Making it easier to access services

1.1.1.

Commissioners and providers should work together to:

• make information about abortion services (including how to access them) widely available
• ensure that women are promptly referred onwards if a service cannot provide an abortion after a specific gestational age or by the woman’s preferred method
• avoid the need for women to repeat key steps (such as returning to their GP for referral, or repeated assessments or investigations).

1.1.2.

Commissioners and providers should allow women to self-refer to abortion services.

1.1.3.

Healthcare professionals should not allow their personal beliefs to delay access to abortion services.

1.1.4.

Commissioners should 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.

Commissioners should make information available about any upfront funding to access services.

Waiting times

1.1.5.

Commissioners should work with providers to ensure abortion services have the capacity and resources to deliver the range of services needed with minimal delay.

1.1.6.

Ensure minimal delay in the abortion process, and ideally:

• provide the assessment within 1 week of the request
• provide the abortion within 1 week of the assessment.

1.1.7.

For women who would prefer to wait longer for an abortion, help them to make an informed decision by explaining the implications, including:

• the legal limit for abortions, as stated in the Abortion Act
• that delaying the abortion will increase the risk of complications, although the overall risk is low.

1.1.8.

Do not require women to have compulsory counselling or compulsory time for reflection before the abortion. Provide or refer women for support to make a decision if they request this.

Location of services

1.1.9.

Consider providing abortion assessments by phone or video call, for women who prefer this.

1.1.10.

Consider providing abortion services in a range of settings (including in the community and in hospitals), to meet the needs of the local population.

Workforce and training

1.1.11.

Abortion providers should maximise the role of nurses and midwives in providing care.

1.1.12.

Trainee healthcare professionals and students who may care for women who request an abortion (for example nurses, midwives, and GPs) should have the chance to gain experience in abortion services during their training.

1.1.13.

For specialities that include training in abortion as part of the core curriculum:

• ensure all trainees have the training, unless they opt out due to a conscientious objection
• include practical experience of abortion services and procedures in the curriculum.

1.1.14.

If a trainee’s placement service does not provide abortions, the trainee should gain experience with whoever is providing this service (either in the NHS or in the independent sector).

Complex comorbidities

1.1.15.

Specialist centres should be available as locally as possible, to reduce delays and travel times for women with complex needs or significant comorbidities.

1.1.16.

Providers should develop pathways for women with complex needs or significant comorbidities to:

• refer them to specialist centres if needed
• minimise delays in accessing care.

Avoiding stigma

1.1.17.

When caring for women who are having an abortion, be aware of:

• the anxiety they may have about perceived negative and judgemental attitudes from healthcare professionals
• the impact that verbal and non-verbal communication may have on them.

1.1.18.

Services should be sensitive to the concerns women have about their privacy and confidentiality, including their concerns that information about the abortion might be shared with healthcare professionals not directly involved in their care.

Information for women who are having an abortion because of fetal anomaly

1.2.11.

If a woman who is having an abortion for fetal anomaly cannot have her preferred method of abortion in the maternity service, establish a clear referral pathway with ongoing communication between services so that she can:

• easily transfer to the abortion service
• receive ongoing support from the maternity service
• get more information about the anomaly.

1.2.12.

Explain to women that there may not be any physical signs of a fetal anomaly.

Up to and including 9⁺⁶ weeks’ gestation

1.8.1.

For women who are having a medical abortion and will be taking the mifepristone up to and including 9⁺⁶ weeks’ gestation, offer the option of expulsion at home after they have taken the misoprostol. Misoprostol can be taken at home or in the clinic or hospital^[2].

At 10+0 weeks’ gestation

1.8.2.

For women who are having a medical abortion and will be taking the mifepristone at 10+0 weeks’ gestation, offer the option of expulsion at home after they have taken the misoprostol. Misoprostol can be taken in the clinic or hospital^[2].

Up to and including 13⁺⁶ weeks

1.12.1.

For women who are having a surgical abortion up to and including 13⁺⁶ weeks’ gestation, offer cervical priming with:

• 400 micrograms sublingual misoprostol^[4], given 1 hour before the abortion or
• 400 micrograms vaginal misoprostol^[4], given 3 hours before the abortion.

If misoprostol cannot be used, consider cervical priming with 200 mg oral mifepristone^[3], given 24 to 48 hours before the abortion.

1.12.2.

Explain to women that cervical priming:

• reduces the risk of incomplete abortion for women who are parous
• makes dilation easier for women who are parous or nulliparous
• may cause bleeding and pain before the procedure.

Between 14⁺⁰ and 23⁺⁶ weeks

1.12.3.

For women who are having a surgical abortion between 14⁺⁰ and 23⁺⁶ weeks’ gestation, offer cervical priming.

