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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

Updates to this NICE Pathway

26 January 2021 Abortion care (NICE quality standard 199) added.
5 February 2020 Contraception (NICE quality standard 129) added.

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.

Updates

Updates to this NICE Pathway

26 January 2021 Abortion care (NICE quality standard 199) added.
5 February 2020 Contraception (NICE quality standard 129) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Abortion care (2019) NICE guideline NG140
Abortion care (2021) NICE quality standard 199
Contraception (2016) NICE quality standard 129

Quality standards

Contraception

These quality statements are taken from the contraception quality standard. The quality standard defines clinical best practice for contraception and should be read in full.

Abortion care

These quality statements are taken from the abortion care quality standard. The quality standard defines clinical best practice for abortion care and should be read in full.

Quality statements

Contraceptive information and methods

This quality statement is taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statement

Women asking for contraception from contraceptive services are given information about, and offered a choice of, all methods including long-acting reversible contraception.

Rationale

Offering information about the full range of contraceptives available, including long-acting reversible contraception, will ensure women asking for routine or emergency contraception can make an informed choice. Helping women choose the method of contraception that suits them best and increasing their awareness of how to use contraceptives effectively, will help to reduce unplanned pregnancies.

Quality measures

Structure
a) Evidence that accessible information is available about the full range of contraceptive methods, including long-acting reversible contraception, and the local services that provide them.
Data source: Local data collection.
b) Evidence of local processes and referral pathways to ensure that women asking for contraception from contraceptive services are given information about, and offered a choice of, all methods including long-acting reversible contraception.
Data source: Local data collection.
Process
a) Proportion of women who ask for contraception from contraceptive services who are given information about all methods, including long-acting reversible contraception.
Numerator – the number in the denominator who are given information about all methods, including long-acting reversible contraception.
Denominator – the number of women who ask for contraception from contraceptive services.
Data source: Local data collection.
b) Proportion of women who ask for contraception from contraceptive services who are offered a choice of all contraceptive methods, including long-acting reversible contraception.
Numerator – the number in the denominator who are offered a choice of all contraceptive methods, including long-acting reversible contraception.
Denominator – the number of women who ask for contraception from contraceptive services.
Data source: Local data collection.
Outcome
a) Contraceptive use in women.
Data source: Local data collection.
b) Uptake of long-acting reversible contraception.
Data source: Local data collection.
c) Women’s satisfaction with their choice of contraceptive method.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (including GPs, community pharmacies and sexual and reproductive health services) ensure that processes are in place to offer women information about, and a choice of, all contraceptive methods, including long-acting reversible contraception. Service providers work together so that they can refer women to a suitable alternative service if they cannot provide the preferred method of contraception.
Healthcare practitioners (including GPs, community pharmacists, sexual and reproductive health consultants and nurses) ensure that they give women who ask for contraception information about, and a choice of, all contraceptive methods, including long-acting reversible contraception. If they cannot provide the woman’s preferred method of contraception they refer them to a suitable alternative service.
Commissioners (clinical commissioning groups, local authorities and NHS England) commission contraceptive services that provide information on all contraceptive methods, including long-acting reversible contraception, and offer all contraceptive methods to all women. Commissioners ensure providers work together to ensure women are provided with their preferred method of contraception.
Women attending a contraceptive service are offered a choice of all contraceptive methods, including long-acting reversible contraception, and the information they need to decide which method is suitable for them. If the service cannot provide their preferred method of contraception they tell them where they can get it from.

Source guidance

Definitions of terms used in this quality statement

Contraceptive services
Contraceptive services include those offered in education, GP services, pharmacies, maternity and postnatal care services, walk in centres, acute and emergency care, and the voluntary and private sectors. This includes open access contraceptive services that are available to everyone and provide walk in and appointment clinics.
[NICE’s guideline on contraceptive services for under 25s, recommendation 3 and expert opinion]
Information about contraceptive methods
This information covers all contraceptive methods and includes:
  • how the method works
  • how to use it
  • how it is administered
  • insertion and removal (for implants and intrauterine devices)
  • suitability
  • how long it can be used for
  • risks and possible side effects
  • failure rate
  • non-contraceptive benefits
  • when to seek help.
All contraceptive methods
This quality standard focuses on all methods of contraception. These are divided into 3 groups:
Long-acting reversible contraceptives that need administration less than once per month. These are:
  • contraceptive implant
  • contraceptive injection
  • intrauterine system (IUS)
  • intrauterine device (IUD).
Methods that depend on the person remembering to take or use them. These include:
  • combined vaginal ring
  • combined transdermal patch
  • combined oral contraception
  • progestogen-only pill
  • male condom
  • female condom
  • diaphragm or cap with spermicide
  • fertility awareness.
Permanent methods of contraception. These are:
  • vasectomy
  • female sterilisation.

