London School of Hygiene & Tropical Medicine

Findings and recommendations from the largest study on abortion in Britain are being presented to the All Party Parliamentary Group on Sexual and Reproductive Health in the House of Commons today (7 March 2023).

The Shaping Abortion for Change (SACHA) study, led by researchers from the London School of Hygiene & Tropical Medicine (LSHTM) and funded by NIHR, charts significant changes in abortion healthcare practice.

The study’s recommendations are based on evidence from around the world as well as, in Britain, a survey of 772 healthcare professionals, interviews with 48 women with recent experience of abortion, and consultations with 15 key stakeholders.

The researchers found that medical abortions, in which patients typically take abortion medication at home, now account for 87% of abortions in England and Wales.

Increasingly, nurses are supervising medical abortions but under the 1967 Abortion Act two doctors are still required to authorise an abortion. As the Act is currently interpreted, nurses are not allowed to perform Vacuum Aspirations (VA) for abortion even though they can conduct the same procedures for miscarriages with patients who are up to 14 weeks pregnant.

Health professionals and patients alike took the view that nurses and midwives should be able to sign authorising an abortion as they are the ones in contact with the patient. The study recommends that appropriately trained nurses and midwives should be allowed to prescribe abortion medication and perform VA.

Women said they valued the convenience, ease and comfort, and privacy and confidentiality of medical abortion at home while also wanting a choice of options, including surgical abortion. Health professionals were concerned that an over-reliance on medical abortion could lead to loss of crucial skills and stressed the need to ensure sufficient numbers of staff were trained in surgical abortion so that this could be offered if preferred.

Current law also states that abortions can only be performed in an NHS hospital or a place approved by the Secretary of State. The study suggests that, if adequately resourced, abortion provision could beneficially be integrated into community sexual and reproductive health services.

Kaye Wellings, SACHA co-lead and Professor of Sexual and Reproductive Health Research at LSHTM, said: “Ultimately, it seems likely that Britain will follow other countries – Ireland, Northern Ireland, Sweden, Australia and Canada – in decriminalising abortion entirely and having it subject to the professional and regulatory, rather than criminal, sanctions that apply to other aspects of health care. In the meantime, as abortion provision is increasingly nurse-led, it makes sense for nurses and midwives to be able to sign off abortions instead of having to pass their paperwork to two doctors, who usually have no contact with the patient.

“There is also merit in permitting nurses and midwives to prescribe abortion medications and also to carry out vacuum aspiration which they perform anyway in the management of miscarriage This would ensure that sufficient cadres of professionals have the skills needed to offer women a choice and address the current risk of valuable skills being lost. Evidence from NICE has already shown that women prefer nurse-delivered services, and our research has confirmed the current law that compels abortions to be performed by doctors is preventing best practice, compassionate care in the UK.”

Dr Rebecca French, SACHA co-lead and Associate Professor of Reproductive and Sexual Health at LSHTM, said: “Abortion is one of the most common health procedures, likely to be experienced by one in three women in their lifetime. Yet, in our study nearly nine out of 10 health care professionals working outside of specialist abortion services said lack of training was a barrier to providing care. Abortion is a health issue and should be covered in health professional training.

“The ability for patients to have early medical abortion at home via telemedicine has transformed abortion care.  Home medical abortion is safe, effective and acceptable to patients. However, some patients prefer to have their medical abortion at a clinic or to have a surgical abortion. Choice is important. We need to make sure options for patients are available, timely and accessible.”

The Shaping Abortion for Change recommendations:

Authorisation/certification of abortion: Health care professionals other than doctors should be permitted to sign off abortions for patients they are caring for.

Integration of abortion provision into routine health care: Abortion provision could beneficially be integrated into – given levels of support revealed in the study – in community sexual and reproductive health services with adequate resources and appropriate commissioning.

Extension of roles: Appropriately trained nurses and midwives should be allowed to prescribe abortion medication and perform vacuum aspiration in the context of abortion provision as they already do in miscarriage care which needs identical procedures and treatments.

Provision of training: attention is needed to provision of both undergraduate training and professional education to increase knowledge and awareness and to equip new cadres of health care professionals to contribute to abortion care and support.

Patient choice: Women seeking abortion should, where possible, be offered options in terms of where they have their abortion, which procedure to have, and how they receive care and support (eg. remotely by telemedicine or in person in the case of medical abortion), and choice of surgical procedure if preferred).

Patient support: Interventions to improve abortion care should be clearly positioned across the patient journey, e.g. to support decision-making about where and how, to manage expectations and pain relief, and to facilitate contraceptive care.

Selected media coverage

The Guardian - Nurses and midwives should be able to approve abortions, UK study concludes

BBC Radio 4 Woman’s Hour

Evening Standard - NHS nurses and midwives should be able to approve abortions, report argues

The BMJ - The two doctors rule for authorising abortion should be scrapped, recommends review