1.12.4.

For women who are having a surgical abortion between 14⁺⁰ and 16⁺⁰ weeks’ gestation, consider:

• osmotic dilators or
• buccal, vaginal or sublingual misoprostol^[4] or
• 200 mg oral mifepristone^[3], given the day before the abortion.

1.12.5.

For women who are having a surgical abortion between 16⁺¹ and 19⁺⁰ weeks’ gestation, consider:

• osmotic dilators or
• buccal, vaginal or sublingual misoprostol^[4].

1.12.6.

For women who are having a surgical abortion between 19⁺¹ and 23⁺⁶ weeks’ gestation, offer osmotic dilators. In addition, consider:

• 200 mg oral mifepristone^[3] the day before the abortion and
• inserting osmotic dilators at the same time as the mifepristone.

1.12.7.

For women who are having a surgical abortion between 14⁺⁰ and 23⁺⁶ weeks’ gestation and are having cervical priming with osmotic dilators, consider inserting the osmotic dilators the day before the abortion.

1.12.8.

Do not offer misoprostol for cervical priming if the woman has had an osmotic dilator inserted the day before the abortion.

Follow-up after medical abortion up to and including 10⁺⁰ weeks

1.14.1.

For women who have had a medical abortion up to and including 10⁺⁰ weeks’ gestation with expulsion at home, offer the choice of self-assessment, including remote assessment (for example telephone or text messaging), as an alternative to clinic follow-up.

1.14.2.

Provide women with a low-sensitivity or multi-level urine pregnancy test to exclude an ongoing pregnancy.

Support after an abortion

1.14.3.

Explain to women:

• what aftercare and follow-up to expect
• what to do if they have any problems after the abortion, including how to get help out of hours
• that it is common to feel a range of emotions after the abortion.

1.14.4.

Advise women to seek support if they need it, and how to access it (if relevant). This could include:

• support from family and friends or pastoral support
• peer support, or support groups for women who have had an abortion
• counselling or psychological interventions.

1.14.5.

Providers should be able to provide emotional support after abortions. They should tell women this support is available if they need it.

1.14.6.

Providers should provide or refer women for counselling if requested.

Terms used in this guideline

1. Antibiotic prophylaxis for surgical abortion

What is the optimal antibiotic prophylaxis regimen for women who are having a surgical abortion?

To find out why the committee made the research recommendation on antibiotic prophylaxis for surgical abortion see rationale and impact.

2. Cervical priming before surgical abortion

What are the most effective and acceptable methods of cervical priming before dilatation and evacuation after 16⁺⁰ weeks’ gestation?

To find out why the committee made the research recommendation on cervical priming before surgical abortion see rationale and impact.

3. Anti-D prophylaxis for surgical abortion

Should women having a surgical abortion up to and including 10⁺⁰ weeks’ gestation have anti-D prophylaxis if they are RhD (or D) negative?

To find out why the committee made the research recommendation on anti-D prophylaxis for surgical abortion see rationale and impact.

4. Expulsion at home for medical abortion

For women who are having medical abortion between 10⁺¹ and 12⁺⁰ weeks, what is the efficacy and acceptability of expulsion at home compared with expulsion in a clinical setting?

To find out why the committee made the research recommendation on expulsion at home for medical abortion between 10⁺¹ and 12⁺⁰ weeks see rationale and impact.

5. Anaesthesia and sedation for surgical abortion

What local anaesthetic techniques are most effective for women having surgical abortion?

To find out why the committee made the research recommendation on anaesthesia and sedation for surgical abortion see rationale and impact.

Medical abortion after 23⁺⁶ weeks

What is the effectiveness and safety of regimens using mifepristone and misoprostol for women who are having medical abortion after 23⁺⁶ weeks’ gestation, particularly for those who have had a previous caesarean section or uterine surgery?

Anaesthesia and sedation for surgical abortion

What is the optimal regimen for general anaesthesia for women having surgical abortion?

Why the committee made the recommendations

How the recommendations might affect current practice

Improving access to abortion services is likely to result in substantial cost savings. Most of this saving comes from women having a medical rather than a surgical abortion. Earlier abortions also have lower rates of complications. Recommendations on location of services, ease of access and complex comorbidities could reduce inequalities for:

• women living in remote areas
• women with low income
• women with comorbid physical and/or mental health problems
• vulnerable women
• girls and younger women.

Funding for travel is already available for women with low income under the NHS Healthcare Travel Costs Scheme, but this policy requires that women pay upfront and claim back costs after the abortion. Setting up processes for upfront funding will involve some initial costs, but otherwise the recommendation for women with a low income will only affect the timing of the payment and not the absolute cost. There will be some costs involved with providing funding for women who do not have a low income but who are travelling for a service that is not available locally. The new costs involved with funding travel and accommodation may be regained through women having earlier abortions.