Equality and diversity considerations

Contraceptive options may be limited for women with a learning disability or cognitive impairment. Contraceptive services should make it clear to women why specific methods cannot be offered to them.
Age, religion and culture may affect which contraceptive methods the woman considers suitable. When discussing contraception, healthcare practitioners should give information about all methods and allow the woman to choose the one that suits her best.
If a healthcare practitioner’s beliefs do not let them supply contraception, they should ensure that the woman can see another practitioner as soon as possible.

Emergency contraception

This quality statement is taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statement

Women asking for emergency contraception are told that an intrauterine device is more effective than an oral method.

Rationale

An intrauterine device (IUD) has a lower failure rate than oral methods of emergency contraception. Also, once in place, it can be used on an ongoing basis. If women use an IUD this will reduce the risk of unplanned pregnancies and avoid the need for emergency contraception. If a woman chooses to have an IUD as a form of emergency contraception, but the healthcare practitioner cannot fit it there and then, they should direct the woman to a suitable service and give her an oral method in the interim.

Quality measures

Structure
Evidence of local processes to ensure that women asking for emergency contraception are told that an intrauterine device is more effective than an oral method.
Data source: Local data collection.
Process
Proportion of requests for emergency contraception where the woman is told that an intrauterine device is more effective than an oral method.
Numerator – the number in the denominator where the woman is told that an intrauterine device is more effective than an oral method.
Denominator – the number of requests for emergency contraception.
Data source: Local data collection. Quality and Outcomes Framework indicator CON003 captures data on the provision of information about long-acting reversible methods of contraception to women who are prescribed emergency hormonal contraception by their GP.
Outcome
a) Intrauterine device use as an emergency contraceptive.
Data source: Local data collection. NHS Digital’s Sexual and Reproductive Health Activity Dataset includes information on methods of contraception for people using dedicated sexual and reproductive health services.
b) Abortion rate.
Data source: Local data collection. The Department of Health’s Abortion statistics can be analysed geographically.

What the quality statement means for different audiences

Service providers (including GPs, community pharmacies and sexual and reproductive health services) ensure that protocols and procedures are in place to tell women asking for emergency contraception that an IUD is more effective than an oral method. Service providers ensure that rapid referral pathways are in place for women who choose an emergency IUD if they are not able to fit one immediately. Service providers also ensure that protocols are in place to offer them an oral emergency method in the interim.
Healthcare practitioners (including GPs, community pharmacists, sexual health consultants and nurses) tell women who ask for emergency contraception that an IUD is more effective than an oral method. Practitioners unable to fit IUDs at presentation refer women to a service that can and offer them an oral emergency method in the interim.
Commissioners (clinical commissioning groups, local authorities and NHS England) ensure that services providing emergency contraception tell women that an IUD is more effective than an oral method. Commissioners ensure that referral pathways are in place for women who choose to have an emergency IUD fitted if the service cannot provide this on presentation, and that the service offers an oral emergency method in the interim.
Women asking for emergency contraception are told that an intrauterine device (IUD, also known as the coil) is more effective than an oral method (an emergency pill) and can also be used as a long-term method of contraception.

Source guidance

Definitions of terms used in this quality statement

Emergency contraception
If a woman has had sex without using contraception, or thinks that her contraception did not work, an emergency contraceptive can be used. There are 3 different types:
  • emergency contraceptive pill, levonorgestrel 1.5 mg
  • emergency contraceptive pill, ulipristal acetate 30 mg
  • copper intrauterine device.
Both emergency contraceptive pills are also referred to as the ‘morning after pill’.
Intrauterine device
Also referred to as an IUD or coil, this is a small, T shaped copper device that is inserted in the uterus. It has 1 or 2 threads on the end that hang through the entrance of the uterus (the cervix). In addition to ongoing contraception, the IUD can be used for emergency contraception.

Equality and diversity considerations

Age, religion and culture may affect which contraceptive methods the woman considers suitable. When discussing contraception, healthcare practitioners should give information and allow the woman to choose the one that suits her best.
If a healthcare practitioner‘s beliefs do not let them supply contraception, they should ensure that the woman can see another practitioner as soon as possible.

Contraception after an abortion

This quality statement is taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statement

Women who request an abortion discuss contraception with a healthcare practitioner and are offered a choice of all methods when they are assessed for abortion and before discharge.

Rationale

Ensuring women can make an informed choice about contraception following an abortion will reduce the risk of future unplanned pregnancies. Having the opportunity to discuss contraception when they are being assessed for an abortion will give them time to consider all the options. Further discussion before discharge from the abortion service can help ensure timely access to contraception.

