Recommendations

Women have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Note that mifepristone and misoprostol do not have UK marketing authorisations for most of the uses recommended in this guideline. When an unlicensed use is recommended, this is highlighted with a footnote in the recommendation.

Abortion Act 1967

Abortion in England, Scotland and Wales is primarily regulated by the Abortion Act 1967 (as amended by the Human Fertilisation and Embryology Act 1990) and regulations made under that Act – currently the Abortion Regulations 1991 (SI 1991/499). The Abortion Act regulates when and where abortions can take place lawfully.

In May 2014, the Department of Health issued guidance in relation to requirements of the Abortion Act 1967. This guidance is intended for those responsible for commissioning, providing and managing the provision of abortion services to help them comply with the Abortion Act. Also in May 2014, the Department published procedures for the approval of independent sector places for the termination of pregnancy. Further government guidance has recently been issued in the form of letters from the Chief Medical Officer.

Providers of abortion services must comply with the Health and Social Care Act 2008 and regulations made under that Act. In particular, providers must register with the Care Quality Commission (CQC). This is because under section 10 of the Health and Social Care Act 2008, it is an offence to carry out a regulated activity without being registered with the CQC, and abortion is a 'regulated activity' under Regulation 3 and Schedule 1 (paragraph 11) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). The CQC imposes specific requirements on providers that are not English NHS bodies (see regulation 20 of the Care Quality Commission (Registration) Regulations 2009).

Additional relevant guidance:

This NICE guideline makes evidence-based recommendations on how to organise services and on how to conduct abortions within the legal framework set out by the Abortion Act 1967. It does not repeat things already covered by the legislation, Department of Health and Social Care guidance or other statutory regulations, and practitioners should therefore ensure they are adhering to all other applicable requirements when using this guideline.

Consent and Montgomery

Healthcare professionals should ensure that women have the information they need to make decisions and to give consent in line with General Medical Council guidance and the 2015 Montgomery ruling.

Gender

This guideline makes recommendations for women and people who are pregnant. For simplicity of language the guideline uses the term women throughout, but this should be taken to also include people who do not identify as women but who are pregnant.

1.1 Service organisation

Making it easier to access services

1.1.1 Commissioners and providers should work together to:

  • make information about abortion services (including how to access them) widely available

  • ensure that women are promptly referred onwards if a service cannot provide an abortion after a specific gestational age or by the woman's preferred method

  • avoid the need for women to repeat key steps (such as returning to their GP for referral, or repeated assessments or investigations).

1.1.2 Commissioners and providers should allow women to self-refer to abortion services.

1.1.3 Healthcare professionals should not allow their personal beliefs to delay access to abortion services.

1.1.4 Commissioners should consider upfront funding for travel and accommodation for women who:

  • are eligible for the NHS Healthcare Travel Costs Scheme and/or

  • need to travel to a service that is not available locally.

    Commissioners should make information available about any upfront funding to access services.

Waiting times

1.1.5 Commissioners should work with providers to ensure abortion services have the capacity and resources to deliver the range of services needed with minimal delay.

1.1.6 Ensure minimal delay in the abortion process, and ideally:

  • provide the assessment within 1 week of the request

  • provide the abortion within 1 week of the assessment.

1.1.7 For women who would prefer to wait longer for an abortion, help them to make an informed decision by explaining the implications, including:

  • the legal limit for abortions, as stated in the Abortion Act

  • that delaying the abortion will increase the risk of complications, although the overall risk is low.

1.1.8 Do not require women to have compulsory counselling or compulsory time for reflection before the abortion. Provide or refer women for support to make a decision if they request this.

Location of services

1.1.9 Consider providing abortion assessments by phone or video call, for women who prefer this.

1.1.10 Consider providing abortion services in a range of settings (including in the community and in hospitals), to meet the needs of the local population.

Workforce and training

1.1.11 Abortion providers should maximise the role of nurses and midwives in providing care.

1.1.12 Trainee healthcare professionals and students who may care for women who request an abortion (for example nurses, midwives, and GPs) should have the chance to gain experience in abortion services during their training.

