Termination of pregnancy

Synonyms: induced/therapeutic abortion; abortion is a widely used synonym amongst the general public

What is termination of pregnancy?

Termination of pregnancy (TOP), otherwise known as abortion, is a medical procedure which ends a pregnancy prior to independent viability, using pharmacological or surgical means.

How common are pregnancy terminations? (Epidemiology)

Incidence

Statistics provided by the Office for Health Improvement and Disparities for 2022 show the following: ²

• There were 251,377 TOPs for women resident in England and Wales, the highest number since the Abortion Act was introduced in 1967 and an increase in 17% over the previous year.

• Over the last 10 years TOP rates have increased year on year, with the increase being more marked in the most recent statistics.

• Nearly 9 out of 10 TOPs were carried out under 10 weeks.

• 3,124 TOPs were due to the risk that the child would be born seriously handicapped, 25% of which were at 22 weeks of gestation or higher.

• 86% of TOPs were medically induced, the continuation of a 10-year trend showing a relative increase in medical TOPs and reduction in surgical TOPs as a percentage of the total.

• Almost all TOPs (99%) in England and Wales were funded by the NHS in 2018, with 80% of these taking place in the independent sector.

In 2023 in Scotland, TOPs are also increasing year on year, with a 10% (1,600) increase from 2022 numbers. Increases were seen in all areas of Scotland and across all ages, with numbers rising more in the most deprived areas, possibly due to inequity in provision of contraception. ³

Since TOP was decriminalised in Northern Ireland (NI) in 2019, numbers have increased year on year, with 2,168 TOPs being carried out in NI in 2022 - 2023. TOPs performed in England and Wales for NI residents have decreased to 172 in 2022, from a peak of 1,855 in 1990. ⁴

Legal requirements

The 1967 Abortion Act allows TOP throughout the UK (Northern Ireland in line with the rest of UK from 2020) before 24 weeks of gestation:

• If it reduces the risk to a woman's life; or

• If it reduces the risk to her physical or mental health; or

• If it reduces the risk to physical or mental health of her existing children; or

• If the baby is at substantial risk of being seriously mentally or physically handicapped.

Two medical practitioners must certify in good faith by signing form HSA1 (Certificate A in Scotland) that at least one of these criteria applies. Most terminations are performed under the second of these criteria.

There is a general debate in political and public circles every so often that the upper gestational age limit ought to be reduced from 24 weeks to 22 or 20. This is due to the recognition of advances in neonatal care and improving the survival rates of some premature infants born around this time, setting up an environment of moral concern that babies who could survive are having their lives ended. 4-dimensional ultrasound also appears to show 20-week gestation fetuses displaying complex behaviours, prompting a call for a shift from viability as the main criterion, towards sentience.⁵

The Abortion Act did not decriminalise TOP, merely allowing it under certain circumstances. The BMA favours decriminalisation of TOP, when done within the context of a healthcare professional's clinical practice, or for women who procure their own TOPs. This is not the same as deregulation and the BMA agrees with criminal sanctions when TOP is performed without appropriate training, without the woman's consent, or when abortifacients are illegally procured or supplied.

Currently, the British Medical Association (BMA) does not favour a reduction in the gestational age limit for TOP.⁶ This is based on the fact that there is no significant improvement in survival statistics for babies born under the age of 24 weeks. The BMA also supports the position that the need for two doctors to certify should be removed in the first trimester.

There is no upper limit on gestational time if there is:

• Risk to the mother's life.

• Risk of grave, permanent injury to the mother's physical/mental health (allowing for reasonably foreseeable circumstances).

• Substantial risk that, if the child were born, it would have such physical or mental abnormalities as to be seriously handicapped. Such terminations must be conducted in an NHS hospital.

A minority of TOPs are performed after 20 weeks - 0.1% of the total in England and Wales in 2022. This is usually for medical reasons following an antenatal diagnosis.

Termination of pregnancy in girls under 16 years⁷

GMC guidelines state that girls under the age of 16 may be able to make an informed decision without parental consent if they are deemed to have capacity to do so. The guidance states that TOP can be provided without parental knowledge or consent if:

• The girl understands all aspects of the advice and its implications.

• You cannot persuade her to tell her parents or to allow you to tell them.

• Their physical or mental health is likely to suffer unless they receive such advice or treatment.

• It is in the best interests of the young person to receive the advice and treatment without parental knowledge or consent.

The GMC further advises you should keep consultations confidential even if you decide not to provide advice or treatment (for example, if your patient does not understand your advice or the implications of treatment), other than in exceptional circumstances. These might include an overriding public interest in the disclosure, when disclosure is in the best interests of a child or young person who does not have the maturity or understanding to make that decision, or when disclosure is required by law.