Quality measures

Structure
a) Evidence of local processes to ensure that women discuss contraception and all contraceptive methods with a healthcare practitioner when being assessed for an abortion.
Data source: Local data collection.
b) Evidence of local processes to ensure that a healthcare practitioner offers women a choice of all contraceptive methods before discharge from an abortion service.
Data source: Local data collection.
Process
a) Proportion of women who discuss contraception and all contraceptive methods with a healthcare practitioner at an assessment for abortion.
Numerator – the number in the denominator who discuss contraception and all contraceptive methods with a healthcare practitioner.
Denominator – the number of women having an assessment for abortion.
Data source: Local data collection.
b) Proportion of women who are offered a choice of all contraceptive methods before discharge from an abortion service.
Numerator – the number in the denominator who are offered a choice of all contraceptive methods before discharge.
Denominator – the number of women discharged from an abortion service.
Data source: Local data collection.
Outcome
a) Uptake of long-acting reversible contraception at the time of abortion.
Data source: Local data collection.
b) Contraception uptake rate after abortion.
Data source: Local data collection.
c) Women who have more than 1 abortion.

What the quality statement means for different audiences

Service providers (including secondary care, community genitourinary medical and private sector services) establish protocols to ensure that healthcare practitioners discuss contraception and all contraceptive methods with women at their assessment for abortion and before discharge. Service providers offer women a choice of all contraceptive methods before discharge. If contraceptives are not provided at discharge, service providers ensure that referral pathways to a contraceptive service are in place.
Healthcare practitioners (including GPs, hospital doctors and nurses) discuss contraception and all contraceptive methods with women at their assessment for an abortion and before discharge. Healthcare practitioners offer women a choice of all contraceptive methods before discharge. If contraceptives are not provided at discharge, they offer to refer women to a contraceptive service.
Commissioners (clinical commissioning groups) ensure that abortion services discuss contraception and all contraceptive methods with women at their assessment for an abortion and before discharge. Commissioners ensure that abortion services offer women a choice of all contraceptive methods before discharge, or offer a referral to a contraceptive service if contraceptives are not provided. Commissioners could consider a local performance indicator for abortion services to improve uptake of contraception at discharge.
Women who plan to have an abortion are offered the chance to discuss contraception with a healthcare practitioner during assessment for their abortion and again before they are discharged. They are offered a choice of all contraceptive methods before they are discharged or referral to a contraceptive service if contraception is not provided.

Source guidance

Definitions of terms used in this quality statement

Discussion about contraception
When discussing contraception, emphasise that women are fertile immediately after an abortion and give details of all contraceptive methods including:
  • how the method works
  • how to use it
  • how it is administered
  • insertion and removal (for implants and IUDs)
  • suitability
  • how long it can be used for
  • risks and possible side effects
  • failure rate
  • non-contraceptive benefits
  • when to seek help.
All contraceptive methods
This quality standard focuses on all methods of contraception. These are divided into 3 groups:
Long-acting reversible contraceptives that need administration less than once per month. These are:
  • contraceptive implant
  • contraceptive injection
  • intrauterine system (IUS)
  • intrauterine device (IUD).
Methods that depend on the person remembering to take or use them. These include:
  • combined vaginal ring
  • combined transdermal patch
  • combined oral contraception
  • progestogen-only pill
  • male condom
  • female condom
  • diaphragm or cap with spermicide
  • fertility awareness
Permanent methods of contraception. These are:
  • vasectomy
  • female sterilisation.

Equality and diversity considerations

Age, religion and culture may affect which contraceptive methods the woman considers suitable. When discussing contraception, healthcare practitioners should give information about all methods and allow the woman to choose the one that suits her best.
If a healthcare practitioner’s beliefs do not let them supply contraception, they should ensure that the woman can see another practitioner as soon as possible.

Contraception after childbirth

This quality statement is taken from the contraception quality standard. The quality standard defines clinical best practice in contraception and should be read in full.

Quality statement

Women who give birth are given information about, and offered a choice of, all contraceptive methods by their midwife within 7 days of delivery.

Rationale

Supporting women to make an informed choice about contraception after childbirth will reduce the risk of future unplanned pregnancies. Advice and information should be given as soon as possible after delivery because fertility may return quickly, including in women who are breastfeeding. Providing advice about contraception after childbirth also helps avoid the risk of complications associated with an interpregnancy interval of less than 12 months.