Even small reductions in waiting times would result in large cost savings. A reduction of 1 day in the average waiting time would save the NHS £1.6 million per year on procedure costs and treating adverse events. Because of this, even relatively expensive interventions would be cost saving if they decrease waiting times. To reduce waiting times, services will need to consider ways to enable more rapid referral and develop pathways for self-referral. Some abortion services may need to reconfigure so that they are available on a greater number of days per week. More collaboration between NHS services and the independent sector may also be needed. However, recommendations on expulsion at home and remote follow-up will minimise the number of appointments needed, again leading to cost savings.

Establishing dedicated phone and online booking systems, or centralised booking services, will have upfront costs. However, they are likely to lead to substantial savings through reduced waiting times.

Many services already have videoconferencing facilities. Videoconferencing software is not expensive, so services that don’t have these facilities in place will not face significant upfront costs.

There has been an increase in community-based services in recent years, so additional costs associated with providing services in the community will be minimal. Women having an abortion in the community may need to make fewer arrangements regarding time off work, childcare and travel. This may enable them to present earlier for an abortion, which would result in cost savings for the NHS.

Women prefer care led by nurses or midwives. Expanding the role of these professionals should increase the number of appointments available and enable women to present earlier. Any upfront costs associated with providing training for nurses and midwives will likely be offset by cost savings from earlier abortions and reduced doctor hours.

Commissioners will need to work with national organisations such as Health Education England to agree changes to training curriculums.

Full details of the evidence and the committee’s discussion are in evidence review A: accessibility and sustainability of abortion services and evidence review B: information needs of women undergoing an abortion.

Return to recommendations

Why the committee made the recommendations

The recommendations are based on evidence showing what women want to know about abortion, and what formats they want information in. Some evidence came from women who were having abortions for specific reasons, such as fetal anomaly (under the Abortion Act). However, the committee agreed that improving information provision would benefit all women who are having an abortion, so made recommendations that could apply to everyone.

The committee also made some recommendations based on their knowledge and experience covering:

• medical abortions at home
• what to expect when viewing a fetus after abortion.

The committee were aware of systematic reviews and guidance from the Academy of Medical Royal Colleges (2011), American College of Obstetricians and Gynecologists (2009) and Royal College of Obstetricians and Gynaecologists (2011; 2015) that indicate there is no evidence that an abortion increases the risk of infertility, breast cancer or mental health issues. As there was evidence that women looked on the internet for information about abortion, and the committee were concerned that some of this information may be inaccurate, they made a recommendation about these risks to inform women.

The committee were aware that women wanted information on the options for management and disposal of pregnancy remains (including burial) after an abortion. However, the committee did not make a detailed recommendation in this area as this is covered by 2015 guidance from the Human Tissue Authority that outlines:

• the options (including the right to take remains home)
• the information that should be provided to the woman and how this should be communicated
• the importance of meeting religious and cultural needs where possible.

How the recommendations might affect current practice

Services already provide women with information about their abortion. These recommendations may mean services need to change what information they are providing, but the cost of giving women more information is minimal and will result in women being better informed about their options and the process for abortion.

Full details of the evidence and the committee’s discussion are in evidence review B: information needs of women undergoing an abortion.

Return to recommendations

Why the committee made the recommendations

There was no evidence on anti-D prophylaxis for women having an abortion up to and including 13⁺⁶ weeks’ gestation. There is also no international consensus on this, with significant variation between different international and national guidelines.

Current practice in the NHS is to give anti-D to all women who are having an abortion and are rhesus D negative. However, testing for rhesus status and then administering anti-D can result in significant delays for women. They may need to visit the service more than once to receive anti-D, and this can be a particular problem for women who are travelling a long way or who find it difficult to afford travel. The cost of testing for rhesus status and giving anti-D also needs to be considered.

With these points in mind, the committee made recommendations based on their knowledge and experience. They agreed that, for women up to and including 10⁺⁰ weeks’ gestation, the volume of fetal blood cells transmitted to the mother is unlikely to cause maternal sensitisation. The impact of delays to the abortion, travel problems, and costs to services are likely to outweigh any benefit prophylaxis provides. The NICE guideline on ectopic pregnancy and miscarriage recommends against anti-D prophylaxis for women having medical management for these conditions. The committee agreed that the risks and benefits of anti-D prophylaxis would be similar for women having a medical abortion. Therefore, the committee made a recommendation in line with the NICE guideline on ectopic pregnancy and miscarriage.

