Abortion Care Study Day, 28 April 2008 - Consensus Statement

Introduction

The Abortion Care Study Day a was jointly sponsored by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Faculty of Sexual and Reproductive Healthcare (FSRH). The goal was to identify effective ways to improve services for women, with a focus on achieving women-centred, comprehensive abortion care throughout the UK. The Participants represented a diverse background of knowledge and experience, in order that they could identify all the issues as well as recommend appropriate solutions. They were asked to make recommendations, and identify who would be best placed to implement these and to bring about change. Discussion was focused on three main areas, namely Training, Service Provision and Commissioning.

Training

One of the major issues in Training is access and exposure to clinical services. In many locations it appears that Services are no longer provided by NHS Provider Units. Most RCOG recognised training programmes are based in NHS Hospitals, and the lack of service provision has had a significant impact on training. This is of particular relevance to specialist trainees for whom the new specialist training curriculum requires access to all aspects of abortion care, but it will also have an impact on undergraduate education, as well as postgraduate training for those entering other relevant specialties, particularly general practice. Training in abortion care has become an integral part of generic and reproductive healthcare, with particular relevance for patient choice, communication skills, and tolerance of diversity, as well as clinical including surgical care. Even those who do not participate in abortion services for moral or religious reasons should have knowledge of choices, procedures, risks and sequelae, as outlined in the specialist training curriculum.

Recommendations for consideration are:

  1. In circumstances where specialist trainees do not have access to abortion services in their own or associated hospitals, then arrangements should be made for training in other NHS Hospitals or registered non-NHS service provider. Such an arrangement may be necessary to fulfil the core training requirements, and would require Deaneries and educational leads to make the appropriate arrangements. Where commissioning of services is in the non- NHS sector, then the provision of training to post-graduates and education to undergraduates should, where relevant, be included in the contract.
  2. The RCOG National Undergraduate Curriculum Working Group is finalising its recommendations at present, and should emphasis the importance of fertility control, including the care of women seeking induced abortion, in making its recommendations to the General Medical Council.
  3. All specialist trainees, regardless of moral or religious objections to abortion, should fulfil the knowledge and attitude aspects of the specialist training curriculum, as indicated in the GMC guidance 'Personal Beliefs and Medical Practice' 1. This should be implemented and reviewed by the Educational Leads during formative assessments.
  4. For those following the training programmes of The Faculty of Sexual and Reproductive Healthcare, the same issues will apply and should be addressed as above.

Service Delivery

Participants in the study day reported problems in service delivery in a number of areas including delays in referral as well as quality issues in service provision, including aftercare.

It appears that delays in referral are associated with a lack of awareness of the possibility of pregnancy as well as delays in diagnosis, access to and the availability of abortion services, including assessment appointments, and negative attitudes towards abortion exercised by some referring practitioners.

Recommendations for consideration are:

  1. Improved access to free clearly signposted same-day pregnancy testing in a variety of settings both clinical and non-clinical 2 . Such settings should also provide objective evidence-guided information including support and pregnancy choices. Primary care organisations (PCOs) should ensure that such services are provided, while the Sex and Relationships Educational Review should ensure that school pupils have accurate information and education about all aspects of sexual health, including objective and accessible information about pregnancy choices.
  2. Access to abortion services should be improved to include the possibility of self-referral. Prompt referral from primary care should be monitored, and a central booking service for direct or onward referral with clear clinical care pathways should be in place in all services. Improved information on access to fertility services including abortion services should be clearly sign-posted in all general practices and other primary care settings. These issues should receive attention when services are being commissioned by PCOs and based on a comprehensive needs assessment . It is also recommended that the Department of Health should consider the reclassification of abortion services as an Open Access service.
  3. Commissioners should monitor access to abortion services, as well as delays associated with failure to comply with GMC guidance 'Personal Beliefs and Medical Practice' 1 , paragraphs 17-29 , as well as similar guidance given elsewhere . 3
  4. Furthermore, Commissioners should ensure all aspects of the abortion services meet standards outlined in the RCOG Guideline 'The Care of Women Seeking Induced Abortion ' 4 and the recently published 'RCOG Standards for Gynaecology' 5.
    The quality of service provision is frequently diminished by a lack of appropriate choice of abortion method, appropriate to gestation, particularly in the second trimester. Similarly there is a lack of provision for women with complex or unstable medical conditions (including obesity). These issues should be specified in service Commissioning.

