Results: Two prospective cohort studies (n = 3821) and two
randomised controlled trials (RCTs) (n = 3821) were included.
Three thousand seven hundred and forty-nine women underwent
a procedure administered by an MLP and 3893 women underwent
a physician-administered procedure. Three studies used surgical
TOP with maximum gestational ages ranging from 12 to 16+
weeks; a medical TOP study had maximum gestational ages up to
There was no difference in incomplete/failed TOP for
procedures performed by MLPs compared to doctors in RCTs of
surgical (OR: 2.00; 95% CI: 0.85, 4.68) and medical TOP (OR:
0.69; 95% CI: 0.34, 1.37). One prospective cohort study showed
increased odds of incomplete/failed TOP among MLPs versus
physician groups (OR: 4.03; 95% CI 1.07–15.28).
None of the included studies found a difference in the odds of
overall complications between provider groups.
Conclusions: Based on this evidence, there is no indication that
procedures performed by MLPs are less effective or safe than
those provided by physicians.
Conclusion: Women undergoing a TOP who wish to avoid
another unintended pregnancy should consider immediate
initiation of either intrauterine contraception or the progestogen-
only implant. Service providers should be trained and supported
to provide these methods to women at the time of TOP.
Integrating abortion within a community sexual and reproductive health service: a qualitative study of the experiences of women and health professionals
Carrie Purcell1, Sharon Cameron1 ,2, Anna Glasier1, Julia Lawton1, Jeni Harden1 1University of Edinburgh, Edinburgh, UK, 2NHS Lothian, Edinburgh, UK - firstname.lastname@example.org
Background: Abortion in Scotland has historically been provided in a hospital setting. The availability of early medical abortion (EMA), and the possibility for women at early gestations choosing to go home to pass the pregnancy (soon after receiving misoprostol form the abortion service), have enabled the provision of abortion from an integrated community sexual and reproductive health (SRH) service. However, little is known about the impact of the clinical setting on the experiences of staff involved in the EMA service. This paper presents findings from the staff experience arm of a qualitative evaluation of EMA provision in both SRH and hospital settings. Objectives: - To examine the experience of nurses, nursing aides, doctors and sonographers involved in EMA provision. - To explore whether, and in what ways, the clinical setting shapes this experience - To highlight areas for good practice/ improvement Method: Qualitative interviews (N=35) were conducted with staff involved in EMA provision at one SRH-based and two hospital-based abortion services in central Scotland, between October 2013 and April 2014. Interviews were coded using NVivo 10 software and analysed thematically. Results: Staff in both settings emphasised the importance of team working and cited the quality of care offered as a success of the EMA service. They also described experiencing challenges, including: boundaries between roles, training, resource constraints, adjustment to change, and the perceived marginalisation of abortion services. Relative differences were identified between clinical settings, for example: nursing staff in the SRH setting described greater involvement with post-abortion contraceptive uptake; nursing aides in the SRH context expressed more negative views on their work role. Conclusions: There are many similarities of experience across staff groups and between clinical settings. Differences between the settings reflect the benefits and the challenges of the new SRH service.
Is there a reduction in abortion rates?
Sharon Cameron (Scotland)
University of Edinburgh, Scotland
Emergency Contraception (EC) can prevent pregnancy. Effectiveness of EC has been based upon estimates of the risk of pregnancy depending on the timing of unprotected intercourse within the menstrual cycle. Research demonstrated that the main barriers to use of EC were lack of knowledge of EC and difficulty in obtaining EC.
It was anticipated therefore that increasing the availability of EC would lead to a reduction in unintended pregnancies, reflected in lower abortion rates. In some countries, EC is available without prescription at pharmacies. In the UK and France, cross sectional surveys have shown that this has led to more women obtaining EC from the pharmacy rather than other sources.
However, increased use of EC has not been associated with a reduction in abortion rates in UK or Sweden. This may be because abortion is linked to other social, economic and political factors.
A Cochrane database systematic review of RCT’s that examined effects of advance provision of EC (women supplied with EC to have rapid access in case of need) compared to standard access, showed increased use of EC but no difference in unintended pregnancy rates. In those cycles resulting in pregnancy where women with EC did not use it, this was mostly due to a misperception that they were not at risk of pregnancy.
Encouraging use of more effective methods of contraception before or during sex may be a more effective strategy to prevent unintended pregnancies than use of EC.
Outcomes for women based on psychological background
Sharon Cameron (Scotland)
University of Edinburgh, Scotland
It has been claimed that the decision to terminate an unwanted pregnancy can lead to mental health problems for women. However, childbirth can be a physically and emotionally demanding time for mothers and many studies have demonstrated an increase in depression and anxiety post-partum. There has been a lack of research on the long term mental health of women choosing an abortion. Of those studies which have been published, many have suffered from methodological problems or failed to account of possible confounding factors.