Although there is no evidence to distinguish surgical and medical abortion on this topic, the committee agreed there may be risk of more fetal blood cell transmission during a surgical abortion. Because of this, anti-D prophylaxis may be beneficial for women having a surgical abortion up to and including 10⁺⁰ weeks’ gestation.

In the independent sector, point-of-care testing is used and anti-D is provided immediately. In contrast, NHS transfusion laboratories usually follow the same processes for managing anti-D as they do for managing whole transfusion systems. This is unnecessary and introduces delays, and means that women must choose between not having testing and prophylaxis or returning to the service after the abortion. To help reduce delays, the committee made a recommendation in line with current practice in the independent sector.

In the absence of evidence, the precise benefits and risks of anti-D prophylaxis are unclear. The uncertainty is highest for women having a surgical abortion up to and including 10⁺⁰ weeks’ gestation, so the committee made a research recommendation covering this group.

How the recommendations might affect practice

Restricting anti-D prophylaxis to women who are most likely to benefit from it could potentially produce cost savings of over £1 million annually across the NHS. Staff will be freed up to focus on more important and beneficial areas of the abortion service.

NHS Trusts and transfusion laboratories may need to amend their systems and processes to ensure they can provide rhesus status testing and anti-D prophylaxis without introducing delays to the abortion process.

Full details of the evidence and the committee’s discussion are in evidence review C: anti-D prophylaxis for women up to 13⁺⁶ weeks’ gestation.

Return to recommendations

Why the committee made the recommendations

Recommendations 1.4.1 to 1.4.5

The evidence on antibiotic prophylaxis for women who are having medical abortion showed lower rates of severe infection with antibiotic prophylaxis compared with no antibiotic prophylaxis. However, the committee had concerns with the quality of the evidence, and the absolute risk of severe infection was very low. In addition:

• routinely prescribing antibiotics after medical abortion may increase the risk of antibiotic resistance
• adherence is likely to be low
• if using routine antibiotics the potential reduction in the risk of post-abortion infection is uncertain.

With these points in mind, the committee did not recommend routine antibiotic prophylaxis for women who are having a medical abortion. The committee believed that prophylaxis may be appropriate for women who are at high risk of infection, or who would find it difficult to access treatment at a later date if they screened positive for a sexually transmitted infection. However, there was no evidence to support recommending prophylaxis for a specific group.

Antibiotic prophylaxis is part of current clinical practice for women having a surgical abortion. The committee wanted to encourage this, so they made a recommendation in support.

The evidence reviewed did not identify which specific antibiotic regimen is most effective. Because of this, the committee agreed that further research would be beneficial and made a research recommendation. However, the committee were aware of a Cochrane review which showed the effectiveness of nitroimidazoles (such as metronidazole), tetracyclines (such as doxycycline) and beta lactams (such as amoxicillin).

A 7-day course of doxycycline is currently used in practice. There was no evidence comparing doxycycline with other antibiotics; however, there was some limited evidence on duration of doxycycline. The evidence was unclear on whether or not there were clinically important differences between 3-day and 7-day courses of doxycycline in the rates of pelvic inflammatory disease after abortion, patient adherence, vomiting, or diarrhoea. The committee recommended a 3-day course because this may be as effective and adherence is likely to be better with a shorter course.

Metronidazole in combination with another broad-spectrum antibiotic is not routinely recommended because:

• compared with doxycycline alone for surgical abortion, it was unclear if it made a clinically important difference to the rate of pelvic inflammatory disease after abortion in women who had elevated vaginal pH and amines in vaginal discharge, or a positive gram stain for bacterial vaginosis
• although there was no evidence on the gastrointestinal side effects when compared with doxycycline alone, the committee agreed that in clinical practice metronidazole may be poorly tolerated with significant side effects.

However, the committee agreed that metronidazole is effective for anaerobic infections, so there may be situations where it is clinically indicated.

The evidence for the recommendations on doxycycline and metronidazole was based on antibiotic prophylaxis for surgical abortion. However, the committee agreed that the recommendations would also be appropriate if there is a need to use antibiotic prophylaxis for medical abortion as the causes of infection would be similar for both procedures, although the level of risk may differ.

The committee could not make recommendations about screening for sexually transmitted infections, because they did not review the evidence this. A cross-reference has been included to the NICE guideline on preventing sexually transmitted infections and under-18 conceptions.

How the recommendation might affect practice

Despite the shortage of evidence, it is current clinical practice to offer antibiotic prophylaxis to women who are having medical abortion. Because of this, the recommendations will reduce the number of women having antibiotic prophylaxis for medical abortion. This has the potential to be cost saving and to reduce the risk of antibiotic resistance. The recommendation may also increase the number of women who accept screening for sexually transmitted infections. This is because women are more likely to accept screening if they are not given prophylactic antibiotics (which could make them believe screening and treatment for sexually transmitted infections, if present, was not needed).