Quality measures

Structure
a) Evidence of local processes to ensure that women who give birth are given information about all contraceptive methods by their midwife within 7 days of delivery.
Data source: Local data collection.
b) Evidence of local processes and referral pathways to ensure that women who give birth are offered a choice of all contraceptive methods by their midwife within 7 days of delivery.
Data source: Local data collection.
Process
a) Proportion of women who give birth who are given information about all contraceptive methods by their midwife within 7 days of delivery.
Numerator – the number in the denominator who are given information about all contraceptive methods by their midwife within 7 days of delivery.
Denominator – the number of women who give birth.
Data source: Local data collection.
b) Proportion of women who give birth who are offered a choice of all contraceptive methods by their midwife within 7 days of delivery.
Numerator – the number in the denominator who are offered a choice of all contraceptive methods by their midwife within 7 days of delivery.
Denominator – the number of women who give birth.
Data source: Local data collection.
Outcome
a) Satisfaction with advice about contraceptive methods after childbirth.
Data source: Local data collection.
b) Contraception uptake rates in women who have given birth.
Data source: Local data collection.
c) Women who have a short interpregnancy interval.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (secondary care and community maternity services) establish protocols to ensure that midwives give women information about all contraceptive methods, and offer them a choice of all methods, within 7 days of delivery. Service providers ensure women are referred to a contraceptive service if their chosen contraceptive cannot be provided immediately.
Healthcare practitioners (midwives) give women information about and offer them a choice of all contraceptive methods within 7 days of delivery. Midwives refer women to a contraceptive service if their chosen contraceptive cannot be provided immediately.
Commissioners (clinical commissioning groups) ensure that maternity services give women information about and offer them a choice of all contraceptive methods within 7 days of delivery, and refer them to a contraceptive service if contraception cannot be provided immediately.
Women who give birth are offered a choice of all contraceptive methods and given the information they need to decide which method is suitable for them by their midwife. This happens within a week of delivery. The midwife tells them how to get their chosen contraceptive.

Source guidance

Definitions of terms used in this quality statement

Information about contraceptive methods
Information covers all contraceptive methods and includes:
  • how the method works
  • how to use it
  • how it is administered
  • insertion and removal (for implants and intrauterine devices)
  • suitability
  • how long it can be used for
  • risks and possible side effects
  • failure rate
  • non-contraceptive benefits
  • when to seek help.
All contraceptive methods
This quality standard focuses on all methods of contraception. These are divided into 3 groups:
Long-acting reversible contraceptives that need administration less than once per month. These are:
  • contraceptive implant
  • contraceptive injection
  • intrauterine system (IUS)
  • intrauterine device (IUD).
Methods that depend on the person remembering to take or use them. These include:
  • combined vaginal ring
  • combined transdermal patch
  • combined oral contraception
  • progestogen-only pill
  • male condom
  • female condom
  • diaphragm or cap with spermicide
  • fertility awareness.
Permanent methods of contraception. These are:
  • vasectomy
  • female sterilisation.

Equality and diversity considerations

Age, religion and culture may affect which contraceptive methods the woman considers suitable. When discussing contraception healthcare practitioners should give information about all methods and allow the woman to choose the method that suits her best.
If a healthcare practitioner’s beliefs do not let them supply contraception, they should ensure that the woman can see another practitioner as soon as possible.

Access to abortion services

This quality statement is taken from the abortion care quality standard. The quality standard defines clinical best practice for abortion care and should be read in full.

Quality statement

Healthcare commissioners and providers work together to make abortion services easy to access.

Rationale

Providing abortion services that are easy to access will help to improve women’s experiences, enable earlier presentation and reduce delays and complications. It will help women to avoid stigma and negative attitudes when requesting an abortion and to maintain their privacy and confidentiality. Commissioners and providers should work together to remove barriers to accessing abortion services to meet the needs of the local population.

Quality measures

Structure
a) Evidence that healthcare commissioners and providers work together to make abortion services easy to access.
Data source: Local data collection, for example a joint plan to reduce barriers to accessing abortion services.
b) Evidence of joint local arrangements to provide information about how to access abortion services.
Data source: Local data collection, for example availability of information in different formats and signposting from services such as general practices and sexual health services.
c) Evidence that women can self-refer to abortion services.
Data source: Local data collection, for example online booking system or drop-in service with no requirement for a referral.
Outcome
a) Proportion of abortions performed at under 10 weeks.
Numerator – the number in the denominator performed at under 10 weeks.
Denominator – the number of abortions.
Data source: The Department of Health and Social Care’s abortion statistics includes data on abortions performed at under 10 weeks.
b) Proportion of women assessed for an abortion who are satisfied with ease of access to abortion services.
Numerator – the number in the denominator who are satisfied with ease of access to abortion services.
Denominator – the number of women assessed for an abortion.
Data source: Local data collection, for example survey of women assessed for an abortion.

