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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

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

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
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.

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.

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Effective interventions library

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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: June 2020

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