The recommendation for surgical abortion supports routine antibiotic prophylaxis, which is current practice.

The 7-day course of doxycycline is currently used in practice. Metronidazole is also currently used in combination with other broad-spectrum antibiotics. Switching to shorter courses of doxycycline and not using metronidazole in combination with other broad-spectrum antibiotics may lead to cost savings.

Full details of the evidence and the committee’s discussion are in evidence review D: antibiotic prophylaxis for medical and surgical abortion.

Return to recommendations

Why the committee made the recommendations

There was no evidence on the optimal timing and duration of venous thromboembolism (VTE) prophylaxis for women having an abortion who need pharmacological thromboprophylaxis. In the absence of evidence, the committee made a recommendation based on the recommendations for women who have had a termination in the last 6 weeks in the NICE guideline on reducing the risk of venous thromboembolism.

The recommendation for women at high risk is based on the committee’s knowledge and experience. They agreed that it may be safer to start prophylaxis earlier and provide it for longer in this group. However, the lack of evidence meant they were unable to be more specific. The recommendation is in line with antenatal and postnatal risk assessment tools from the Royal College of Obstetricians and Gynaecologists.

How the recommendations might affect practice

These recommendations are in line with the NICE guideline on reducing the risk in venous thromboembolism. Unlike that guideline, the recommendations here cover all women at risk, rather than just those admitted to hospital. This means there may be an increase in the number of women receiving prophylaxis.

There will be increased costs from the increased use of low-molecular-weight heparin and the training needed to administer it. The size of this increase will depend on current local practice and the number of women who are at risk of thrombosis. These costs will be partially offset by a reduction in the incidence of VTE, but the savings associated with this may be small as VTE is rare in this context.

Full details of the evidence and the committee’s discussion are in evidence review E: venous thromboembolism prophylaxis for women having abortion.

Return to recommendations

Why the committee made the recommendation

The evidence showed that women having an abortion for fetal anomaly preferred a choice between medical or surgical abortion, and in the committee’s experience women having an abortion for other reasons also valued having a choice of procedure.

Comparing medical and surgical abortion in women between 13⁺⁰ and 23⁺⁶ weeks’ gestation, the evidence showed that it was unclear whether or not there was a clinically important difference in:

• haemorrhage that needed transfusion, or blood loss of 500 ml or more
• abortion completed by the chosen method
• uterine injury
• infection within 1 month of the abortion.

It was also unclear from the evidence whether or not there was a clinically important difference in cervical injury between medical and surgical abortion. However, the committee agreed that the risk of cervical injury with medical abortion would be extremely low as no instruments or dilators are inserted into the cervix. There was a higher clinically important rate of incomplete abortion needing surgical intervention for women who had medical abortion. There was also some evidence that women prefer surgical abortion. However, the evidence in this area was limited, and the committee did not feel confident in making a recommendation in favour of one method. This guideline did not review evidence comparing medical and surgical abortion for women up to and including 12⁺⁶ weeks’ gestation, because it is well established that both methods are highly safe at this gestational age and that they have similar effectiveness. In addition, evidence for abortions after 23⁺⁶ weeks was not reviewed because all abortions in England and Wales after this gestational age are medical procedures, with the exception of surgical abortions when feticide has been given at or before 23⁺⁶ weeks.

Given the evidence that women preferred a choice of procedure, and the lack of evidence that either procedure is superior, the committee recommended offering women up to and including 23⁺⁶ weeks a choice (as long as it is clinically appropriate).

How the recommendation might affect current practice

This recommendation will lead to a change in practice because abortion services for women vary widely nationally. Many services only offer either surgical or medical abortion. There are also relatively few doctors trained to provide surgical abortion in the second trimester in the NHS, and most independent sector services are not set up to provide inpatient medical abortion.

To address these issues, greater collaboration may be needed between and across sectors to provide women with a choice of methods. Theatre teams in the NHS may also need support if they are going to introduce a new service offering surgical abortion by dilatation and evacuation. Modern dilatation and evacuation practice uses ultrasound scanning during surgery, so scan machines need to be in theatre and staff need to be able to undertake intraoperative scanning when needed.

Before services can start offering medical abortion, they need to ensure they have beds available and nursing staff who are trained to care for women having medical abortion in the second trimester.

Full details of the evidence and the committee’s discussion are in evidence review B: information needs of women undergoing an abortion and evidence review K: medical versus surgical abortion between 13⁺⁰ and 24⁺⁰ weeks’ gestation.