What the quality statement means for different audiences

Service providers (such as NHS hospital trusts and independent abortion providers) work with commissioners to ensure that abortion services are easy to access. Service providers support initiatives to improve access. This includes making information about abortion services widely available, allowing self-referral (for example through an online booking system or drop-in service), considering telemedicine (providing assessments by phone or video call) and providing information about any upfront funding for travel and accommodation.
Health and social care practitioners (such as doctors, midwives, nurses and social workers) give women information on how to access abortion services. Health and social care practitioners do not allow their personal beliefs to delay access to abortion services.
Commissioners (clinical commissioning groups and NHS England) work with providers to ensure that abortion services are easy to access, including facilitating self-referral pathways. Commissioners identify the needs of the local population and work with providers to improve access for women with pregnancies at all gestational stages where abortion is legal. This includes making information about abortion services widely available, providing online booking systems and drop-in services that do not need referral from a healthcare professional, and considering telemedicine (providing assessments by phone or video call) and upfront funding for travel and accommodation.
Women who are considering an abortion can easily find out how to contact an abortion service and arrange a convenient first appointment.

Source guidance

Abortion care. NICE guideline NG140 (2019), recommendations 1.1.1, 1.1.2 and 1.1.9

Definitions of terms used in this quality statement

Make abortion services easy to access
Healthcare commissioners and providers should work together to:
  • make information about abortion services (including how to access them) widely available
  • allow women to self-refer to abortion services
  • consider providing abortion assessments by phone or video call, for women who prefer this (telemedicine)
  • consider upfront funding for travel and accommodation for women who are eligible for the NHS Healthcare Travel Costs Scheme and/or need to travel to a service that is not available locally
  • make information available about any upfront funding for travel and accommodation.
[NICE’s guideline on abortion care, recommendations 1.1.1, 1.1.2, 1.1.4 and 1.1.9]

Equality and diversity considerations

Healthcare commissioners and providers should ensure that pregnant women who self-refer to an abortion provider and are eligible for the NHS Healthcare Travel Costs Scheme or upfront funding for travel and accommodation do not need a GP referral to access the funding.
Healthcare commissioners and providers should ensure that information about how to access abortion services is easily available to women in vulnerable groups. These include sex workers, women who are homeless, women in prison and women who may find it difficult to access healthcare services because they are not registered with a GP.
Women should be provided with information that they can easily read and understand themselves, or with support. Information should be in a format that suits their needs and preferences, for example video or written information. It should be accessible to women who do not speak or read English, and it should be culturally and age appropriate. Women should have access to an interpreter or advocate if needed. For women with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.
Providing assessments by phone or video call can be particularly beneficial for women living in remote areas; women experiencing domestic violence, abuse or coercion from their partner or family; and women experiencing cultural barriers to accessing abortion services. Providers should, however, ensure that safeguarding procedures are in place for all women, including those accessing the service remotely. Providing a choice of assessment by phone, video call or face to face ensures that women can access abortion services in the way that best suits their personal circumstances.

Choice of abortion procedure

This quality statement is taken from the abortion care quality standard. The quality standard defines clinical best practice for abortion care and should be read in full.

Quality statement

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.

Rationale

If clinically appropriate, medical and surgical abortion procedures are both safe and effective up to and including 23+6 weeks’ gestation. A woman’s experience is better if she can choose the abortion procedure to suit her individual circumstances. To support a woman’s choice, it is important that women can access services as locally as possible and avoid lengthy travel times. If a provider does not offer the preferred method, the woman should be able to easily access the procedure from an alternative provider.

Quality measures

Structure
a) Evidence of local processes to support a discussion about the differences between medical and surgical abortion, including the benefits and risks, with women who request an abortion.
Data source: Local data collection, for example service protocol. The NICE patient decision aid on abortion care can help women discuss their options with healthcare professionals.
b) Evidence of referral pathways to alternative services that are as local as possible if a provider cannot provide an abortion by the woman’s preferred method.
Data source: Local data collection, for example referral strategies and shared care pathways, including pathways for women with complex needs.
Process
a) Proportion of women who had an abortion up to and including 23+6 weeks’ gestation with a record of their choice of medical or surgical abortion.
Numerator – the number in the denominator with a record of their choice of medical or surgical abortion.
Denominator – the number of women who had an abortion up to and including 23+6 weeks’ gestation.
Data source: Local data collection, for example local audit of patient records.
b) Proportion of women who had an abortion up to and including 23+6 weeks’ gestation who had a medical abortion.
Numerator – the number in the denominator who had a medical abortion.
Denominator – the number of women who had an abortion up to and including 23+6 weeks’ gestation.
Data source: The Department of Health and Social Care’s abortion statistics includes data on method of abortion. It is not expected that achievement will be 100%. Healthcare commissioners may wish to focus on variation in method for different gestational ages for their population compared with the national average.
c) Proportion of women who had an abortion up to and including 23+6 weeks’ gestation who had a surgical abortion.
Numerator – the number in the denominator who had a surgical abortion.
Denominator – the number of women who had an abortion up to and including 23+6 weeks’ gestation.
Data source: The Department of Health and Social Care’s abortion statistics includes data on method of abortion. It is not expected that achievement will be 100%. Healthcare commissioners may wish to focus on variation in method for different gestational ages for their population compared with the national average.
Outcome
Proportion of women who had an abortion who were satisfied with their abortion care.
Numerator – the number in the denominator who were satisfied with their abortion care.
Denominator – the number of women who had an abortion.
Data source: Local data collection, for example survey of women who had an abortion.