Recently, a systematic review of the literature relating to mental health of women following abortion, was conducted by the American Psychological Association. This concluded, based upon the available evidence, that among adult women who have an unplanned pregnancy, the relative risk of mental health problems is no greater if they have a single first trimester abortion, than if they deliver that pregnancy.
Whilst there may not be a causal link between abortion and mental health problems, nevertheless some women do experience negative psychological responses including depression and anxiety. Risk factors that have been identified include ambivalence about the decision to have the abortion, whether the pregnancy was originally intended, lack of a supportive partner, a psychiatric history and membership of a cultural group that considers abortion to be wrong. Some of these risk factors are also predictive of mental health problems following childbirth.
Further, more robust and definitive research studies are required on mental health after both abortion and alternative reproductive outcomes such as childbirth or miscarriage
Outcomes of very early medical termination of
pregnancy at ££6 weeks of gestation
Heller, R; Cameron, S
NHS Lothian, UK
Background and methods: In 2010 the termination of pregnancy
(TOP) service at The Royal Inﬁrmary of Edinburgh, Scotland, UK
introduced a protocol that allowed women at very early gestation
without ultrasonic evidence of an ongoing intrauterine pregnancy,
but who fulﬁlled certain criteria (£6 weeks of gestation by dates,
eccentric placed intrauterine gestational sac of £3 mm, decidual
reaction, no risk factors for ectopic) to proceed directly
with medical TOP, without the need for further investigations
or ultrasound scans. Follow up consisted of routine
telephone follow up with home low sensitivity urine pregnancy
A retrospective audit of the management of this group of
women attending in 2011 was conducted. Hospital computerised
records and case notes were used to determine the number of
visits made, investigations performed and outcome of the
Results: Five hundred and eighty women attended over the audit
period requesting a TOP at £6 weeks of gestation. Of these
women 3.7% (n = 21) had a serum hCG performed prior to TOP,
and 2% of women (n = 12) had more than one ultrasound before
TOP. Seventy-three percent of women (n = 414) had routine
follow up (telephone follow-up with LSUP) only, 24.4% (n = 138)
had one post-TOP ultrasound, and 1.5%, (n = 9) returned for
more than one post-TOP ultrasound. At follow up ultrasound,
two women were found to have ongoing pregnancies (0.3%).
There were no ectopic pregnancies.
Discussion and conclusions: Most women at early gestation
(£6 weeks) without deﬁnite evidence of a viable intrauterine
pregnancy can proceed to medical TOP without the need for
additional pre-TOP or post-TOP ultrasonography
Dr. Sharon Cameron, United Kingdom
The reported incidence of post -abortal infection (in countries where abortion is legal ranges from 1% to10%, depending on the population, diagnostic criteria used to define infection, use of peri-abortal antibiotics and the method used. Prospective comparative studies have suggested that medical abortion may be associated with an overall lower risk of infection, possibly because it is less invasive procedure. The presence of chlamydia, gonorrhoea or bacterial vaginosis in the lower genital tract at the time of abortion has been shown to be associated with an increased risk of post-abortal infection. Strategies for preventing post- abortal infection include (i) a screen-and-treat policy (ii) universal antibiotic prophylaxis or (iii) a combined approach, of both screening and prophylaxis. Meta-analysis of randomised trials have shown that antibiotic prophylaxis at the time of abortion is associated with a reduction in the risk of subsequent infection of around 50%. Furthermore, antibiotic prophylaxis has been shown to benefit women who have negative pre abortion genital swabs and is less costly than the other strategies. However, failure to test for sexually transmitted infections pre-abortion and to identify infected women, perpetuates the risk of re-infection by an infected partner. This is important since it is believed that re-infection with chlamydia may increase the likelihood of complications such as tubal infertility.
Self-assessment of success of early medical
termination of pregnancy: a service evaluation
Cameron, S1,2; Glasier, A1,2; Dewart, H1,2;
Johnstone, A1,2; Burnside, A1,2; Paterson, B1,2;
Hunt, L1,2; Rahimi-Rizi, J1,2
1 NHS Lothian, UK; 2 University of Edinburgh, UK
Introduction: In a recent study, we demonstrated that telephone
follow- up with a self-performed low sensitivity urine pregnancy
(LSUP) test was effective to determine the success of early medical
TOP (<9 weeks of gestation). In the latter study, one half of
women surveyed stated that they would have chosen self
assessment (without a telephone call), if available. We
subsequently introduced self-assessment with a self-performed
LSUP test to our hospital TOP service in Edinburgh, Scotland.