Why the committee made the recommendations

Only limited evidence was available for this area. However, it suggested that abortion (medical or surgical) works just as well before there is definitive ultrasound evidence of an intrauterine pregnancy (that is, a yolk sac) as it does afterwards. There was no clinically important difference in the rates of complete abortion, whereas it was unclear whether or not there was a clinically important difference in the rates of missed ectopic pregnancy and ongoing pregnancy.

These findings matched the clinical experience of the committee for medical abortion at this stage for women who do not have signs or symptoms of an ectopic pregnancy. In addition, evidence from other areas of the guideline showed that women prefer to have the abortion as soon as possible.

As the evidence was limited, the committee felt that it was important to make women aware of the potential risk of not identifying an ectopic pregnancy, and what they should do if there is a problem.

How the recommendations might affect current practice

Some services do not currently provide abortion before there is definitive ultrasound evidence of pregnancy. As a result, the recommendation will make abortion available earlier than it is currently provided. This will make it easier for women to access services and reduce waiting times. There may be a larger impact on providers of surgical abortion, as this is not always offered as early as medical abortion.

Services providing surgical abortion before ultrasound evidence will need to have systems to confirm that the pregnancy has been aspirated. For example, they will need to have staff trained to inspect the products of conception for the presence of chorionic villi and a gestational sac, and provide the necessary equipment to do this (typically a light box and a clear receiver) or immediate access to ultrasound. Services offering surgical or medical abortion before ultrasound evidence of pregnancy will also need to be able to assess serum human chorionic gonadotrophin (hCG), and have staff trained in interpreting test results. If an ectopic pregnancy is suspected, services will need to have processes in place to refer the woman promptly to an early pregnancy assessment unit.

Full details of the evidence and the committee’s discussion are in evidence review F: abortion before ultrasound evidence.

Return to recommendations

Why the committee made the recommendation

These recommendations are based on the evidence on the safety of home expulsion. Separate recommendations were made for women up to and including 9⁺⁶ weeks gestation and women at 10⁺⁰ weeks gestation due to the legal limit at which misoprostol can be taken at home.

Comparing women up to and including 9⁺⁰ weeks’ gestation at the time they take mifepristone with women who take it between 9⁺¹ and 10⁺⁰ weeks, the evidence on home expulsion showed no difference in:

• the risk of serious complications, such as the need for emergency care or hospitalisation, haemorrhage needing transfusion, or 500 ml or more blood loss
• the rate of adverse events such as pain, vomiting and diarrhoea.

It was unclear whether or not there was a difference in rates of completed abortion without the need for surgical intervention in women who were up to and including 9⁺⁰ weeks when home expulsion was performed or between 9⁺¹ and 10⁺⁰ weeks. Evidence on patient satisfaction showed it was the same in both groups.

The committee noted that the evidence on women having home expulsion up to and including 12⁺⁰ weeks was from a single low-quality study from settings outside the UK. They agreed that further research on home expulsion up to and including 12⁺⁰ weeks in the UK would be beneficial to inform future practice and made a research recommendation.

How the recommendation might affect current practice

Currently, medical abortion with expulsion at home is offered for women who are up to and including 10⁺⁰weeks gestation at the time they take mifepristone in some areas, but only up to and including 9⁺⁰ weeks in others. As well as standardising practice, the recommendations are likely to result in more women being able to have an early medical abortion at home. In current practice women need to be admitted to hospital and have to wait for bed availability. Expanding home expulsion would reduce the number of women admitted to hospital, reducing waiting times.

Full details of the evidence and the committee’s discussion are in evidence review G: expulsion at home for early medical abortion.

Return to recommendation

Why the committee made the recommendations

There was limited evidence comparing simultaneous mifepristone and misoprostol with interval treatment (misoprostol given 23 to 48 hours after mifepristone) for abortion in women who were up to and including 9⁺⁰ weeks’ gestation. The evidence that was available showed no difference in:

• ongoing pregnancy rate
• rates of haemorrhage that needed transfusion, or blood loss of 500 ml or more
• patient satisfaction
• the need for repeat misoprostol
• incomplete abortion needing surgery.

However, for all of these outcomes apart from patient satisfaction, it was unclear whether or not there was a clinically important difference. In addition, the committee were concerned that the findings from this review were inconsistent with their experience. There is also another study (Lohr 2018) with different results to the studies that were covered in the evidence review. This study was not included in the review because it was not a randomised controlled trial. However, it was a much larger study (nearly 29,000 participants compared with 1,100 in the largest randomised controlled trial) and had a similar population to the studies in the evidence review. This study showed that:

• the success rates of simultaneous administration were inversely proportional to the
• gestational age
• as gestational age increases simultaneous administration becomes increasingly inferior to interval administration
• for ongoing pregnancy, while the risk was low in both groups, the absolute risk was 1.5% higher after simultaneous treatment (2.4%) than after interval treatment (0.9%).

