New evidence-based guideline: The Care of Women Requesting Abortion
By Ellie Lee
13/3/2000

A new evidence-based guideline, The Care of Women Requesting Abortion, was published on 13 March 2000. The guideline, produced by the Royal College of Obstetricians and Gynaecologists, states that abortion services should 'provide high quality, efficient, effective and comprehensive care that respects the dignity, individuality and rights of women to exercise personal choice over their treatment'. The document, which is the result of more than a year of research and consultation by an expert development group and has been funded and approved by the Department of Health, is expected to influence the way that abortion care is provided throughout Britain. It aims to set standards of good practice that will be used as the basis for the development of local protocols.

The introduction to the guideline summary states: 'Induced abortion is one of the most commonly performed gynaecological procedures in Great Britain with around 180,000 terminations performed annually in England and Wales and around 12, 000 in Scotland. At least a third of British women will have had an abortion by the time they reach the age of 45. Over 98% of induced abortions in Britain are undertaken because the pregnancy threatens the mental or physical health of the woman or he children. This guideline has been developed in relation to the care of women seeking abortion on such grounds. Two recent RCOG publications have addressed legal, ethical and service issues relating to the minority of abortions undertaken because of fetal abnormality. Therefore, the recommendations in this guideline do not address the special issues relating to abortion for fetal abnormality.

The guideline development group view induced abortion as a healthcare need and reiterate the recommendation of the RCOG Working Party on Unplanned Pregnancy (1991) that 'health authorities should accept responsibility for the abortions needed by women resident in their districts'. Although this guideline addresses the discrete topic of abortion care, the development group strongly support the concept that abortion services should be provided as an integral part of broader sexual health services. The concept of National Service Frameworks presented in the White Paper 'The New NHS: Modern, Dependable' is welcomed as an opportunity to place abortion, contraception and genito-urinary medicine services together within a National Service Framework for sexual and reproductive health'.

A summary of the guideline recommendations is given below.

The guideline has been welcomed by those who support women's choice in abortion. Ann Furedi, speaking for Britain's largest provider of abortion services, British Pregnancy Advisory Service, said: 'The development of this guideline is a clear sign that medical profession, policy makers and society at large are beginning to accept abortion as part of essential reproductive health care. Abortion may have been legal in Britain for 30 years but it has yet to be recognised as entirely legitimate and is often the subject of controversial debate. If the RCOG succeeds in establishing these principles of care nationally it will represent the 'coming of age' of abortion services'.

Pro-Choice Forum drew attention the large amount of evidence provided in the guideline which supports the claim that abortion is a safe medical procedure, and the complications are uncommon. In particular, PCF noted the confirmation in the guideline that abortion is not associated with psychological trauma. Ellie Lee, co-ordinator of PCF said: ' 'The RCOG guideline is a breath of fresh air. It is very important and encouraging to see that the extent and severity of negative feelings women experience after abortion have been accurately presented, and compared with the psychological effects of denied abortion. There has been an unfortunate tendency on the part of media commentators and other opinion formers to exaggerate the negative psychological effects of abortion. Abortion is often talked about as a 'psychologically traumatic experience' or as 'inevitably distressing and difficult for women to cope with'. Hopefully the RCOG guideline will be taken seriously, and the psychological effects of abortion will from now on be discussed in less sensationalist terms'.

Predictably, representatives of anti-choice organisations have expressed their opposition to the guideline. Nuala Scarisbrick, speaking for the anti-abortion organisation Life, said: 'It is deeply depressing that the leading professional organisations should be calling for easier abortions'.

Jack Scarisbrick, chairman of Life, said, in contradiction to the vast amount of evidence cited in the guideline: 'We can show that abortion is at least three times more dangerous than childbirth. And most women suffer depression and sadness afterwards'.