What the quality statement means for different audiences

Service providers (such as NHS hospital trusts and independent abortion providers) ensure that processes are in place so that staff give women a choice between medical and surgical abortion to take place up to and including 23+6 weeks’ gestation, if clinically appropriate. Providers ensure that referral pathways are in place so that women can be promptly referred to an alternative provider that is as local as possible if the service cannot provide their preferred method.
Healthcare professionals (such as doctors, nurses and midwives) give women who request an abortion a choice between medical and surgical abortion to take place up to and including 23+6 weeks’ gestation, if clinically appropriate. If any of the methods would not be clinically appropriate, healthcare professionals explain the reason why. Healthcare professionals are aware of local referral pathways for abortion care and ensure that women are promptly referred to an alternative provider if the service cannot provide their preferred method.
Commissioners (clinical commissioning groups and NHS England) ensure that they commission the range of abortion services needed, with the capacity across services so that women can choose between medical and surgical abortion to take place up to and including 23+6 weeks’ gestation. Commissioners support collaboration between providers and ensure that shared care pathways are in place for women to be promptly referred to an alternative provider that is as local as possible, if the service cannot provide their preferred method.
Women who ask for an abortion to take place before 24 weeks can choose between taking medicines and having an operation to end their pregnancy. If the service cannot provide their chosen method, they are referred to a service that can. This should be in an area that is as close to them as possible.

Source guidance

Abortion care. NICE guideline NG140 (2019), recommendation 1.6.1

Equality and diversity considerations

Women should be provided with information that they can easily read and understand themselves, or with support. Information should be in a format that suits their needs and preferences, for example video or written information. It should be accessible to women who do not speak or read English, and it should be culturally and age appropriate. Women should have access to an interpreter or advocate if needed. For women with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Waiting time for an abortion

This quality statement is taken from the abortion care quality standard. The quality standard defines clinical best practice for abortion care and should be read in full.

Quality statement

Women who decide to go ahead with an abortion have the option to have the procedure within 1 week of assessment.

Rationale

Abortion is very safe overall, but as morbidity and mortality increases for every additional week of gestation, earlier abortions are safer than later ones. Reducing waiting times for assessment and treatment can ensure that women have more options for procedures, reduce the risk of complications and improve the woman's experience. Once a woman has decided to go ahead with a medical or surgical abortion at their assessment with the abortion provider, they should have the option to have the procedure within 1 week if they wish.

Quality measures

Structure
a) Evidence of local arrangements to ensure that women who decide to go ahead with an abortion have the option to have the procedure within 1 week of assessment.
Data source: Local data collection, for example service protocol and availability within 1 week of assessment for different abortion methods and gestational ages.
b) Evidence of local referral pathways if a service cannot provide the procedure within 1 week of assessment.
Data source: Local data collection, for example referral strategies and shared care pathways, including pathways for women with complex needs.
Process
a) Proportion of women who decide to go ahead with an abortion who have the option to have the procedure within 1 week of assessment.
Numerator – the number in the denominator who have the option to have the procedure within 1 week of assessment.
Denominator – the number of women who decide to go ahead with an abortion.
Data source: Local data collection, for example waiting time to the next available treatment slot.
b) Proportion of women who decide to go ahead with an abortion who have the procedure within 1 week of assessment.
Numerator – the number in the denominator who have the procedure within 1 week of assessment.
Denominator – the number of women who decide to go ahead with an abortion.
Data source: Local data collection, for example audit of patient records. As some women will choose to wait longer for an abortion, local areas should agree the expected performance in relation to this measure.
Outcome
a) Average waiting time for abortion from initial referral to receipt of procedure.
Data source: Local data collection, for example abortion provider annual reports include data on average waiting times for medical and surgical abortions and different gestational ages.
b) Proportion of abortions performed at under 10 weeks.
Numerator – the number in the denominator performed at under 10 weeks.
Denominator – the number of abortions.
Data source: The Department of Health and Social Care’s abortion statistics includes data on abortions performed at under 10 weeks.