The consent of a competent young person overrides parental refusal to allow treatment. If a young person lacks capacity, someone with parental responsibility can consent on their behalf. The young person's views must be heard and taken into consideration. Consider the possibility of sexual abuse; if the young person does not have the capacity to consent to TOP, do they have the capacity to consent to sexual intercourse?

See the separate Consent to treatment in children (Mental capacity and mental health legislation) article.

It is strongly recommended that you seek medico-legal advice from your medical indemnity organisation regarding your statutory and ethical duties, and the rights of patients and/or their parents, regarding terminations in girls aged <16 if you have any uncertainty.

Before termination of pregnancy⁸⁹¹⁰¹¹

GPs who are approached by a woman wanting a TOP should do the following:

• Refer to a local TOP provider - depending on local pathways, this may be a direct referral, or done by giving the person contact details for self-referral.

• Provide information on what to expect, which may include some of the factors listed below.

• Discuss contraception, if the patient wants to do so.

• Details of the different options, and the taking of consent, would be done by the TOP provider, but it may be useful for a GP to explain that in general, either medical or surgical TOP can be done at any gestation, rather than there being absolute limits after which medical TOP cannot happen. Following the COVID-19 pandemic, the law has permanently changed to allow early medical TOP to be done at home for women in England, Scotland and Wales, with the medication being accessed by teleconsultation if this is preferred by the woman.

A service which provides TOP should do the following before the procedure is carried out:

• Confirm the patient is pregnant and the duration of the pregnancy - this can usually be done from the date of the last menstrual period, with routine ultrasound scanning not being necessary.

• Confirm that she is seeking a TOP voluntarily, rather than being coerced into doing so.

• Enquire about medical history and social circumstances including sexual and domestic abuse.

• Offer optional counselling and decision-making support. Both counselling and a period of time for reflection are optional rather than mandatory.

• Discuss the methods of TOP and choices available.

If she chooses TOP, the RCOG recommends the following:

• Risk assess everyone for STIs and conduct screening if appropriate, for example for chlamydia, gonorrhoea, HIV and syphilis. Arrange partner notification when an STI is found.

• In order to not delay the TOP, give prophylactic antibiotics to those with symptoms and signs of an STI.

• Discuss future contraceptive needs unless this is unwanted - all methods can be started at the time of a surgical TOP and all methods except the intrauterine device can be started at the time of a medical TOP. Prescribe a bridging method if the choice of method is not available and refer on for the first choice of method. Women who request sterilisation should be advised that there is a possible increased risk of failure and regret when done at the time of TOP and that this should ideally only be performed some time later.

• Consider checking Rhesus status if the TOP is being done at 12 weeks or more - other blood tests such as FBC are not needed unless there is a clinical reason.

Analgesia and anaesthesia⁸

For medical TOPs, the RCOG recommends an analgesic such as a non-steroidal anti-inflammatory drug (NSAID) be offered. Stronger analgesia may be required in some cases.

Ideally there should be the option of local anaesthesia or conscious sedation for surgical TOPs; general anaesthetic is associated with higher rates of complications and longer hospital admissions and is therefore not usually recommended. An NSAID should be routinely offered for pain relief.

Aftercare ⁸

Medical

If available, Anti-D should be offered to all non-sensitised RhD-negative women having a TOP over 12 weeks gestation. Discuss contraception and supply if accepted. TOP services should be able to supply contraception immediately after the procedure. Intrauterine contraceptives can be inserted immediately after a TOP as long as successful TOP has been confirmed.

Written

Provide a list of possible symptoms, highlighting those that need urgent medical attention, with a 24-hour number where it can be obtained. Also, a letter with enough details to allow another doctor to be able to deal with any complications. If TOP has been confirmed at the time of the procedure there is no need for routine follow-up. Arrange further counselling for women who experience long-term distress.

Complications of pregnancy terminations⁸

TOP is considered a safe procedure and major complications are rare, occurring at the following rates:

• Infection - less than 1% for medical or surgical TOP.

• Cervical trauma - less than 1%. A risk of surgical TOP only.

• Continuing pregnancy - 1-2% for medical TOP, 0.1% for surgical TOP.

• Bleeding which requires a transfusion - less than 0.1% at < 20 weeks gestation, 0.4% > 20 weeks gestation.

• Uterine perforation - 0.1 - 0.4%. A risk of surgical TOP only.

• Uterine rupture - less than 0.1%. A risk of second trimester medical TOP only.

Occasionally, more intervention than planned will be needed to complete the procedure. This occurs in 7% of medical TOPs and 3.5% of surgical TOPs under 14 weeks gestation, and 13% of medical and 3% of surgical TOPs over 14 weeks.

Psychological effects

Only a small proportion of women experience long-term adverse psychological sequelae. Although early distress is common, it is usually a continuation of the symptoms present before the TOP. There is no link between TOP and subsequent mental health problems.