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Abstract
Background Guidelines from the UK recommend that women should be able to self-refer to abortion services. In 2016, a self-referral system was introduced to the abortion service in Edinburgh, Scotland, as an option for women. Women could telephone a dedicated phone line during office hours and speak to an administrative assistant working in the abortion service who provided them the next available appointment to be seen in the service. This study aimed to evaluate a self-referral service to abortion by investigating its impact on women’s experiences of the referral process.
Methodology 21 semistructured interviews of women attending a specialist abortion service in Edinburgh, Scotland, were conducted. Interviews were transcribed verbatim and thematically analysed. The interviews focused on women’s experience of the referral process.
Results Three main themes arose from the interviews, including reasons for choosing self-referral, experience of self-referral and challenges to using self-referral. Reasons for choosing self-referral were related to convenience, privacy and autonomy. Women found the experience of self-referral to be pleasant, non-judgemental and patient-centred, and self-referral prepared them for the appointment at the specialist abortion service. However, some women felt rushed, and self-referral made them anxious to attend the appointment. Challenges were difficulty with getting through on telephone lines, varying levels of support required for different individuals and awareness about the option of self-referral.
Conclusion Women valued the option of self-referral. Women felt that the service should be expanded to increase availability,and promoted to women more widely within the community .
- abortion
- qualitative research
- service delivery
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Key messages
The necessity to request abortion referral from a healthcare provider creates a barrier for women accessing abortion.
Self-referral was valued by women for its convenience, privacy and autonomy.
Self-referral was able to give a positive impression of the specialised abortion service to women.
Introduction
In Great Britain, most women seeking abortion have been referred to abortion services from their general practitioner (GP).1 2 This can introduce unnecessary delay and distress for women.3–5 In one UK study, up to 56% of women reported having to wait more than 21 days after their first appointment with their referring doctor to have the abortion.1 The earlier the abortion is conducted, the less pain and bleeding there is,6–10 so delays in receiving an appointment with the specialist abortion service reduce the likelihood that the woman can have the abortion at an early gestation.
More worryingly, some surveys have reported that 20%–29% of British GPs identified as being antiabortion, or practised conscientious objection towards abortion.1 11–13 Negative GP attitudes can adversely impact on women’s experiences,1–4 and in some cases, women have reported that deliberate actions were taken by the GP to try and prevent the woman from pursuing abortion.3 4 14
Recent guidelines from the National Institute for Health and Care Excellence recognise the barriers women face to obtain an abortion referrral and recommends that abortion services should provide women with the opportunity to self-refer.15
NHS Lothian (Edinburgh and surrounding region) operates a centralised referral service for abortion: Lothian Centralised Abortion Referral Service (LARS). This was first introduced in 1988 as a central service that GPs in the region could contact in order to receive the next available appointment for their patient to be seen in the specialist abortion service in NHS Lothian.16
In 2016, LARS introduced the option of self-referral, where women could telephone LARS directly from Monday to Friday 09:00–15:00 to book an appointment. During the phone call, the women would have some details taken, given the next available appointment and directed to the clinic website with information about the clinic visit and abortion process. This option was promoted using posters displayed in GP surgeries, pharmacies and sexual health clinics throughout the region. The information was included in relevant NHS web pages and circulated to GPs in the region.
This study aimed to evaluate the self-referral service by exploring the experiences of women using the service. Specifically, the reasons for choosing self-referral, the impact of using self-referral on the women’s experiences leading up to abortion, challenges to using self-referral and any areas of improvement in the self-referral service were explored. A qualitative design was used in order to fully explore the women’s perspective.
Methods
Semistructured interviews were conducted between January and March 2019, facilitated by a topic guide (online supplementary figure 1). Participants were women presenting for abortion at the main abortion service in NHS Lothian at Chalmers Centre.17 In order to be eligible to participate, women had to be at least 16 years old and should not require an interpreter. Participants recruited using convenience sampling were a mixture of women who self-referred and via other routes to the service. Women who did not self-refer were also included to garner the views of women who chose not to self-refer, or who did not know about self-referral. Eligible patients, identified by the reception staff, were given a study information sheet when they registered for their appointment. Women who agreed to participate could choose to be interviewed during the wait for their consultation with the clinician or to be interviewed at a later date.
