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Abortion care

About

What is covered

This NICE Pathway covers care of women of any age (including girls and young women under 18) who request an abortion.

Updates

Abortion Act 1967

Abortion in England, Scotland and Wales is primarily regulated by the Abortion Act 1967 (as amended by the Human Fertilisation and Embryology Act 1990) and regulations made under that Act – currently the Abortion Regulations 1991 (SI 1991/499). The Abortion Act regulates when and where abortions can take place lawfully.
In May 2014, the Department of Health issued guidance in relation to requirements of the Abortion Act 1967. This guidance is intended for those responsible for commissioning, providing and managing the provision of abortion services to help them comply with the Abortion Act. Also in May 2014, the Department published procedures for the approval of independent sector places for the termination of pregnancy. Further government guidance has recently been issued in the form of letters from the Chief Medical Officer.
Providers of abortion services must comply with the Health and Social Care Act 2008 and regulations made under that Act. In particular, providers must register with the Care Quality Commission (CQC). This is because under section 10 of the Health and Social Care Act 2008, it is an offence to carry out a regulated activity without being registered with the CQC, and abortion is a 'regulated activity' under Regulation 3 and Schedule 1 (paragraph 11) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). The CQC imposes specific requirements on providers that are not English NHS bodies (see regulation 20 of the Care Quality Commission (Registration) Regulations 2009).
Additional relevant guidance:
This NICE Pathway makes evidence-based recommendations on how to organise services and on how to conduct abortions within the legal framework set out by the Abortion Act 1967. It does not repeat things already covered by the legislation, Department of Health and Social Care guidance or other statutory regulations, and practitioners should therefore ensure they are adhering to all other applicable requirements when using this guidance.

Gender

This NICE Pathway makes recommendations for women and people who are pregnant. For simplicity of language the guidance uses the term women throughout, but this should be taken to also include people who do not identify as women but who are pregnant.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on abortion care in an interactive flowchart.

What is covered

This NICE Pathway covers care of women of any age (including girls and young women under 18) who request an abortion.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Abortion care (2019) NICE guideline NG140

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Abortion Act 1967

Abortion in England, Scotland and Wales is primarily regulated by the Abortion Act 1967 (as amended by the Human Fertilisation and Embryology Act 1990) and regulations made under that Act – currently the Abortion Regulations 1991 (SI 1991/499). The Abortion Act regulates when and where abortions can take place lawfully.
In May 2014, the Department of Health issued guidance in relation to requirements of the Abortion Act 1967. This guidance is intended for those responsible for commissioning, providing and managing the provision of abortion services to help them comply with the Abortion Act. Also in May 2014, the Department published procedures for the approval of independent sector places for the termination of pregnancy. Further government guidance has recently been issued in the form of letters from the Chief Medical Officer.
Providers of abortion services must comply with the Health and Social Care Act 2008 and regulations made under that Act. In particular, providers must register with the Care Quality Commission (CQC). This is because under section 10 of the Health and Social Care Act 2008, it is an offence to carry out a regulated activity without being registered with the CQC, and abortion is a 'regulated activity' under Regulation 3 and Schedule 1 (paragraph 11) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). The CQC imposes specific requirements on providers that are not English NHS bodies (see regulation 20 of the Care Quality Commission (Registration) Regulations 2009).
Additional relevant guidance:
This NICE Pathway makes evidence-based recommendations on how to organise services and on how to conduct abortions within the legal framework set out by the Abortion Act 1967. It does not repeat things already covered by the legislation, Department of Health and Social Care guidance or other statutory regulations, and practitioners should therefore ensure they are adhering to all other applicable requirements when using this guidance.

Gender

This NICE Pathway makes recommendations for women and people who are pregnant. For simplicity of language the guidance uses the term women throughout, but this should be taken to also include people who do not identify as women but who are pregnant.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