RCOG press release, 'Royal College of Obstetricians and Gynaecologists Launches Abortion Guidelines'. 13/3/2000

BPAS press release, 'BPAS welcomes new national guidance on abortion care'. 13/3/2000

Pro-Choice Forum news release, 'RCOG findings on the psychological effects of abortion are 'a breath of fresh air' say researchers'. 13/3/2000

'A New Right to Abortion', Daily Mail, 11/3/2000

'Improve abortion services, says Royal College Report', Independent on Sunday, 12/3/2000

'Abortion guidelines hailed by campaigners', Guardian, 13/3/2000

The Care of Women Requesting Induced Abortion

The recommendations within this Guideline summary are extracted from the main Guideline document. This summary is intended only to provide a quick reference and is not intended to be considered without reference to the main Guideline. The full guideline document is available from the Royal College of Obstetricians and Gynaecologists and it is strongly recommended that readers consult it to understand the evidence base of the recommendations and the background to the Guideline development.

The Care of Women Requesting Induced Abortion is available from the RCOG bookshop, 27 Sussex Place, Regent's Park, London NW1 4RG, tel: 020 7772 6276 e-mail: bookshops@rcog.org.uk or via the website: www.rcog.org.uk

£12 plus postage and packing

The recommendations have been graded according to the level of evidence upon which they were based. The grading system used was formulated by the Clinical Outcomes group (COG) and recommended by the NHS Executive:

A             Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation.

B            Requires the availability of well conducted clinical studies, but no randomised clinical trials on the topic of the recommendation.

C            Requires evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities. Indicates an absence of directly applicable clinical studies of good quality.

Good Practice Points

-            Recommended best practice based on the clinical experience of the guideline development group

The strength of the evidence on which each recommendation is based is shown. It is accepted that in this grading system, the evidence itself is not graded according to quality - although it is discussed narratively in the text supporting each recommendation given in the full guideline.

The validity of some grade 'C' recommendations and Good Practice Points may be questionable, as they are not based on incontrovertible evidence. However, the views of the Guideline Group combined with comments from the extensive peer review suggest that the recommendations with these gradings are acceptable to a wide body of expert opinion, pending the results of future research.

Organisation of services:

-         Abortion services should have local strategies in place for providing information to both women and healthcare professionals on the choices available within the service and on routes of access to the service.

-         Any woman considering undergoing induced abortion should have access to clinical assessment.

-             Appropriate information and support should be available for those who consider, but do not proceed to, abortion.

B          The earlier in pregnancy an abortion is performed, the lower the risk of complications. Services should therefore offer arrangements (e.g. a telephone referral system and direct access from referral sources other than general practitioners) which minimise delay.

C          Service arrangements should be such that:

· ideally, all women requesting abortion are offered an assessment appointment within five days of referral

· as a minimum standard, all women requesting abortion are offered an assessment appointment within two weeks of referral

· ideally, all woman can undergo the abortion within seven days of the decision to proceed being agreed

· as a minimum standard, all women can undergo the abortion within two weeks of the decision to proceed being agreed

· as a minimum standard, no individual woman need wait longer than three weeks from her initial referral to the time of her abortion.

-         The assessment appointment should be within clinic time dedicated to women requesting abortion.

-         In the absence of specific medical, social or geographical contra-indications, induced abortion should be managed on a day-case basis.

C          An adequate number of staffed inpatient beds must be available for those women who are unsuitable for day-case care. In a typical abortion service, up to 10% of women will require inpatient care.

-         Access to services should be ensured for women with special needs. For example, as appropriate, special arrangements should be made for non-English speaking women and a woman doctor should be available.

-         As far as possible, women admitted for termination should be cared for separately from other gynaecological patients.

-         Women having second trimester terminations by medical means must be cared for by an appropriately experienced midwife or nurse. Ideally, they should have the privacy of a single room.

B          Verbal advice must be supported by accurate, impartial printed information which the woman considering abortion can understand and may take away and read before the procedure.

-            Information for women and professionals should emphasise the duty of confidentiality by which, as for any form of health care, all concerned with the provision of induced abortion are bound.

-            Professionals providing abortion services should possess accurate knowledge about possible complications and sequelae of abortion. This will permit them to provide women with the information they need in order to give genuinely informed consent.