Supplemental material
All interviews were conducted by a single researcher, STL, and took place in a private interview room at the clinic. All but one participant was interviewed before the consultation. Participants signed a consent form. Audio recordings were transcribed verbatim within a week. No identifying information were included. All data were kept in a password-protected computer.
Steps for data analysis were adapted from Mason.18 After interviews were completed, familiarisation with the data was carried out, and possible codes were generated. Then, transcripts were coded manually; key themes were identified; and similar subthemes clustered together. Finally, data were interpreted according to each theme.
Patient public involvement
This student project did not involve patient or public involvement in the design or recruitment. Feedback from initial interviews were useful in refining the interview guide. The summary of the study will be made available in the abortion service waiting area.
Results
Twenty-one women were interviewed. Seventeen had self-referred and four had referred from another healthcare provider (HCP). Details about participants’ age and method of referral are shown in table 1. The mean age of the participants was 25 years (range 19–40 years old).
Age and method of referral of participants
The interviews explored three key areas: reasons for choosing self-referral, experience of self-referral and challenges to using self-referral. Participants who did not self-refer were asked about their experience of referral by an HCP and what they thought about self-referral.
Reasons for choosing self-referral
Women were asked why they chose their method of referral. Broadly, women who self-referred spoke about convenience, privacy and autonomy.
Convenience
Women who self-referred generally preferred the quick nature of self-referral and being able to bypass perceived long waiting times for GP appointments. One woman was living outside the UK when she discovered that she was pregnant, and self-referral facilitated access to the service.
I think in terms of something like this - the easier the better…it was just so good and reassuring to go straight to the service rather than detour around…. SR9
Three of the four non-self-referral participants (NSRs) said they would have preferred self-referral to ‘save everyone’s time’.
Privacy
Many participants appreciated the discreet nature of self-referral, which meant they only had to divulge the pregnancy to as few people as possible. They did not see the point of involving a ‘middle man’ and liked that self-referral saved them from having to ‘explain it to a doctor’.
…it isn’t something I want a lot of people to know about, so the fewer people I can tell the better. SR17
One NSR said she would have appreciated self-referral as she ‘felt judged going to the GP’. Other participants, both SRs and NSRs, commented how helpful the confidential nature of self-referral can be for abortion, a topic that is still taboo, especially for women who find it uncomfortable and women in difficult or in abusive situations.
…sometimes it can be a bit of an uncomfortable subject, and yeah, (it) made it easier. SR8
Autonomy
Women appreciated the independence self-referral gave them to make the referral and decisions ‘in the comfort of your own home’. One participant felt strongly about maintaining her autonomy regarding her own health.
… it was nice to be able to just pick up the phone and say I want to do this, know that I would have medical discussions when I got there but not have to be persuading doctors and explaining myself and explaining myself before I got there. SR14
Women also thought it was better for them to make the referral as they understood their situation best, rather than a doctor.
I think it's a very sensitive issue, and I think it's only something that you can understand yourself. I think that if all the information is there… you can work through everything and decide if you want to self-refer - you're not going to self-refer yourself if you don't want to. SR11
Experience of self-referral
Women who self-referred were asked to describe their experience of the process, as well as to point out any positive aspects or negative aspects of the service. The majority of participants (14 of 17) had an overall positive experience of self-referral, while the rest (3 of 17) felt negatively. Positive and negative aspects are summarised as follows, with quotes in table 2.