Recommendations for consideration are:

  1. Services should be offered by clinically appropriate providers in appropriate settings. Services should be appropriate to women's needs and preferences and should be based on recommendations on treatment options as outlined in the RCOG Guideline 4.
  2. The involvement of nurses in medical abortion should be encouraged, and if future legislation permits, as recommended in the report from the House of Commons Science and Technology Committee 6, nurses should play a larger part in extending the availability and provision of service, including surgical procedures.
  3. Furthermore the provision and availability of services would be considerably improved if proposed change in legislation permitted that medical abortions could be carried out in community care settings, with the establishment of appropriate care pathways 7.
  4. Second trimester procedures and abortions for women with unstable or complex medical conditions should be categorised as specialised services for commissioning purposes. PCOs should agree on regional commissioning arrangements in liaison with Strategic Health Authorities.

Post-abortion care is dependant on the availability of advice and support where needed. In particular the immediate provision of contraception by abortion providers, including long acting reversible contraceptives, as outlined in the NICE Guideline 8, is crucial if the risk of further unwanted pregnancy and repeat abortion is to be diminished. The importance of integrated contraception, abortion and other sexual health services is fundamental to the prevention of sexually transmitted infection and emotional well-being. After care must include clear information about complications and clear pathways for self-referral where problems develop. This is particularly important where abortions are carried out remote from the patients' home.

Recommendations for consideration are:

  1. PCO commissioning should include information about, and immediate provision of, all contraceptive methods, including long acting reversible contraceptives, and an offer of infection testing and treatment as part of the package of care. Implementation requires a clear clinical care pathway to include onward referral as appropriate to contraceptive care and treatment for sexually transmitted infections, including partner notification.
  2. Women should be provided with written information about the symptoms and side effects they may experience after an abortion and details of which make urgent medical care necessary. There must be a clear indication of how that care can be accessed by self-referral. This will include information about a 24 hour helpline. Implementation of this recommendation will require clear consumer pathways to support clinical pathways, which should include post-abortion treatment care. Such pathways, for some services, will require communication between NHS and independent providers.

There is evidence of uneven quality with respect to the availability of decision making support and counselling including a lack of post abortion support. This may increase the risk of regret and distress. In many services the patient journey from suspicion of pregnancy to completion of the procedure can be overly complex, particularly in the patients' perception. This is even more pertinent for vulnerable members of the community for whom particular help and support is needed to enable them to use the services more effectively.

Recommendations for Consideration:

  1. Counselling and Support Services should be commissioned as part of the package of care. PCOs should ensure that the services provided are audited against Department of Health Guidance for the registration of Pregnancy Advice Bureaux 9. In reviewing its commissioning advice the Department of Health should consider the advertising code applicable to pregnancy counselling options. Similarly the signposting of services should be audited against DH Guidance.
  2. The RCOG should work with the Department of Health to develop clear clinical care (including consumer) pathways and service specifications for local adaptation by Commissioners.

Commissioning

Problems identified with commissioning include variable bundling of abortions with other services and lack of recognition of the relative cost effectiveness of efficient contraception and abortion services. There needs to be agreement about the uniformity of standards for commissioning of abortion and other fertility control services. Sexual health networks have been identified as the best model for abortion care commissioning, delivery and evaluation, but are lacking in many localities. There is also a lack of reliable and accurate data to enable comparisons in quality of care among abortion providers. In particular there is a lack of agreed patient reported outcome measures (PROMs). National data are needed to identify quality issues in abortion services and evaluate the impact of quality improvement strategies 10.