Information on complications and sequelae:

B            Haemorrhage at the time of abortion is rare. It complicates around 1.5/1000 abortions overall. The rate is lower for early abortions (1.2/1000 at <1- weeks; 8.5/1000 at >20 weeks).

B          Uterine perforation at the time of surgical abortion is rare. The incidence is of the order 1-4 per 1000. The rate is lower for abortions performed early in pregnancy and performed by experienced clinicians.

B            Cervical trauma: the rate of damage to the external cervical os at the time of surgical abortion is no greater than 1%. The rate is lower when abortions are performed early in pregnancy and when they are performed by experienced clinicians.

B          Failed abortion/ongoing pregnancy: all methods of first trimester abortion carry a risk of failure to terminate the pregnancy, thus necessitating a further procedure. The rate for surgical abortion is around 2.3/1000 and for medical abortion around 6.0/1000.

B          Post-abortion infection: genital tract infection of varying degrees of severity, including pelvic inflammatory disease, occurs in up to 10% of cases. The risk is reduced when prophylactic antibiotics are given or when lower genital tract infection has been excluded by bacteriological screening.

B          Breast cancer risk: available evidence on an association between induced abortion and breast cancer is inconclusive.

B          Future reproductive outcome: there are no proven associations between induced abortion and subsequent infertility or preterm delivery.

B            Psychological sequelae: only a small minority of women experience any long term adverse psychological sequelae after abortion. Early distress, although common, is usually a continuation of symptoms present before the abortion. Conversely, long-lasting negative effects on both mothers and their children are reported where abortion has been denied.

The abortion decision

C            Clinicians caring for women requesting abortion should try to identify those patients who require more support in decision making than can be provided in the routine clinic setting. Facilities for additional support, including access to social services, should be available.

Blood tests

C          Pre-abortion assessment should include:

-             Measurement of haemoglobin concentration

-             Determination of ABO and Rhesus blood groups with screening for red cell antibodies

-            (Screening for other conditions such as haemoglobinopathies, HIV and hepatitis B if indicated on clinical grounds)

B          It is not cost-effective to routinely cross-match women undergoing termination of pregnancy.

Cervical cytology

-            Assessment prior to induced abortion may be viewed as an opportunity to ascertain each woman's cervical cytology history. Women who have not had a smear within the interval recommended in their local programme may be offered a smear taken opportunistically.

-         If a cervical smear is taken opportunistically within the abortion service, then mechanisms to ensure that the smear result is communicated to the woman, acted on appropriately and recorded within the local cervical cytology programme are essential.

Ultrasound scanning

C            Ultrasound scanning is not considered to be an essential prerequisite of abortion in all cases. However, all units must have access to scanning as it can be a necessary part of pre-abortion assessment, particularly where the gestation is in doubt or where extrauterine pregnancy is suspected.

C          When ultrasound scanning is undertaken, it should be done in a setting and manner which are sensitive to the woman's situation. It is inappropriate for pre-abortion scanning to be undertaken in an antenatal department alongside women with wanted pregnancies.

Prevention of infective complications

A          Abortion care should encompass a strategy for minimising the risk of post abortion infective morbidity. Appropriate strategies include:

B             antibiotic prophylaxis, or screening for lower genital tract organisms with treatment of positive cases.

· metronidazole 1g rectally at the time of abortion

plus

· doxycycline 100mg twice daily for 7 days, commencing post abortion

-         As a minimum, all services should be able to offer abortion by one of the recommended methods for each gestation band.

B          Ideally, abortion services should be able to offer a choice of recommended methods for relevant gestation bands.

B            Conventional suction termination should be avoided at gestations of <7 weeks.

B          Medical abortion, using mifepristone plus prostaglandin, is a appropriate method at gestations of <7 weeks.

B          Early surgical abortion using a rigorous published protocol may also be an appropriate method at gestations of <7 weeks.

A          For early medical abortion, a dose of 200mg of mifepristone, in combination with a prostaglandin is adequate.

A            Misoprostol (a prostaglandin E  analogue), given vaginally is a cost-effective alternative for all abortion procedures for which the E  analogue, gemeprost is conventionally used (early medical abortion, cervical priming, mid-trimester medical abortion).

