• abortion
• family planning service provision
• service delivery

Abortion services in the UK are increasingly commissioned within the independent sector. This has improved accessibility and lowered costs for the care of women who have no significant medical problems, but creates access problems for women requiring hospital-based abortion care, as hospital-based National Health Service (NHS) units lose funding and cease to operate. To indicate the scale of need for hospital-based abortion care, The British Pregnancy Advisory Service (bpas), an independent-sector abortion provider, has reported that in 2016 and 2017 it arranged referrals to NHS providers for 2900 women. Due to the shortage of hospital-based services, particularly those offering care in the second trimester, these patients often have to wait several weeks for a referral to be accepted and may face a further wait until their appointment. They also may need to travel large distances. A significant minority of these women are unable to access abortion at all and are forced to continue pregnancies they would almost certainly be eligible to terminate within the UK legal framework1. These ongoing pregnancies will furthermore be complicated by the same condition that complicates their abortion. Given that comorbid medical conditions account for two-thirds of maternal deaths in the UK, this represents a serious ethical and clinical failure.2

In response to this situation, Homerton University Hospital in London expanded its abortion service to accept referrals from outside its local area, and increased the departmental gestational limit from 17 to 24 weeks gestational age for terminations provided under section 1 (1)a of The Abortion Act, or Ground C as stated on the HSA1 form (Certificate A). We provide a brief retrospective report of the first year of this service development to demonstrate the success of the service, and to invite other hospitals to implement similar changes. We present here an analysis of patients referred into the service and the outcomes of their care.

Between October 2016 and September 2017, the service accepted 75 referrals. 55% came from outside London, including Scotland and Wales. Sixteen women did not attend their appointments. Some of these women chose to continue their pregnancy, but a minority reported that the costs of travel and accommodation were an insurmountable barrier that played a role in their decision not to attend.

The mean age of our patient group was 29 years (table 1). The mean gestation at the time of referral was 17 weeks and 6 days, with 47% of women referred at a gestation of 20 weeks or more. The median interval between referral and abortion was 16 days. 49% of women had a history of at least one previous caesarean section, 37% had a history of at least one vaginal delivery, and 45% had a history of previous abortion (table 1).

57% of the women were referred due to conditions with implications for anaesthetic safety, such as poorly controlled asthma and epilepsy.43% were referred due to surgical concerns, such as a history of previous caesarean section(s) (with or without a low or anterior placenta) or anticipated difficult transcervical access (e.g. the presence of lesions obstructing access to the cervical canal, for example, fibroids, large ovarian cysts; or previous cervical procedures such as, trachelectomy). 10% were referred for other reasons, including haematological conditions (such assevere anaemia, sickle cell disease, clotting disorders) or rare genetic syndromes (table 2).

Mean gestational age at time of abortion was 20 weeks, with 64% performed at a gestation of 20 weeks or more and 5% at less than 13 weeks. 88% of patients underwent surgical termination by transcervical dilatation and evacuation (D&E). One patient underwent hysterotomy. The remainder had either inpatient medical abortion or manual vacuum aspiration under local anaesthesia (which we provide to 13 weeks gestational age).

All patients at 14–17 weeks and 6 days of gestation underwent cervical preparation with mifepristone 200 mg 24 hours prior to the procedure, and misoprostol 400 μg 1–2 hours pre-operation. All patients at 18 weeks gestation or greater had Dilapan-S osmotic dilators (MEDICEM International, Prague, Czech Republic) inserted into the cervical canal the day prior to the operation. Feticide was performed prior to all D&Es at a gestational age of 20 weeks and 0 days or greater, using ultrasound-guided intracardiac injection of potassium chloride. We have since revised our protocols to insert overnight Dilapan-S in all patients at 14 weeks and 0 days or greater gestational age because of its superior cervical priming effect and the reassuring data regarding subsequent pregnancy outcome.3

Complications occurred in five women. There was one case of laceration of the external cervical os, which was repaired transvaginally. Four women suffered postabortion haemorrhage (>500 ml estimated blood loss). Two of these cases were due to uterine atony, which in both cases was managed with uterotonics and an obstetric balloon.Two cases of haemorrhage were due to morbidly adherent placenta (MAP). In both cases of MAP this condition was suspected pre-operatively: both patients had a history of multiple previous caesarean sections and low anterior placentas, with ultrasound features suspicious for MAP. Both patients were counseled regarding the increased risk of complications and hysterectomy. Both cases resulted in uncomplicated emergency hysterectomy immediately after D&E, and subsequent histology confirmed a diagnosis of placenta accreta.

82% of the patients were treated as day cases and were discharged on the day of abortion. In addition to the cases in which surgical complications necessitated a hospital stay, the remainder of the postoperative admissions were for monitoring of the comorbid condition which led to their referral. 66% of women started contraception immediately after their abortion.