Recommendations for consideration:

  1. PCOs should ensure that national and local tariffs are agreed for abortion and contraception services within contracts, which include costs for the whole care pathway, including counselling, support, training and clinical governance, particularly clinical audit. In discussing commissioning we recommend that the Department of Health, with the support of the RCOG agrees a number of performance indicators for abortion services.
  2. The RCOG should work with the Department of Health to produce a best practice model for world class commissioning in sexual and reproductive health services and particularly in the provision of abortion services 11.
  3. PCO commissioners should work with all local providers of sexual health care and other stake holders to develop local and regional Sexual Health Networks, which include the provision of abortion care.
  4. Those leading Sexual Health Networks should agree a common set of key measures and establish sources of data which will facilitate the assessment and comparison of quality in abortion service provision.

Participants

Contributors to this Abortion Care Study Day were

Ms Toni Belfield, Consumers' Forum Representative, Royal College of Obstetricians and Gynaecologists
Ms Hayley Blackburn, (on behalf of Baroness Gould of Potternewton, Chair of the Independent Advisory Group on Sexual Health and HIV)
Dr Audrey Brown, Sandyford Initiative, Glasgow
Mrs Kay Ellis, Department of Health (observer)
Dr Robbie Foy, Institute of Health and Society, Newcastle University
Ms Ann Furedi, British Pregnancy Advisory Service
Dr Kate Guthrie, Royal College of Obstetricians and Gynaecologists/ Faculty of Sexual and Reproductive Health
Mr Simon Henning, Cheshire & Merseyside Sexual Health Network
Professor Roger Ingham, University of Southampton
Dr Patricia Lohr, British Pregnancy Advisory Service
Dr Sharon Moses, University Hospitals of Leicester NHS Trust (Royal College of Obstetricians and Gynaecologists trainee representative)
Mr Emeka Oloto, University Hospitals of Leicester NHS Trust
Ms Anne Quesney, Head of Advocacy, Marie Stopes International
Ms Laura Riley, London (recorder)
Dr Sam Rowlands, Faculty of Sexual and Reproductive Health
Dr John Spencer, Marie Stopes International
Dr Ewen Stewart, Royal College of General Practitioners
Mr Hong Tan, London Sexual Health Programme
Mr Richard Warren, Royal College of Obstetricians and Gynaecologists

Notes and References

  1. www.gmc-uk.org/guidance/ethical_guidance/personal_beliefs/personal_beliefs.asp#A
  2. www.medfash.org.uk/publications/documents/Recommended_standards_for_sexual _health_services.pdf
  3. ACOG Committee Opinion No. 385 November 2007: the limits of conscientious refusal in reproductive medicine. Obstet Gynecol 2007;110:1203-8.
  4. www.rcog.org.uk/index.asp?PageID=662.
  5. 5 http://www.rcog.org.uk/resources/public/pdf/GYNStandardsWPR(web)0608.pdf
  6. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_080925
  7. Evaluation of Early Medical Abortion (EMA) pilot sites. May 2008. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_084618
  8. NICE Clinical guideline 30: Long Acting Reversible Contraception. http://www.nice.org.uk/CG030
  9. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAnd Guidance/DH_4005566
  10. Review of the National Strategy for Sexual Health and HIV. MedFASH 2008 http://www.medfash.org.uk/publications/documents/Progress_and_priorities...
  11. DH 2007. World Class Commissioning: vision http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...

a Since the abortion care study day which led to the above statement, there have been a number of developments relevant to the provision of abortion services in the UK. Two RCOG study groups have been set up, firstly to consider Termination of Pregnancy for Fetal Abnormality and secondly to consider issues around Fetal Awareness (as recommended by the House of Commons Science and Technology Committee). Furthermore when the legislative changes are clear (anticipated in November 2008) the RCOG will, supported by the Department of Health, then embark on a revision and updating of the Guideline The Care of Women Requesting Induced Abortion. In the very near future the Department of Health will publish a good practice guideline on The Commissioning of Contraceptive and Abortion Services. We understand that many of the recommendations in the above statement have been included. The RCOG will continue to work with the Department of Health and with Commissioners to ensure the improved quality and safety of Abortion Services in the country

Date published: 28/04/2008

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