Published regimens for early medical abortion:

·            mifepristone 600mg orally followed 36-48 hours later by Gemeprost 1mg vaginally (mifepristone data sheet)

·      >*mifepristone 200mg orally followed 36-48 hours later by misoprostol 800µ>g (4x200µ>g tabs) vaginally

·      >*mifepristone 200mg orally followed 36 hours later by Gemeprost 0.5mg vaginally

* Regimens are unlicensed as described above

Methods for women presenting between 7-15 weeks gestation

A          Medical abortion using the regimes described above continues to be an appropriate method for women in the 7-9 week gestational band.

B            Conventional suction termination is an appropriate method at gestations of 7-15 weeks, though individual practitioners may prefer to offer medical abortion at gestations above 12 weeks.

B          Suction termination may be safer under local anaesthesia than under general anaesthesia. Consideration should be given to making this option available.

B          Cervical preparation is beneficial prior to suction termination and should be routine when the woman is aged under 18 years or at a gestation of >10 weeks.

Published regimens for cervical priming:

·            Gemeprost 1mg vaginally, 3 hours prior to surgery (Gemeprost data sheet)

·            *misoprostol 400µg (2x200µg tabs) vaginally, 3 hours prior to surgery

·      >Mifepristone (as in data sheet)

* Regimens are unlicensed as discussed above

B          For women beyond 12 weeks gestation, second trimester abortion with mifepristone followed by prostaglandin has been shown to be safe and effective.

A          For mid-trimester medical abortion, a dose of 200mg mifepristone is adequate.

B          Surgical evacuation of the uterus is not required routinely following mid-trimester medical abortion. It should only be undertaken if there is clinical evidence that the abortion is incomplete.

Methods for women presenting at greater than 15 weeks gestation

A          Mid-trimester abortion by dilatation & evacuation (D&E), preceded by cervical preparation, is safe and effective when undertaken by specialist practitioners with access to the necessary instruments and who have a sufficiently large case-load to maintain their skills.

B          As an alternative to D&E, services may prefer to offer medical abortion using the regimens described below for women in this gestation band.

Published prostaglandin regimens include the following:

·            Mifepristone 600mg orally, followed 36-48 hours later by Gemeprost 1mg vaginally every 3 hours to a maximum of 5 pessaries.

·      >*Mifepristone 200mg orally, followed 36-48 hours later by misoprostol 800µ>g vginally, then misoprostol 400µg orally, three hourly, to a maximum of 4 oral doses.

·      >*Mifepristone 200mg orally, followed 36 hours later by Gemeprost 1mg vaginally every 6 hours.

* Regimens are unlicensed as discussed above

-            Oxytocics are effective in reducing intraoperative blood loss.

-         In cases of suspected uterine perforation laparoscopy is the investigation of choice.

B          Anti-D IgG should be given to all non-sensitised RhD negative women following abortion, whether by surgical or medical methods and regardless of gestational age.

-         After an abortion, women must be given a written account of the symptoms they may experience and a list of those that would make urgent medical consultation necessary. They should be given a 24 hour help-line telephone number to use if they feel worried about pain, bleeding or high temperature. Urgent clinical assessment, and emergency gynaecological admission, must be available when necessary.

C          A follow-up appointment (either within the abortion service or with the referring clinician) within two weeks of the procedure should be offered to each patient following abortion.

C          Referral for further counselling should be available for the small minority of women who experience long term post-abortion distress (Risk factors are ambivalence before the abortion, lack of a supportive partner, a psychiatric history or membership of a cultural group that considers abortion wrong).

B          Before she is discharged following abortion, future contraception should have been discussed with each patient and contraceptive supplies should have been offered if required. The chosen method of contraception should be initiated immediately following abortion.

-         On discharge, each patient should be given a letter that gives sufficient information about the procedure to allow another practitioner elsewhere to deal with any complications.

B            Sterilisation can safely be performed at the time of induced abortion. However combined procedures are associated with higher rates of failure and of regret on the part of the woman.

A          It is safe and effective to insert an IUCD for contraceptive use immediately following induced abortion.