1.1.13 For specialities that include training in abortion as part of the core curriculum:

  • ensure all trainees have the training, unless they opt out due to a conscientious objection

  • include practical experience of abortion services and procedures in the curriculum.

1.1.14 If a trainee's placement service does not provide abortions, the trainee should gain experience with whoever is providing this service (either in the NHS or in the independent sector).

Complex comorbidities

1.1.15 Specialist centres should be available as locally as possible, to reduce delays and travel times for women with complex needs or significant comorbidities.

1.1.16 Providers should develop pathways for women with complex needs or significant comorbidities to:

  • refer them to specialist centres if needed

  • minimise delays in accessing care.

Avoiding stigma

1.1.17 When caring for women who are having an abortion, be aware of:

  • the anxiety they may have about perceived negative and judgemental attitudes from healthcare professionals

  • the impact that verbal and non-verbal communication may have on them.

1.1.18 Services should be sensitive to the concerns women have about their privacy and confidentiality, including their concerns that information about the abortion might be shared with healthcare professionals not directly involved in their care.

To find out why the committee made the recommendations on service organisation and how they might affect services, see rationale and impact.

1.2 Providing information

1.2.1 Reassure women that having an abortion is not associated with increased risk of infertility, breast cancer or mental health issues.

1.2.2 Provide information about the differences between medical and surgical abortion (including the benefits and risks), taking account of the woman's needs and preferences. Do this without being directive, so that women can make their own choice. See the NICE patient decision aids to help support these decisions.

1.2.3 As early as possible, provide women with detailed information to help them prepare for the abortion. Cover:

  • what it involves and what happens afterwards

  • how much pain and bleeding to expect.

1.2.4 Provide information in a range of formats, for example video or written information. Include information based on the experiences of women who have had an abortion.

1.2.5 For more guidance on providing information and helping women to make decisions about their care, see the NICE guideline on patient experience in adult NHS services.

1.2.6 Ask women if they want information on contraception, and if so provide information about the options available to them (see improving access to contraception).

1.2.7 For women who are having a medical abortion, explain:

  • that they may see the products of pregnancy as they are passed

  • what the products of pregnancy will look like and whether there may be any movement.

1.2.8 For women who are having a medical abortion at home, explain how to be sure that the pregnancy has ended (see follow-up after medical abortion up to and including 10+0 weeks).

1.2.9 Provide women with information on signs and symptoms that indicate they need medical help after an abortion, and who to contact if they do.

1.2.10 Provide women with information about the different options for management and disposal of pregnancy remains.

Information for women who are having an abortion because of fetal anomaly

1.2.11 If a woman who is having an abortion for fetal anomaly cannot have her preferred method of abortion in the maternity service, establish a clear referral pathway with ongoing communication between services so that she can:

  • easily transfer to the abortion service

  • receive ongoing support from the maternity service

  • get more information about the anomaly.

1.2.12 Explain to women that there may not be any physical signs of a fetal anomaly.

To find out why the committee made the recommendations on providing information and how they might affect practice, see rationale and impact.

1.3 Anti-D prophylaxis

1.3.1 Offer anti-D prophylaxis to women who are rhesus D negative and are having an abortion after 10+0 weeks' gestation.

1.3.2 Do not offer anti-D prophylaxis to women who are having a medical abortion up to and including 10+0 weeks' gestation.

1.3.3 Consider anti-D prophylaxis for women who are rhesus D negative and are having a surgical abortion up to and including 10+0 weeks' gestation.

1.3.4 Providers should ensure that:

  • rhesus status testing and anti-D prophylaxis supply does not cause any delays to women having an abortion

  • anti-D prophylaxis is available at the time of the abortion.

To find out why the committee made the recommendations on anti-D prophylaxis and how they might affect practice, see rationale and impact.

1.4 Preventing infection

1.4.1 For guidance on testing for sexually transmitted infections for women who are having an abortion, see the NICE guideline on preventing sexually transmitted infections and under-18 conceptions.

