Induced abortion is one of the most commonly performed gynaecological procedures in Great Britain with around 180,000 terminations performed annually in England and Wales and around 12,000 in Scotland. Over 98% of induced abortions in Britain are undertaken because the pregnancy threatens the mental or physical health of the woman or her children. This guideline has been developed in relation to the care of the women seeking abortion on such grounds.

The guideline development group views induced abortion as a healthcare need. The aim of this guideline is to ensure that all women considering induced abortion have access to a service of uniformly high quality.

RCOG guidelines have been developed using three keystones i.e. evidence-based systematic and structured search of literature review, evidence-linked graded recommendations and multi-disciplinary consensus which complements evidence.

Grades of recommendations can be classified as:

A. Meta analysis of RCTs

B. Clinical studies other than RCTs

C. Expert reports and opinions

Developing the guidelines means working through these stages i.e. clinical questions, search strategies, obtaining papers, critical appraisal, evidence tables, developing and grading recommendations, authoring, editing and peer review.

Abortion services should have local strategies in place for providing information to both women and healthcare professionals on the choices available within the service and on routes of access to the service. Any woman considering undergoing induced abortion should have access to clinical assessment. Appropriate information and support should be available for those who consider, but do not proceed to, abortion.

Verbal advice must be supported by accurate, impartial printed information, which the women considering abortion can understand and may take away and read before the procedure. Information for women and professionals should emphasize the duty of confidentiality. Professionals providing abortion services should possess accurate knowledge about possible complications and sequelae of abortion. Patients should be counseled regarding pre-abortion decision-making.

Ideally, abortion services must be able to offer a choice of recommended methods for relevant gestation bands. After an abortion, women must be given a written account of the symptoms they may experience and a list of those that would make an urgent medical consultation necessary.

A follow-up appointment should be offered at 2weeks and future contraception discussed.

In the absence of specific medical, social or geographical contraindications, induced abortions may be managed on a day care basis. An adequate number of staffed inpatient beds must be available for those women who are unsuitable for day care In typical abortion service, up to 10% of women will require in- patient care for either a complication or their geographical location (Grade C).

Recommended Abortion Procedures at Different Gestation Bands

• At less than 7 weeks gestation, women can be offered early surgical abortion or medical abortion with mifepristone plus PG.

• Between 7-9 weeks gestation, medical abortion continues to be an appropriate method.

• Between 7-15 weeks gestation, conventional suction termination under local or general anesthesia is appropriate, but individual practitioners may prefer to offer medical abortion.

• For women greater than 15 weeks gestation, mid trimester abortion by D & E, preceded by cervical preparation is safe and effective. Medical abortion also can be offered in this gestation band.

Early Medical Abortion Recommendations

• For early medical abortion, a dose of 200 mg of mifepristone in combination with a PG is adequate (Grade A).

• Misoprostol (a PGE1 analogue) given vaginally is a cost-effective alternative for all abortion procedures for which the E1 analogue, Gemeprost, is conventionally used (Grade B).

After-care recommendations

Abortion care should encompass broader aspects of reproductive healthcare.

• Before she is discharged following abortion, future contraception should have been discussed with each patient and contraceptive supplies should have been offered, if required. The chosen method of contraception should be initiated immediately following abortion (Grade B).

Is there any evidence to state that guidelines actually work and change practice?

Cochrane reviews on this issue have related that printed educational materials or clinical guidelines actually have very limited potential to change professional behaviour or clinical outcome. We are increasingly aware that simple dissemination of guidelines has very little impact on healthcare behaviour and clinical outcome. The approaches described to improve the impact of guidelines are educational outreach, opinion leaders, patient information, reminders, audit and feedback and multifaceted interventions. With this in view, patient version of RCOG guideline was made stating, "What you need to know about abortion care" Patient empowerment would actually prompt them to demand better quality care from their clinicians. This would serve as a means of change in the professional behaviour.

Audit and feedback exercises were undertaken related to the guidelines. Scottish National Audit across 26 gynaecological units in Scotland was undertaken 6 months after the launch of the RCOG guidelines. By review of individual woman’s case records, 75% of women used contraception after abortion. Another development that took place in UK supportive of RCOG guidelines was in relation to the RH procedures for the approval of independent sector undertaking termination of pregnancy. NHS hospitals do not require any special permission to provide abortion services, as do private sector hospitals. Prior to 1999, there was a very cumbersome set of recommendations called "assurances" which private sector establishments had to meet but DH altered these guidelines and indicated that "clinical practice and good quality clinical care should be guided by authoritative clinical guideline such as those provided by the Royal Colleges".

To summarise, RCOG abortion care guideline was published in March, 2000 and is to be revised this year. It was developed using robust stepwise methodology. It includes recommendations on all aspects of medical abortion procedures and after-care. We are very aware that dissemination of guidelines alone is ineffective in changing clinical practice.

Implementation of RCOG guidelines was supported by complementary patient information, national audit exercises and active promotion by DH.