How health services can improve access to abortion

Previous editorials have dealt with unsafe abortion in Africa1 and the law in Spain2. This editorial will confine itself to factors within health services that affect access to abortion in high-income countries. Factors that either obstruct or facilitate access to abortion in such countries have recently been reviewed3.

The quality of the health services of the country in which a woman resides will affect her access, both generally and more specifically, to abortion services. Health ministries often fail to take a lead in abortion care. Where there is not enough confidence in how the law should be interpreted, there may be unnecessary restrictions, as is the case in Northern Ireland4. World Health Organization (WHO) guidance recommends that policy-makers and health care managers should ensure that safe abortion is readily accessible and available to the full extent of the law5. Abortions are already being provided by general practitioners (GPs) in countries such as France, Switzerland and the Netherlands; WHO supports more abortion care at primary care level.

Information on local abortion services should be widely available on websites, in telephone directories, in public libraries, in pharmacies and in GP premises. A system of direct access (self-referral) to abortion services avoids any delays associated with the need for referral. Central booking systems have been shown to facilitate access6.

In many countries fees are charged for abortion7. Some countries subsidise abortions performed for medical reasons, rape and in the case of minors. In the USA, under the Hyde Amendment, 32 out of the 50 states do not provide Medicaid funding for abortion, and federal funding is prohibited8. For individuals without health insurance in systems in which charges for health care apply, an abortion may be simply unaffordable. In other countries abortion procedures are free, although there may be some charges for hospital stay and investigations. More needs to be done to assist women in countries that charge fees for abortion which cannot be reimbursed. Where fees are charged for abortion, such fees should be matched to women’s ability to pay, and procedures should be developed for exempting the poor and adolescents from paying for services5. As far as possible, abortion services should be mandated for coverage under insurance plans. The barrier of high costs to women is likely to generate much higher costs for the health system, by increasing the number of women who attempt to self-induce abortion or go to unsafe providers and, as a result, require hospitalisation for serious complications5.

Depending on whether a referral is needed by the provider, the responsiveness of health services generally to booking appointments can affect a woman’s pathway to the appropriate provider. The need for a referral from a GP can cause a delay if that doctor has a negative attitude or is a conscientious objector. About one-quarter of GPs do not refer women for abortions9^,10. Professional guidelines on maximum acceptable waiting times between referral and assessment11,12 and assessment and treatment12 will tend to be incorporated into local service delivery and should be encouraged.

There may or may not be a choice of provider. Some individuals may prefer not to go to a hospital. Choice is a highly valued element of services by women13.

Negative staff attitudes and imposition of artificial requirements such as gestational limits will tend to deter women seeking abortion3. Unregulated conscientious objection results in high conscientious objection prevalence areas where abortions are hard to access14. The system operated in Norway is the best example of how conscientious objection can be overseen to ensure proper service delivery in all regions of the country. Regulations on conscientious objection ensure that all conscientious objectors are known about and that local providers have enough non-objectors to ensure the availability of adequate services14.

Availability of abortion depends on adequate equipment; adequate availability of theatre time for surgical procedures¹⁵; necessary drugs being licensed for use; and trained, experienced health personnel. Furthermore, for surgical abortion in the second trimester, access to abortion depends on doctors having the necessary skills, which can become a problem unless younger doctors have the motivation and training to acquire these skills15. Abortion care is not usually integrated into doctors’ residency programmes16.

Insistence on all women having an ultrasound scan can limit availability of services. WHO policy is that ultrasound scanning is not routinely required for the provision of abortion5. This should be kept in mind in the organisation of abortion services particularly in more rural areas17.

In some countries there is no access to mifepristone. This limits what can be offered in primary care and greatly reduces choice for women. Mifepristone should be included on national essential drugs lists. Ideally, mifepristone should be licensed, but it is acknowledged that in smaller countries there is a lack of economic viability for pharmaceutical companies to market a drug where profits will be small. However, some countries allow importation through the WHO Certification Scheme on the Quality of Pharmaceutical Products Moving in International Commerce5.

In some countries, Catholic hospitals are permitted to refuse to offer abortion services. In the USA, Catholic-sponsored health care companies are gradually taking over non-Catholic hospitals; one in nine beds is now in a Catholic hospital system18. A solution to this problem needs political will.

Providers tend to be concentrated in more urban areas. This means that those living in rural areas may have to travel long distances for their care. Examples are the more remote parts of Australia, Canada and New Zealand³; for instance, abortion is unobtainable in the Canadian province of Prince Edward Island. Young women, indigenous women and women on low incomes are disproportionately affected. To ensure adequate care for women living in rural areas, telemedicine and task sharing are two ways of facilitating delivery of care nearer to the woman’s home. Two types of telemedicine are in operation. The first is a full medical consultation by remote communication with the patient19^,20. The second is an internet-based medical screening questionnaire to assess eligibility before sending out pills for medical abortion by post21. The latter is used in high-income countries that have restrictive abortion laws such as the Republic of Ireland as well as in low- and middle-income countries. Two organisations in particular operate internet-based telemedicine services: Women on Web and Women Help Women.

In some high-income countries, health professionals other than doctors are permitted to carry out surgical abortions22. In a Swedish study, women undergoing medical abortion who expressed a preference chose nurse-midwives rather than physicians for their care23. Comparative studies of both medical and surgical abortion have shown no difference in complication rates between women who undergo first trimester abortions performed by mid-level health care providers and those who have the procedure performed by a physician. Task sharing allows women more choice, is highly acceptable and saves money24.

Conclusion

Health ministries ought to facilitate and make explicit precisely what the abortion law allows. Professional societies should write their own abortion guidelines or disseminate international guidelines for the benefit of health care professionals.

Wide dissemination of information about abortion services is needed to allow choice for women. Services should be delivered as close to women’s homes as possible. Where possible, primary care facilities are an ideal setting for first trimester procedures. Special arrangements should be considered for women who live far away from cities or towns.

Care pathways should be mapped out for the whole of a woman’s journey, making it as seamless as possible. Medical and surgical methods of abortion at all legal gestations should be available.

Women should be able to make their own appointments via a centralised booking system. Efforts should be made in countries where women currently pay for abortions to enable exemptions or reimbursement.

Consideration should be given to greater participation in all elements of abortion procedures by staff other than doctors. Conscientious objection by clinical staff should be tightly regulated and monitored.

Declaration of interest

The authors report no conflict of interest. The authors alone are responsible for the content and the writing of the paper.