Quotes from women describing positive and negative aspects of their experience of self-referral
Positive aspects
Participants described having a pleasant phone call. It helped normalise the situation for some participants, with one participant saying that it ‘made it seem like a good choice’. One participant appreciated that it was a woman on the phone, saying that the gender of the receptionist would have affected the conversation. The phone call was commonly described as straightforward but helpful. Participants expected a similar environment at the clinic, including the ‘level of professionalism’ over the phone, which helped them feel more comfortable and confident about attending the appointment.
Many participants expressed anxiety about making the phone call and about the whole situation in general. Nine women who were self-referral participants (SRs) found the phone call reassuring due the ‘calm’ or ‘relaxed’ nature of the administrative assistant, having their questions answered, as well as just the fact that they had made the referral. Three participants appreciated that the administrative assistant proactively helped calm them by talking them through the process or by subsequently seeking a nurse to speak to the woman.
Participants appreciated not being questioned on their decisions. One NSR felt ‘judged going to the GP’, and one SR said she feels her GP ‘might have influenced me in other ways’. The process of self-referral was described as ‘non-judgemental’.
Many participants described how the patient-centred nature of the phone call made a positive impact. They appreciated feeling like the referral focused on their needs when it came to appointment options, preparation for the appointment and their feelings.
Four SRs felt satisfied with the amount of information received on the phone, which helped them feel more prepared mentally and practically. Participants generally felt supported after self-referral. There was a feeling of trust towards the abortion service.
Negative aspects
In contrast, three SRs perceived a lack of empathy over the phone. One participant thought the phone call was ‘harsh’ and ‘cold’, while others felt rushed. They had unanswered questions, and in contrast, one participant felt overwhelmed by the information she received. Two participants felt like their experience made them anxious to attend their appointment.
Challenges to using self-referral
Throughout the interviews, challenges to using self-referral were identified from the women’s experiences. These were the phone line, varying levels of support required by different individuals and finding out about self-referral. Some participants gave suggestions to improve the service and discussed what barriers may be faced by others seeking abortion.
Phone line
Seven SRs found the phone line difficult to get through. Some mentioned how it was inconvenient, or impossible to call during work. Two of the four NSRs opted for GP or a family planning clinic referral as they felt anxious after not being able to get through.
Varying levels of support required by different individuals
Some women felt dissatisfied with relying on online resources and thought it was too long to wait before speaking to someone face-to-face. Two participants also preferred having someone else help them make the referral. Some participants were directed to self-referral from their GP surgery without being offered the option for a GP referral.
In terms of information, some participants wanted more details, while some preferred being given resources to read through in their own time.
…I kind of preferred to do my own research, like if they guide me to where to go, so that was quite good. SR4
I don't want to go online and read bibles of information… I don't have time to sit and go through everything to do with patient leaflets. SR1
Finding out about self-referral
Participants felt it was important to increase awareness about self-referral. Ten participants had not seen posters in their GP surgery; 3 thought they might have seen posters or leaflets; while only 1 was sure that she had. Participants found out about self-referral via the internet or were signposted to it from other healthcare services.
Some participants felt very positively about posters being put up in more public spaces, believing it could have a good impact by normalising abortion, reassuring people and increasing awareness about the different options available. One participant was sceptical about how other people would receive this, saying she would prefer it if they were promoted more discreetly.
I don't think you see it as often enough as you should… if anything you should get it …more shown, so people know that they've got the option and what to do. SR15
I don't know how well people will take the advertisements, so I think it’s more like discreet, which is always what you want. I don’t think - even I wouldn’t like to see like this big posters like in your GP. SR6
Discussion
Analysis of the interviews revealed that women choose self-referral for reasons relating to convenience, privacy and autonomy. The majority of women had an overall positive experience of self-referral, with a minority reporting a negative experience. Positive aspects included the phone call itself being pleasant and reassuring, non-judgemental and patient-centred, and gave women positive expectations for the subsequent appointment, as well as feeling supported and prepared. The reported negative aspects included a perception of lack of empathy from a receptionist on the phone, women feeling ‘rushed’ during the phone call and when the call gave them a negative impression of the service. Three challenges to using self-referral were identified: a busy phone line, varying levels of support required by different individuals and awareness of the self-referral option.