Given the size and relevance of this study, the committee believed it was important to take these findings into account when making recommendations.

There was evidence that bleeding and pain started later with simultaneous mifepristone and misoprostol. This may be an advantage for women who are taking both of the drugs in hospital or clinic before travelling home to complete the abortion. In addition, the total time from start to completion of abortion is shorter, and women may prefer simultaneous mifepristone and misoprostol because of this.

The committee specified vaginal misoprostol for simultaneous treatment because that was the only route of administration used in the evidence. The committee did not recommend simultaneous treatment as an option for women between 9⁺¹ and 10⁺⁰ weeks’ gestation because there was no evidence for women with a longer gestation period. Interval treatment was recommended for these women because it is standard clinical practice.

How the recommendations might affect current practice

Simultaneous administration of mifepristone and misoprostol is not routinely offered, so these recommendations could result in changes to practice.

Full details of the evidence and the committee’s discussion are in evidence review H: medical abortion up to 10⁺⁰ weeks’ gestation.

Return to recommendations

Why the committee made the recommendations

Most studies included a vaginal loading dose of 800 micrograms misoprostol in their regimen. The dose for vaginal misoprostol is the same dose used for abortion up to and including 10⁺⁰ weeks’ gestation, so this will be simpler for services to provide for women between 10⁺¹ and 23⁺⁶ weeks’ gestation. The evidence showed no significant difference between an initial dose of vaginal misoprostol compared with sublingual misoprostol on time to expulsion or rate of completed abortion. Some women will prefer not to have vaginal misoprostol, so giving the option of sublingual administration takes account of patient preference. The sublingual dose was taken from the study comparing the vaginal and sublingual doses. The evidence showed that oral misoprostol had more side effects than sublingual or vaginal regimens and also had a longer interval between induction and abortion. There was no evidence available regarding effectiveness of oral misoprostol administered as a loading dose. Because of this, no recommendation was made on oral misoprostol.

For follow-up doses, most of the studies reviewed used 400 micrograms misoprostol given vaginally, orally, sublingually or buccally. In addition, there was limited evidence that this dose had a shorter time to expulsion than the 200 microgram dose.

There was evidence that time to expulsion was shorter when there was a longer interval between mifepristone and misoprostol administration. In comparisons of different intervals:

• a 36- to 38-hour interval gave a shorter time to expulsion than simultaneous administration
• a 48-hour interval gave higher rates of completed abortion and shorter time to expulsion than a 24-hour interval.

The committee noted that some women would prefer not to wait 36 to 48 hours between taking mifepristone and taking misoprostol, because of factors such as travel difficulties. To take account of patient preference, they recommended giving women the option of a shorter interval.

The committee were aware of guidelines from the Royal College of Obstetricians and Gynaecologists that recommend feticide for abortion after 21⁺⁶ weeks’ gestation. However, the committee did not review the evidence on feticide, so they could not make recommendations on this.

How the recommendations might affect current practice

These recommendations will reduce variations in practice in the use of misoprostol for abortion between 10⁺¹ and 23⁺⁶ weeks. The recommendations will also reduce the use of oral misoprostol, which is used currently.

Full details of the evidence and the committee’s discussion are in evidence review J: medical abortion between 10⁺¹ and 24⁺⁰ weeks’ gestation.

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Why the committee made the recommendations

Abortion after 23⁺⁶ weeks’ gestation is rare. In 2017, these abortions accounted for 0.1% of the total. The statutory grounds for abortion at this stage are for fetal anomaly or, in an emergency, either:

• when continuing the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated or
• to prevent grave permanent injury to her physical or mental health.

There was no evidence on which regimen is optimal for medical abortion after 23⁺⁶ weeks. In the absence of evidence, the committee based the recommendation for women between 24⁺⁰ and 25⁺⁰ weeks’ gestation on the dose regimens for women having an abortion up to and including 23⁺⁶ weeks. Considering the increased sensitivity of the uterus to misoprostol as gestational age increases, the initial high loading dose of misoprostol was not included in the regimen for this group.

For women between 25⁺¹ and 28⁺⁰ weeks’ gestation, the recommendation is based on the committee’s knowledge and experience. They noted that the uterus becomes more sensitive as gestational age increases and so the dose of misoprostol should be reduced. The recommendation is also in line with the International Federation of Gynecology and Obstetrics (FIGO) guidance on misoprostol for women at this gestation.