What the quality statement means for different audiences

Service providers (such as NHS hospital trusts and independent abortion providers) ensure that they have the capacity to provide abortions as soon as possible and within 1 week of assessment. Service providers work together and share information so that women who are referred to another provider do not need a repeated assessment and can have the procedure within 1 week of the original assessment.
Healthcare professionals (such as doctors, nurses and midwives) ensure that women who have decided to go ahead with an abortion have the option to have the procedure within 1 week of their assessment. Healthcare professionals have a discussion with women who would prefer to wait longer for an abortion about the implications of waiting longer. If the woman needs to be referred to another provider, healthcare professionals arrange the referral and share information about the assessment without delay.
Commissioners (clinical commissioning groups) commission abortion services with the capacity and resources to provide abortions as soon as possible and within 1 week of assessment. Commissioners support collaboration between providers and ensure that shared care pathways and information sharing agreements are in place between providers. This is so that women do not need a repeated assessment if they are referred to another provider and the procedure can be arranged without delay.
Women who decide to go ahead with an abortion can have the abortion within 1 week of their assessment if they wish.

Source guidance

Abortion care. NICE guideline NG140 (2019), recommendation 1.1.6

Equality and diversity considerations

Some women in vulnerable groups may find it difficult to attend an appointment for an abortion at short notice for a variety of reasons. These include caring responsibilities, difficulty in making travel arrangements, financial difficulties, mental health problems, domestic violence and stigma. Service providers should have a flexible and supportive approach that helps women to choose a convenient time to have the abortion.
Healthcare commissioners should consider providing upfront funding for travel and accommodation for women on a low income who are eligible for the NHS Healthcare Travel Costs Scheme or need to travel to a service that is not available locally (including those who self-refer to the abortion provider). Healthcare commissioners and providers should make information available about how to access any upfront funding.

Early medical abortion

This quality statement is taken from the abortion care quality standard. The quality standard defines clinical best practice for abortion care and should be read in full.

Quality statement

Women having a medical abortion up to and including 9+6 weeks’ gestation are given the option to take misoprostol at home.

Rationale

Women who are having a medical abortion and taking mifepristone up to and including 9+6 weeks’ gestation should be given the option to take misoprostol at home. They can then be at home when expulsion begins, rather than on their journey home. Home expulsions will reduce hospital attendance and waiting times for early medical abortions. The legal limit for the gestational age at which misoprostol can be taken at home is specified in the Secretary of State's approval order of December 2018.

Quality measures

Structure
Evidence of local processes to ensure that women having a medical abortion up to and including 9+6 weeks’ gestation are given the option to take misoprostol at home.
Data source: Local data collection, for example service protocol.
Process
Proportion of women having a medical abortion up to and including 9+6 weeks’ gestation who take misoprostol at home.
Numerator – the number in the denominator who take misoprostol at home.
Denominator – the number of women having a medical abortion up to and including 9+6 weeks’ gestation.
Data source: The Department of Health and Social Care’s abortion statistics includes data on medical abortions where the second stage treatment was administered at home.
Outcome
a) Hospital attendances for administration of misoprostol for early medical abortion.
Data source: Local data collection, for example provider data returns.
b) Average waiting time for early medical abortion from initial referral to receipt of procedure.
Data source: Local data collection, for example provider annual reports.

What the quality statement means for different audiences

Service providers (such as NHS hospital trusts and independent abortion providers) ensure that processes are in place so that women having a medical abortion up to and including 9+6 weeks’ gestation are given the option to take misoprostol at home. Providers ensure that healthcare professionals can give women information about the options available to help them make decisions about their care.
Healthcare professionals (such as doctors, nurses and midwives) give women who are having a medical abortion up to and including 9+6 weeks’ gestation the option to take misoprostol at home. They give them information about the options available to help them make decisions about their care.
Commissioners (clinical commissioning groups) ensure that they commission abortion services that give women who are having a medical abortion up to and including 9+6 weeks’ gestation the option to take misoprostol at home.
Women having a medical abortion up to and including 9+6 weeks into the pregnancy can take the second medicine (misoprostol) at home rather than in a clinic or hospital, if they prefer.

Source guidance

Abortion care. NICE guideline NG140 (2019), recommendation 1.8.1

Equality and diversity considerations

Women should be given information that they can easily read and understand themselves, or with support. Information should be in a format that suits their needs and preferences, for example video or written information. It should be accessible to women who do not speak or read English, and it should be culturally and age appropriate. Women should have access to an interpreter or advocate if needed. For women with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England's Accessible Information Standard.

Contraception

This quality statement is taken from the abortion care quality standard. The quality standard defines clinical best practice for abortion care and should be read in full.

Quality statement

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.

Rationale

Ensuring that women can access their preferred method of contraception at the time of their abortion, or soon after, will reduce the risk of future unintended pregnancies and abortions. It will improve the uptake of contraception and its continued use, as well as the woman’s satisfaction with ease of access to contraception.

