Abortion

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Abortion

• Joanne Fletcher
• Consultant Nurse Gynaecology
• STHFT

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Learning outcomes

• Abortion statistics
• Sheffield TOP service
• Methods of abortion
• Consent
• Confidentiality

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Pregnancy Statistics Global Overview

• Each year 205 million women become pregnant
• Approximately 40 of these pregnancies are
  unplanned
• This represents 82 million unplanned pregnancies
  each year
• Approximately 42 million abortions occur each
  year (22)
• Approximately 115,000 abortions each day 83 of
  these are in developing countries
• An estimated 43 of all women will have at least
  1 abortion by the time they are 45 years old
• Worldwide the lifetime average is about 1
  abortion per woman
• Guttmacher Institute 2008 www.agi-usa.org

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Number of Abortions carried out in England
Wales 1976-2008
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Number of Abortions carried out in England
Wales by year month
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2008 data England Wales

• the total number of abortions was 195.296
  compared with 198,500 in 2007, a decrease of 1.6
  
• Abortion rate 18.3/1000 women in England,
  (16/1000 in Sheffield)
• Abortion rate highest at 36 per 1000, for women
  aged 19yrs (12), same as 2007
• Under 16 abortion rate 4.2 per 1000, under 18
  rate was 18.9 per 1000 (10), both slightly less
  than 2007
• Biggest rate in 20-24 yrs group 28.6
• 98 abortions carried out under section C of
  Abortion Act 1967, 1 under ground D, 1 under
  ground E
• DH abortion statistics for 2008 (published May
  2009)

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Sheffield Integrated Termination of Pregnancy
(TOP) Service

• Approx 1850 abortions/ year in Sheffield from
  approx 2200 referrals (not including fetal
  anomaly)
• Majority referred through Central Health Clinic
  (SCaSH)
• gt14 wks or complex medical problems directly
  referred STHFT (RHH)
• All patients have treatment in a dedicated
  abortion unit at RHH ward G1
• Integrated referral pathway

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RCOG Referral Guidelines

• Ideally, all women requesting TOP should be
  offered a counselling appointment within 5 days
  of referral
• Ideally, all women women should be able to
  undergo TOP within 7 days of decision to proceed
  being agreed
• As a minimum standard, all women should be able
  to undergo TOP within 2 weeks of decision to
  proceed being agreed

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Methods of abortion

• Surgical ( Aspiration/ DE)
• Manual Vacuum Aspiration
• Medical
• May need referral to other provider (e.g. bpas,
  MSI) if greater than 18 weeks gestation

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Surgical abortion

• Most common abortion procedure (75 nationally)-
  usually daycase
• Can be performed up to 15 weeks (only 12 weeks in
  Sheffield) usually under GA
• Cervix primed with misoprostol 2 - 3 hours
  prior to procedure
• Complication rate lt2

12
Manual Vacuum Aspiration under LA

• Day case - usually only 6 hours in hospital
• complication rate less than 1
• patient awake during procedure
• given oral sedative, anti-inflammatory
  suppository and vaginal prostaglandin's 2-3 hours
  prior to procedure

13
Medical abortion

• 2 visits day 1 anti-progestogen, day 3
  prostaglandins
• lt9 wks 6-8 hour stay
• 9-12 wks possible overnight stay (4)
• gt12 approx 7 overnight stay approx 1-2
  require ERPC
• Approx 5 complication rate (depends on
  gestation)

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Percentage of abortions by method (all
gestations) England Wales
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Complications (all procedures/ gestations)

• Uterine perforation (Surgical only) (lt1)
• Cervical trauma (surgical only) (lt1)
• Haemorrhage (lt1)
• Failed abortion/ongoing pregnancy (1-2)
• Post abortion infection/Endometritis (lt1)
• Retained Products of Conception (2-4)
• Psychological sequelae (??10)
• Future reproductive outcomes (lt1)

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Pre - assessment

• Medical/ obstetric history
• Scan (lt8 weeks usually TVS)
• Sexual health screen chlamydia, gonorrhoea
• Bloods FBC, GS, Rubella
• Info re methods ( potential complications)
  appropriate to gestation
• Written consent
• Legal Abortion Act forms (HSA1/HSA4) completed
• Medication prescribed
• Contraception discussed prescribed/ arranged
• All offered counselling with specially trained
  counsellors at CHC (mandatory for under 18 years
  always seen alone)

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Competent minors (aged 16-17 years)

• Entitled to consent to own medical treatment
  (section 8 of Family Law Reform Act 1869)
• However, refusal can be overridden by person with
  parental responsibility/ court
• Same criteria applied re capacity as for adults
• Good practice to include family in decision
  making but not necessary

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Competent minors (under 16 years)

• Gillick case HC(FP)(86)1 any competent young
  person, regardless of age, can give consent to
  medical treatment
• Fraser criteria formed in relation to
  contraceptive advice refusal to inform parents
• Mansfield case

• Doctor justified in proceeding without parental
  consent if
• Understands advice
• Cannot persuade/ allow him/her to inform
• Likely to begin/ continue having SI with/without
  contraception
• Physical/mental health might suffer without
• Best interests to acquire contraception

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Confidentiality

• Right to confidentiality arises from
• Duty of care in negligence (civil)
• Implied duties on a contract of employment
• Duty to keep a confidence even without a
  pre-existing relationship/contact
• Article 8 of The Human Rights Act 1998Right to
  respect for private and family life

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Confidentiality abortion

• All women (including lt16 yrs) seeking abortion
  have right to confidentiality from all clinical
  and ancillary staff
• HCP have a duty via the Fraser Guidelines to try
  persuade minor to tell parents/ guardian
• Requires responsible adult to act as loco
  parentis for minors
• Only breach in exceptional circumstances e.g.
  health welfare of minor (safeguarding issues),
  or other persons at risk
• Notified centrally to Chief Medical Officer via
  HSA4 form

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Exceptional circumstances

• Wards of court
• Non-competent minors
• Non-competent adults
• Child protection issues (lt13 years/ sexual
  exploitation)
• Rights of spouse or partner no rights legally
  to demand or refuse termination

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Summary

• Abortion free to all Sheffield women
• Direct referral to abortion service via CHC or GP
• Important to access services earlier as increases
  options and gives longer time to consider
  decision/ choices
• Abortion available up to 18 weeks gestation in
  Sheffield, after 18 weeks referred to bpas
• Abortions performed earlier are safer
• All women offered counselling mandatory if less
  than 18 years

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Useful websites

• www.abortionrights.org.uk
• www.efc.org.uk (education for choice)
• www.ippf.com (International planned parenthood
  foundation)
• www.brook.org.uk (Brook Advisory Service)
• www.fpa.org.uk (Family Planning Association)
• www.rcog.org.uk (Royal Collage of Obstetricians
  Gynaecologists)
• www.dh.gov.uk (for teen pregnancy/abortion
  statistics, DH documents)

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Thank you!

• joanne.fletcher_at_sth.nhs.uk