For women after 28⁺⁰ weeks’ gestation, the committee recommended the regimen based on their expertise and on the guidance from FIGO.

Because the uterus becomes more sensitive to misoprostol later in gestation, women who have had a previous caesarean section or uterine surgery may be at higher risk of uterine rupture with increased doses of misoprostol. In the absence of evidence to recommend a different regimen for this group, the committee agreed that clinicians should be made aware of this risk. Given this risk and the lack of evidence in this area, the committee made a research recommendation on drug regimens for medical abortion after 23⁺⁶ weeks, particularly for women who have had a previous caesarean section or uterine surgery.

The committee were aware of guidelines from the Royal College of Obstetricians and Gynaecologists that recommend feticide for abortion after 21⁺⁶ weeks’ gestation. However, the committee did not review the evidence on feticide, so they could not make recommendations on this.

How the recommendations might affect current practice

There is currently no guidance on what regimen to use for medical abortion after 23⁺⁶ weeks. Current practice varies as a result, and some services use lower doses of misoprostol that may not be as clinically effective as higher doses. These recommendations will help to standardise practice.

Full details of the evidence and the committee’s discussion are in evidence review L: medical abortion after 24 weeks’ gestation.

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Why the committee made the recommendations

How the recommendations might affect practice

Why the committee made the recommendations

There was only limited evidence comparing different types of sedation or anaesthesia for surgical abortion. The evidence that was available did not show that any particular method was more effective. The committee are aware that women have different preferences on anaesthesia. For example:

• some women need to minimise their recovery time (if they are driving home, or if they care for dependents)
• some women are anxious about the procedure and would prefer not to be conscious during it.

With this in mind, the committee recommended discussing all the anaesthesia options and explaining the differences to the woman.

There was not enough evidence to recommend a specific method for administering local anaesthesia. The committee agreed that further research on local anaesthesia methods (including intrauterine anaesthesia) would be beneficial, so made a research recommendation.

There was good evidence that women who had intravenous conscious sedation experienced less pain and nausea than women who had oral conscious sedation. Women who had intravenous sedation were also more likely to say they would choose it again.

Inhalational anaesthetics cause dose-dependent uterine relaxation. This may cause more bleeding compared with other medications used for general anaesthesia, such as propofol. The evidence comparing propofol and sevoflurane did not show any difference in haemorrhage requiring transfusion or blood loss greater than 500 ml. However, this is a rare event and the evidence was from a single study, so the committee recommended more research.

How the recommendations might affect practice

These recommendations will increase awareness of the options available for sedation or anaesthesia for surgical abortion, reduce variations in practice, and increase the choice available to women.

The recommendations will also reduce the use of oral conscious sedation, which is currently used but is not as effective as intravenous conscious sedation. Intravenous conscious sedation takes effect quicker than oral conscious sedation and has a shorter recovery time, so resource use should be reduced and scheduling flexibility may be improved as women spend less time in hospital. The recommendations may lead to a rise in the number of women opting for intravenous conscious sedation, causing an increased need for staff trained in administering it. Although conscious sedation is not currently used in all abortion services in the NHS, its use is widespread in other areas (such as endoscopy and assisted conception). As there are staff experienced in administering conscious sedation for other procedures, the resource impact in terms of staff training is not likely to be large.

Full details of the evidence and the committee’s discussion are in evidence review M: cervical priming before surgical abortion.

Why the committee made the recommendations

How the recommendations might affect practice

Why the committee made the recommendations

How the recommendations might affect practice

Currently, some providers do not offer DMPA intramuscular injection immediately, due to concerns that this might affect the efficacy of the abortion. Therefore, these recommendations will reduce variations in practice. There may be an initial cost associated with providing training for staff in abortion services to administer long-acting reversible contraception. However, this will be offset by not needing an additional appointment to administer contraception, and increased access leading to fewer subsequent unintended pregnancies and abortions.

There is unlikely to be a significant change in practice resulting from these recommendations as intrauterine contraception is currently already offered to women after a medical abortion; all that is likely to change is the timing.

These recommendations will reduce variation in practice on contraception provision after abortion. They will also increase the choices available to women. The impact on individual services will depend on current practice. In the independent sector, most services are commissioned to provide all forms of contraception whereas, in the NHS, some trusts have difficulty getting funding for certain contraceptive methods.

Overall, these recommendations should not increase costs or resource use, as the range of contraceptive methods covered is already available to women. However, there may be a change in who is funding contraception, with greater funding from clinical commissioning groups compared with local authorities. This will mean changes in the way services are organised, and commissioners will need to develop services to enable the recommendations.

Full details of the evidence and the committee’s discussion are in evidence review P: contraception after abortion.

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