the woman of a decision around abortion and may avoid an unnecessary intervention.

• Prevention of infection : The NICE suggests that routine antibiotic prophylaxis is not required with medical abortions but should be offered with surgical abortions. Prophylaxis may be appropriate for women at high risk of sexually transmitted infections (STIs) or who would find it difficult to access treatment at a later date if screening was performed.

  Some clinics offer routine STI screening (including Chlamydia trachomatis and Neisseria gonorrhoea ) to all women. This provides a holistic opportunity to detect infection and carry out partner notification (contact tracing) when there is a positive test, thus preventing reinfection of the woman and onward transmission.

  If antibiotics are indicated, doxycycline 100 mg twice daily for 3 days should be considered in medical or surgical abortions. If metronidazole is used, it should not be routinely used in combination with broad-spectrum antibiotics, for example, doxycycline.

• Cervical cytology : If a woman is due cervical cytology within the national screening programme, then this should be offered opportunistically at the time of the clinic visit.

• Provision of information : Information given verbally should be supported with written information for the woman to take away, available in a range of languages and formats. This should include information about the types of abortion available, the risks and complications of abortion, and whom to contact if there are any problems after the procedure.

• Venous thromboembolism (VTE) prophylaxis: Pregnancy increases a woman’s risk of developing VTE; this increased risk begins in the first trimester. All women should be assessed for VTE risk factors and thromboprophylaxis with low-molecular-weight heparin offered if appropriate (see Chapter 24, Maternal Medicine).

Methods of abortion

Historically, a wide range of surgical and medical techniques has been used to induce abortion. Advances made in the past 3 decades in abortion techniques mean that safe and effective methods are now available at all stages of gestation. Medical methods have been increasingly used since the licencing of mifepristone in 1991. Both medical and surgical abortion can be offered up to 24 weeks, but availability varies in different geographical areas.

In England and Wales, around 73% of abortions are performed using medical methods, whereas in Scotland, 88% are medical. The most appropriate method depends on gestation, medical history and the woman’s preference ( Box 20.4 ).