Termination of pregnancy, or therapeutic abortion, has been carried out for thousands of years. The provision of abortion in a legal, medically supervised and safe framework, is one of the most contentious issues in modern-day medicine. Many people have strongly held and often divergent opinions about abortion. Those who are pro-abortion maintain that they are ‘pro-choice’ and support the right of individuals to make their own decisions. They are sensitive to the difficulties of bringing an unwanted baby into the world, and are aware of the impact on both the woman concerned and society more broadly. Those who are anti-abortion, or ‘pro-life’, argue that the fetus is more than just part of the mother; it is a life in itself and should be protected, even if that means limiting the mother’s choices regarding her body.

There are many factors leading to unplanned pregnancy: contraception may have failed, or perhaps was not used at all; occasionally, intercourse without the woman’s consent has resulted in pregnancy. Of course, a woman may have an unplanned pregnancy but be pleased to be pregnant and continue the pregnancy. Another may have planned to be pregnant but then her circumstances may change and she feels unable to continue. Among women attending antenatal clinics, research demonstrates that only two-thirds of women had an intended pregnancy, with the rest either ambivalent or having an unplanned pregnancy. Although abortion should not be considered as a method of contraception, contraceptive failures do occur, and access to abortion allows women complete fertility regulation.

Abortion care forms a large part of the gynaecology workload in the UK, and therapeutic abortion is one of the commonest gynaecological procedures. Although doctors may have differing degrees of involvement in abortion services, most will come into contact with women who are seeking abortion at some point in their career, so need to be familiar with the legal framework and options open to the women.

Worldwide perspectives

There are over 100 million acts of sexual intercourse every day across the world, resulting in over 900 000 pregnancies. It is estimated that about 50% of these pregnancies are unplanned, and about 25% actually unwanted. Many women with an unwanted pregnancy will seek an abortion, and, as a result, about 150 000 pregnancies are terminated by induced abortion every day. There are over 50 million abortions worldwide every year and around one-third of these abortions are carried out in unsafe conditions. Illegal abortions are often performed in unclean conditions by unqualified people, causing considerable morbidity and mortality. Between 100 000 and 200 000 women die each year from unsafe abortion. In contrast, abortion performed in appropriate conditions with trained staff is a very safe procedure, with extremely low morbidity and mortality.

UK perspectives

The Abortion Act was passed in 1967, and after this, there was a rapid rise in the number of abortions carried out in England, Wales and Scotland. Currently, almost 190 000 abortions are carried out each year in England and Wales, with a further 12 500 in Scotland. Women of all reproductive ages have abortions, although the highest rate is among women aged 18–24 years. About 80% of women having abortions are unmarried, although many of these will have a regular partner. Just over half of women have already had a child and over one-third have had an abortion previously. Most terminations (78%) are carried out before 10 weeks of pregnancy, 13% are carried out between 10–12 weeks, and the remaining 9% are carried out at 13 weeks or more.

Legal and ethical aspects

Abortion is not available ‘on demand’ in the UK, and can only be carried out if certain criteria are met. The 1967 Abortion Act, as amended in 1991, states that abortion can be performed if two doctors agree that the pregnancy should be terminated on one or more grounds (Box 26.1).

Box 26.1

Circumstances in which an abortion may be carried out under the Abortion Act 1967 (amended 1991)

A. The continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated

B. The termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman

C. The pregnancy has not exceeded its 24th week and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman

D. The pregnancy has not exceeded its 24th week and continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the existing child(ren) of the family of the pregnant woman

E. There is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped

Most abortions (98%) are carried out under Clause C of the Abortion Act, where two doctors agree that continuing the pregnancy would carry greater risk to the physical or mental health of the woman than abortion. A smaller number of abortions (1%) are carried out to protect the health of existing children. Clauses C and D carry an upper gestational limit of 24 weeks. The 1967 Abortion Act does not apply to Northern Ireland, where abortion is only legal under exceptional circumstances, e.g. to save the life of the mother.

Current methods of inducing abortion are now so safe that it is safer for the woman to have an early abortion than to continue to term and have a delivery. Of course, that does not mean that abortion should be recommended, but a clinician may consider a request for abortion when a woman feels that her health (or that of her children) will be adversely affected by continuing the pregnancy.

Although uncommonly used, the Abortion Act also allows abortion to be performed in an emergency situation upon the single signature of the doctor performing the abortion. Such an emergency abortion can be carried out either to save the life of the pregnant woman, or to prevent grave permanent injury to the physical or mental health of the pregnant woman.

Recent opinion polls have shown that most of the public support the right to abortion, with 65% agreeing that if a woman wants an abortion she should not have to continue with her pregnancy. Women requesting abortion need the agreement of two doctors, and will often rely on the support of their general practitioner for referral. Over 80% of British general practitioners described themselves as ‘broadly pro-choice’, and 18% as ‘broadly anti-abortion’. No doctor has to be involved in referring women for abortion, but the General Medical Council guidance advises that if a doctor is unable to make a referral for termination, then a timely referral of the woman to a colleague who does not hold similar views is obligatory; every doctor has an obligation to treat in an emergency situation.

Counselling before abortion

When a woman is considering abortion, it is important that she is able to weigh up the practical and emotional aspects of her decision, to ensure that the best choice is made in the circumstances. The Royal College of Obstetricians and Gynaecologists’ (RCOG) guidance recommends that the initial consultation appointment should be available within 5 days of referral, to avoid any unnecessary delays. She will require sympathetic but non-directional support so that she is able to explore her own feelings and to make her own informed decision. Many women with an unplanned pregnancy will make their decision within a few days of knowing that they are pregnant. Other women may remain undecided for some time. It is important that the decision to abort is made freely by the woman, and that she is not coerced by another party, for example a parent or partner. For this reason, it is imperative to speak to the woman alone at some point during the consultation.

Psychological problems and rates of depression are not increased after abortion when compared with background population risk, but some women may experience coping problems and distress. The counselling process can help to identify these women, and ensure that appropriate support is offered both before and after the abortion. Box 26.2 outlines risk factors for emotional problems.

Box 26.2

Factors associated with coping problems and distress after abortion

Women with a history of mental health problems