Women choosing this option were given detailed information on
symptoms that may indicate an ongoing pregnancy and advised to
contact the service if symptoms or LSUP suggested ongoing
Methods: Ongoing service evaluation of self assessment with
LSUP test as a method of follow up after early medical TOP,
consisting of review of the proportion of women choosing this
follow-up, contacting the service, and the efﬁcacy for detecting
Results: To date, out of a total of 89 women having early medical
TOP, 66 have opted for self-assessment (74%), 18 for telephone
follow-up (20%) and four for a clinic follow up with ultrasound
(4%). Only three of the ﬁrst 66 women (4.5%) choosing self
assessment have contacted the service, because of pain/bleeding
(n = 1), discharge (n = 1) and a positive LSUP (n = 1). To date
there have been no known ongoing pregnancies in the self
Conclusion: Initial ﬁndings suggest that self-assessment with a
LSUP test is a popular choice for women. Few women contact the
service, suggesting that women are conﬁdent in managing follow-
up in this way.
Quick starting after emergency contraception (EC
NHS Lothian, Edinburgh, UK
Meta-analyses have shown that women who have further episodes of unprotected sex in the same cycle after taking oral EC have a two- to three-fold higher risk of pregnancy than women who do not. This raises the importance of quick starting a regular method of contraception immediately after EC is used. Guidelines advise that when quick starting a hormonal method after taking levonorgestrel for EC, that women use barrier methods/ abstinence for the standard numbers of days until contraceptive effectiveness of the method if achieved (e.g. 7 days for combined hormonal methods, 2 days for progestogen only pills- POP). Since Ulipristal acetate (UPA) is a progesterone receptor modulator, quick-starting a hormonal method after UPA could in theory alter the effectiveness of hormonal contraception by competition at the receptor site or vice versa. Two RCTS have addressed this. One examined the effect of UPA followed by COC on ovarian quiescence and suggested that UPA does not affect the contraceptive efficacy of COC. This study was not designed to examine a potential impact of COC on UPA. The other study examined UPA followed by POP (desogestrel) and also suggested that UPA does affect the contraceptive action of POP. However, this study indicated that commencing a POP 24hrs after UPA can prevent the ability of UPA to delay ovulation. In view of this, women who wish to commence hormonal contraception after UPA for EC are advised not to quick start. Interim guidance from the Faculty of Sexual and Reproductive Healthcare UK, advise that women wait at least 5 days after UPA before commencing hormonal contraception.
From hospital to community
Sharon Cameron1,2 1NHS Lothian, Edinburgh, UK, 2University of Edinburgh, Edinburgh, UK - email@example.com
There is growing recognition that termination of pregnancy (TOP) services should be able to offer both high quality contraceptive advice and provide women with the most effective methods of long-acting reversible of contraception (LARC), to start immediately after the TOP. Women who choose to start LARC immediately post TOP have a significantly reduced risk of having another TOP than counterparts choosing less effective methods. In many countries, TOP services are traditionally delivered from hospital departments of obstetrics and gynaecology where staffing of the labour ward usually takes priority. Junior medical staff delegated to undertake the consultations of women requesting a TOP may be disinterested in TOP care and may lack specialist contraceptive knowledge and training to insert the most effective LARC methods. In contrast, staff working in specialist contraceptive services (family planning/ sexual and reproductive health) in the community possess the knowledge and skills to offer the most effective methods of contraception. Furthermore, early TOP can clearly be delivered from the community setting. This raises the question of whether higher LARC uptake rates and as a consequence, fewer subsequent TOPs could be achieved if more TOP care was delivered from the community specialist contraceptive setting.
Preferred terminology amongst women seeking abortion : A British survey
Sharon Cameron1, Patricia Lohr2, Roger Ingham3
1NHS LOTHIAN, Edinburgh, UK, 2BPAS, London, UK, 3University of Southampton, Southampton, UK
Objectives: Some controversy exists as to whether or not women find the term ‘abortion’ distressing and would prefer alternatives such as ‘termination of pregnancy’. There is a lack of evidence to substantiate any change in terminology. We conducted a study to determine views of women seeking abortion on terminology used.
Methods: A cross-sectional study of the views of 2,259 women presenting for abortion in Britain was conducted over four months in 2015. Self-administered anonymous questionnaires were distributed at 57 abortion services in Scotland, England and Wales. The questionnaire asked for women’s views on preferred terminology and collected basic demographic data.
Results: The mean age of respondents was 27 years (range 13-51), 51% had children and 36% had previously undergone abortion. Most women did not find the words ‘abortion’ or ‘termination of pregnancy’ distressing. 35% (n=738) indicated that they found 'abortion' distressing vs 18% (n=399) who felt 'termination of pregnancy' was distressing (p<0.000). Significantly more respondents stated a preference for 'termination of pregnancy' than 'abortion' (n= 1009; 45% vs n=263; 12% respectively p<0.0001). This preference was not affected by demographic characteristics (e.g. age, reproductive history, residence).
Conclusions: Most women do not find either ‘abortion’ or ‘termination’ to be distressing. However, a relative majority might favour 'termination of pregnancy' and abortion care providers should be sensitive to this when communicating with women.