At the time of publication (September 2019) misoprostol for medical abortion only has a UK marketing authorisation for:
  • 400 micrograms orally as an initial dose for medical abortion of developing intrauterine pregnancy, 36-48 hours after 600 mg mifepristone orally, up to and including 49 days of amenorrhoea
  • 800 micrograms vaginally as an initial dose for medical abortion of developing intrauterine pregnancy, 36-48 hours after 200 mg mifepristone orally, up to and including 63 days of amenorrhoea.
All other uses of misoprostol (including for cervical priming and for abortion at later gestations) are unlicensed. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's prescribing guidance: prescribing unlicensed medicines for further information.
At the time of publication (September 2019) mifepristone for abortion only has a UK marketing authorisation for:
  • 600 mg orally for medical abortion of developing intrauterine pregnancy, followed 36-48 hours later by 400 micrograms misoprostol orally or 1 mg gemeprost vaginally, up to and including 49 days of amenorrhoea
  • 600 mg orally for medical abortion of developing intrauterine pregnancy, followed 36-48 hours later by 1 mg gemeprost vaginally, between 50 days and 63 days of amenorrhoea
  • 200 mg orally for medical abortion of developing intrauterine pregnancy, followed 36-48 hours later by 1 mg gemeprost vaginally, between 50 days and 63 days of amenorrhoea
  • 200 mg orally for medical abortion of developing intrauterine pregnancy, followed 36-48 hours later by 800 micrograms misoprostol vaginally, up to and including 63 days of amenorrhoea
  • 600 mg orally for medical abortion for medical reasons, followed 36-48 hours later by prostaglandin administration, beyond the first trimester
  • 200 mg orally for cervical priming, 36-48 hours before first trimester surgical abortion.
All other uses of mifepristone are unlicensed. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's prescribing guidance: prescribing unlicensed medicines for further information.

Choice of procedure for abortion

Offer a choice between medical or surgical abortion up to and including 23+6 weeks' gestation. If any methods would not be clinically appropriate, explain why. (Surgical abortion can be performed shortly after 23+6 weeks' gestation only if feticide is given at or before 23+6 weeks' gestation, according to the 2019 clarification of the time limits in the Abortion Act.)
To help women decide between medical and surgical abortion, see the NICE decision aids on choosing medical or surgical abortion.

Abortion before definitive ultrasound evidence of an intrauterine pregnancy

Consider abortion before there is definitive ultrasound evidence of an intrauterine pregnancy (a yolk sac) for women who do not have signs or symptoms of an ectopic pregnancy.
For women who are having an abortion before there is definitive ultrasound evidence of an intrauterine pregnancy (a yolk sac):
  • explain that there is a small chance of an ectopic pregnancy
  • explain that they may need to have follow-up appointments to ensure the pregnancy has been terminated and to monitor for ectopic pregnancy
  • provide 24 hour emergency contact details, and advise them to get in contact immediately if they develop symptoms that could indicate an ectopic pregnancy (for recommendations on identifying symptoms and signs of ectopic pregnancy at initial assessment see the NICE Pathway on ectopic pregnancy and miscarriage).
For abortion after definitive ultrasound evidence of an intrauterine pregnancy see medical abortion and surgical abortion.
For women who need pharmacological thromboprophylaxis, consider low-molecular-weight heparin for at least 7 days after the abortion.
For women who are at high risk of thrombosis, consider starting low-molecular-weight heparin before the abortion and giving it for longer afterwards.
For recommendations on assessing the risk of venous thromboembolism in women who have had a termination of pregnancy in the past 6 weeks see the NICE Pathway on venous thromboembolism.
Offer anti-D prophylaxis to women who are rhesus D negative and are having an abortion after 10+0 weeks' gestation.
Providers should ensure that:
  • rhesus status testing and anti-D prophylaxis supply do not cause any delays to women having an abortion
  • anti-D prophylaxis is available at the time of the abortion.
For guidance on testing for sexually transmitted infections for women who are having an abortion, see the NICE Pathway on preventing sexually transmitted infections and under-18 conceptions.
When using doxycycline for antibiotic prophylaxis in medical or surgical abortion, consider oral doxycycline 100 mg twice a day for 3 days.
When using metronidazole for antibiotic prophylaxis in medical or surgical abortion, do not routinely offer it in combination with another broad-spectrum antibiotic such as doxycycline.
Defined as pregnancies falling within section 1(1)(d) of the 1967 Abortion Act. This covers pregnancies where 2 medical practitioners are of the opinion that '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'. This is referred to as ground E in the HSA1 form.

Glossary

depot medroxyprogesterone acetate
(the injection of digoxin or potassium chloride into the fetus, or an injection of digoxin into the amniotic cavity, to stop the fetal heart before an abortion)

Paths in this pathway

Pathway created: September 2019 Last updated: September 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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