• Health Policy
• Reproductive Medicine
• Reproductive Health Services

Abortion is the most common gynaecological procedure in the UK, with an estimated one in three women undergoing an abortion before the age of 45 years.1 In Scotland, the National Health Service (NHS) provides abortion free at the point of care. However, access to post-20-week gestation abortions (hereafter ≥20-week abortion) in Scotland has been a longstanding issue.2 Currently, no Scottish Health Boards routinely offer abortion up to the 24-week legal limit under Ground C of the Abortion Act 1967 (risk to the woman’s physical or mental health).3 Most Health Boards do provide abortions under Ground E (fetal abnormality) up to the legal limit. Consequently, some women travel to England for Ground C abortion care from independent sector providers.

Evidence suggests that since 2019, 282 women have travelled to England for this purpose, with the total number per year increasing since 2021.4 Research on the experiences of women from Scotland travelling for abortion has described the costs and how it induces feelings of stress and stigmatisation,2 but there is limited research on providers' perspectives.5 In their 2013 study, Cochrane and Cameron5 found that providers in abortion services supported offering abortion beyond 16 weeks and preferred a single national service within Scotland. They also identified the need for further research.

We conducted a qualitative study to explore the views of abortion care providers in Scotland regarding barriers to providing Ground C ≥20-week abortion. Data were gathered via (1) an anonymous online qualitative survey with healthcare professionals involved in abortion care and (2) interviews with senior abortion leads. Online qualitative surveys were used to reach a diverse, geographically dispersed group of abortion providers, enabling the collection of rich qualitative data on their views and perspectives6 (see Box 1).

Between June and July 2023, respondents were recruited through professional networks such as the Scottish Abortion Care Providers Network and social media such as X (formerly Twitter), Instagram and Facebook. Recruitment via social media was from the first author’s social media account and shared by several organisations including the British Pregnancy Advisory Service and Back Off Scotland.

The survey and interview data were analysed thematically using an approach based on the principles of reflexive thematic analysis by the first author,7 with the entire team contributing to interpreting the data.

In total, 31 abortion providers completed the survey: 11 doctors, 9 midwives, 9 nurses and 2 healthcare support workers, with experience in abortion care provision ranging from 4 months to 40 years. Two senior leaders with over 20 years of experience in clinical care and abortion policy participated in a semi-structured interview. Hereafter, we refer to both survey participants and interviewees as ‘respondents’.

Analysis of the survey and interview data identified three key themes in the abortion care providers’ responses: healthcare system issues, concerns about possible clinical and ethical issues, and systemic abortion stigma (table 1).

First, healthcare system issues were raised as barriers to the provision of later-stage abortion care in Scotland with respondents identifying several systemic problems. Key issues included limited skills in surgical abortion within the workforce, funding and resource constraints affecting service availability, and perceived reluctance at various levels of the healthcare system from frontline providers to senior leaders. The COVID-19 pandemic was perceived as exacerbating these challenges in recent years, putting additional strain on NHS abortion services, the effects of which continue to be felt.

Second, concerns about clinical and ethical issues related to later-gestation abortions were reported. Respondents described their understanding of perceived health risks, including physical complications and potential negative effects on mental health. Ethical dilemmas specific to ≥20-week abortion were also raised. Advances in neonatal care were described as heightening concerns about fetal viability under 24 weeks, contributing to both ethical concerns (regarding ‘signs of life’) and practical concerns (healthcare system issues outlined earlier) among some providers.

Finally, the role of systemic abortion stigma was highlighted by respondents who believed this caused social and personal barriers to abortion care. Stigma associated with abortion was understood by respondents to influence both public and provider attitudes towards later-stage abortions. Respondents also noted a reluctance among providers to perform abortions for Ground C cases, perceiving these as less justified than Ground E (fetal anomaly). This reluctance seemed to be shaped by both societal stigma and the current medicolegal framing surrounding grounds for abortion.

Online qualitative surveys do not aim for statistical representativeness.6 While they can capture a broader range of perspectives, recruitment methods inherently limit the diversity of participants. Consequently, the findings should be interpreted in the light of study limitations, specifically the relatively small, self-selected sample recruited through professional networks and social media.

This research highlights providers’ perspectives on barriers to the provision of ≥20-week abortion services in Scotland. Urgent action to address these barriers is critical to better meet the needs of people seeking later abortion in Scotland. The Scottish Government should ensure that its actions align with its stated aim by supporting the establishment of services for abortion at ≥20 weeks' gestation, including surgical options. Until this is available, medical abortion should be offered up to the legal limit within Health Boards, allowing people seeking abortion in Scotland to access care without the need to travel to England. The insights from this study are valuable for understanding the challenges involved and for creating strategies to overcome them.