Quality measures

Structure
Evidence that the full range of reversible contraceptive options is available for women before discharge from an abortion provider, either on the same day as their abortion or as soon as possible after expulsion of the pregnancy.
Data source: Local data collection, for example service specification, rota for staff with skills to administer the full range of contraceptive methods, and return appointments for contraception offered if needed.
Process
Proportion of women having an abortion who want contraception who receive their chosen method before discharge.
Numerator – the number in the denominator who receive their chosen method of contraception before discharge.
Denominator – the number of women having an abortion who want contraception.
Data source: Local data collection, for example audit of patient records.
Outcome
Contraception uptake rate after abortion.
Data source: Local data collection, for example survey of women who have had an abortion.

What the quality statement means for different audiences

Service providers (including secondary care, community genitourinary medical services and independent sector services) ensure that staff are trained to administer long-acting methods of contraception. They also ensure that the full range of options for reversible contraception is available to women before discharge, either on the same day as their abortion, or as soon as possible after expulsion of the pregnancy.
Healthcare professionals (including doctors, nurses and midwives) arrange for the woman’s chosen method of contraception to be provided before discharge, either at the same time as the abortion or as soon as possible after expulsion of the pregnancy.
Commissioners (clinical commissioning groups) ensure that they commission abortion services that have the full range of options for reversible contraception available to women before discharge, either on the same day as their abortion or as soon as possible after expulsion of the pregnancy. They ensure that funding is available for abortion providers if a separate appointment to provide contraception is needed.
Women having an abortion who want contraception are able to get their preferred method before discharge from the abortion service, either at the time of their abortion or as soon as possible afterwards.

Source guidance

Abortion care. NICE guideline NG140 (2019), recommendations 1.15.1, 1.15.3, 1.15.4 and 1.15.5

Support after an abortion

This quality statement is taken from the abortion care quality standard. The quality standard defines clinical best practice for abortion care and should be read in full.

Quality statement

Women having an abortion are given advice on how to access care and support after the abortion.

Rationale

After an abortion some women may need support with physical or emotional issues. Women have individual preferences and needs for support after an abortion and they can sometimes find it difficult to get the support they need. Giving them advice about what to expect after the abortion and how to access care and support will help them get support if, and when, they need it.

Quality measures

Structure
a) Evidence of local arrangements to provide care and support to women after an abortion, including referral pathways to counselling or psychological interventions.
Data source: Local data collection, for example telephone helpline and service protocols, including referral pathways.
b) Evidence of local processes to ensure that women having an abortion are given advice on how to access care and support after the abortion, including how to get help out of hours.
Data source: Local data collection, for example service protocol and information sources such as a helpline number, leaflet or webpage.
Process
Proportion of women having an abortion who are given advice on how to access care and support after the abortion, including how to get help out of hours.
Numerator – the number in the denominator who are given advice on how to access care and support after the abortion, including how to get help out of hours.
Denominator – the number of women having an abortion.
Data source: Local data collection, for example audit of patient records and information leaflets.
Outcome
Proportion of women who had an abortion who agree they were able to access care and support after the abortion if they needed to.
Numerator – the number in the denominator who agree they were able to access care and support after the abortion if they needed to.
Denominator – the number of women who had an abortion.
Data source: Local data collection, for example survey of women who had an abortion.

What the quality statement means for different audiences

Service providers (such as NHS hospital trusts and independent abortion providers) ensure that they can provide assessment for physical symptoms and emotional support after an abortion, and provide advice to women about the care and support available locally. Service providers ensure that they can refer women for counselling or psychological interventions if requested.
Healthcare professionals (such as doctors, nurses and midwives) give advice to women on how to access care and support after the abortion, the support available locally and how to get help out of hours. Healthcare professionals carry out assessments for physical symptoms and emotional support after an abortion and refer women for counselling or psychological interventions if requested.
Commissioners (clinical commissioning groups) ensure that they commission abortion services that provide care and support to women after an abortion. Commissioners ensure that referral pathways are in place for women who have had an abortion to be able to access care and support, including counselling and psychological interventions, if needed.
Women having an abortion know how they can get care and support after the abortion if they need it, including how to get help out of hours.

Source guidance

Abortion care. NICE guideline NG140 (2019), recommendations 1.14.3 and 1.14.4

Definitions of terms used in this quality statement

Advice on how to access care and support after the abortion
Explain to women what to do if they have any problems after the abortion, including how to get help out of hours.
Explain that it is common to feel a range of emotions after the abortion. Advise women to seek support if they need it, and how to access it. This could include:
  • support from family and friends or pastoral support
  • emotional support from the abortion service provider
  • peer support, or support groups for women who have had an abortion
  • counselling or psychological interventions.
[NICE’s guideline on abortion care, recommendations 1.14.3, 1.14.4 and 1.14.5]

Equality and diversity considerations

Services that provide care and support after an abortion should make reasonable adjustments to ensure that women with additional needs such as physical, sensory or learning disabilities, and women who do not speak or read English or who have reduced communication skills, can use the service. Women should have access to an interpreter (including British Sign Language) or advocate if needed.

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 patient 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: January 2021

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