Other UK studies confirmed the need for and value of self-referral as an option. Consistent with our findings, qualitative studies report women’s preference for a quick and straightforward referral,2 4 which is not the case if they consult an HCP who does not directly refer them at their request. Studies show that privacy is important to some women but is sometimes made difficult for women who have to make arrangements at work or for childcare to attend appointments, or women living in small communities.3 5 Women’s experiences of HCPs undermining women’s decisions are common.3 4 Women seeking abortion approach the health service for information and support,4 or a space to talk through inner conflicts and reflect,19 rather than influence on their decision-making. This is in line with WHO guidance on provision of safe abortion to respect women’s informed and voluntary decision-making and autonomy.20
The majority of SRs in this study described a positive experience of their self-referral phone call, with a minority who felt rushed during the referral and required more support. In comparison, other UK qualitative data report participants feeling unsupported and judged during their GP appointment, as well as feeling distressed between referral and appointment.1–4 This could be further elevated for people in dangerous situations of domestic abuse or for women with relevant mental illnesses.5
Expansion of phone-based self-referral service inevitably leads to a busy telephone line on occasions. It would be difficult to predict how many women abandon the option of self-referral, or how much it would impact or delay their process of seeking abortion. If staff are busy, then the phone call could also come across as rushed. A solution would be to have more staff or phone lines and extending the opening of the phone line. However, this will inevitably have cost implications for a service.
Alternative routes of self-referral could also be offered, for example, an online booking system with clear information and directions to appropriate resources. However, given many participants appreciated being able to speak to someone and the reassuring nature of the phone call, it is likely that phone referral will remain a popular option. Some participants preferred face-to-face interactions or to have been referred by an HCP. Thus, the option for a GP or a local family planning clinic referral should be maintained with other options for referral made available.
A qualitative study in England highlighted challenges faced by patients during their process of referral, noting that, although self-referral was available in that area, it was not known by HCPs and the general public.4 Indeed, word of mouth via healthcare settings has proven helpful as many participants were informed about self-referral through their GP surgery.
Most participants in this study found out about self-referral via the internet, suggesting the value of the internet as an important facilitator to accessing safe abortion. Promotion of self-referral should then target people who would not routinely rely on the internet for information.
No participants mentioned gaining information about self-referral through posters. This might suggest a suboptimal impact of the poster campaign. Nevertheless, having posters in public spaces could help destigmatise abortion in the general public, as mentioned by some participants. Promotion in public transport or social media can reach a significant proportion of the population. Places such as commercial settings where people buy pregnancy tests can also be considered to increase the chances of those needing the service being informed.
This study is one of few studies evaluating a self-referral system for abortion. Use of semistructured interviews allowed us to explore the participants’ experiences in more depth, and most participants were interviewed on the day of their clinic appointment, which minimised recall bias.
Weaknesses of the study include that it was conducted in a single centre and so may not be representative of self-referral processes elsewhere. In addition, self-selection bias among participants was possible. Young women under the age of 16, and those requiring an interpreter were excluded.
Conclusion
Women choosing abortion considered self-referral to be a valuable option and capable of providing a positive experience of the referral process. The availability of self referral for abortion should be promoted further throughout the UK.
Acknowledgments
The authors thank the CHOICES team at Chalmer’s Centre, Edinburgh, and all participants who contributed to the research project.
References
Footnotes
Contributors STL designed and carried out interviews, transcribed and analysed the data, and drafted and revised the paper. ZEC designed the interviews and revised the paper. SC initiated the project and revised the paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Ethics approval This study was considered a health service evaluation and did not require NHS ethical approval under advice sought from the Scientific Officer of South East Scotland NHS Research Ethics Committee. Management approval was gained from the local NHS Quality Improvement Team.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data sharing not applicable as no datasets generated and/or analysed for this study. No data are available. No data are available.