1.4.2 Do not routinely offer antibiotic prophylaxis to women who are having a medical abortion.

1.4.3 Offer antibiotic prophylaxis to women who are having surgical abortion.

1.4.4 When using doxycycline for antibiotic prophylaxis in medical or surgical abortion, consider oral doxycycline 100 mg twice a day for 3 days.

1.4.5 When using metronidazole for antibiotic prophylaxis in medical or surgical abortion, do not routinely offer it in combination with another broad-spectrum antibiotic such as doxycycline.

To find out why the committee made the recommendations on preventing infection and how they might affect practice, see rationale and impact.

1.5 Venous thromboembolism prophylaxis

1.5.1 For women who need pharmacological thromboprophylaxis, consider low‑molecular‑weight heparin for at least 7 days after the abortion.

1.5.2 For women who are at high risk of thrombosis, consider starting low‑molecular‑weight heparin before the abortion and giving it for longer afterwards.

To find out why the committee made the recommendations on venous thromboembolism prophylaxis and how they might affect practice, see rationale and impact.

1.6 Choice of procedure for abortion

1.6.1 Offer a choice between medical or surgical abortion up to and including 23+6 weeks' gestation[1]. If any methods would not be clinically appropriate, explain why.

1.6.2 To help women decide between medical and surgical abortion, see the NICE patient decision aids on choosing medical or surgical abortion.

To find out why the committee made the recommendations on the choice of procedure for abortion and how they might affect practice, see rationale and impact.

1.7 Abortion before definitive ultrasound evidence of an intrauterine pregnancy

1.7.1 Consider abortion before there is definitive ultrasound evidence of an intrauterine pregnancy (a yolk sac) for women who do not have signs or symptoms of an ectopic pregnancy.

1.7.2 For women who are having an abortion before there is definitive ultrasound evidence of an intrauterine pregnancy (a yolk sac):

  • explain that there is a small chance of an ectopic pregnancy

  • explain that they may need to have follow-up appointments to ensure the pregnancy has been terminated and to monitor for ectopic pregnancy

  • provide 24‑hour emergency contact details, and advise them to get in contact immediately if they develop symptoms that could indicate an ectopic pregnancy (see symptoms and signs of ectopic pregnancy and initial assessment in the NICE guideline on ectopic pregnancy and miscarriage).

To find out why the committee made the recommendations on abortion before definitive ultrasound evidence of an intrauterine pregnancy and how they might affect practice, see rationale and impact.

1.8 Expulsion at home for medical abortion up to and including 10+0 weeks

Up to and including 9+6 weeks' gestation

1.8.1 For women who are having a medical abortion and will be taking the mifepristone up to and including 9+6 weeks' gestation, offer the option of expulsion at home after they have taken the misoprostol. Misoprostol can be taken at home or in the clinic or hospital[2].

At 10+0 weeks' gestation

1.8.2 For women who are having a medical abortion and will be taking the mifepristone at 10+0 weeks' gestation, offer the option of expulsion at home after they have taken the misoprostol. Misoprostol can be taken in the clinic or hospital[2].

To find out why the committee made the recommendations on expulsion at home for medical abortion up to and including 10+0 weeks and how they might affect practice, see rationale and impact.

1.9 Medical abortion up to and including 10+0 weeks

1.9.1 Offer interval treatment (usually 24 to 48 hours) with mifepristone[3] and misoprostol[4] to women who are having a medical abortion up to and including 10+0 weeks' gestation.

1.9.2 For women who are having a medical abortion up to and including 9+0 weeks' gestation, give them the choice of having mifepristone[3] and vaginal misoprostol[4] at the same time, but explain that:

  • the risk of ongoing pregnancy may be higher, and it may increase with gestation

  • it may take longer for the bleeding and pain to start

  • it is important for them to complete the same follow-up programme that is recommended for all medical abortions up to and including 10+0 weeks (recommendations 1.14.1 and 1.14.2).

To find out why the committee made the recommendations on the interval between mifepristone and misoprostol for medical abortion up to and including 10+0 weeks and how they might affect practice, see rationale and impact.

1.10 Medical abortion between 10+1 and 23+6 weeks

1.10.1 For women who are having a medical abortion between 10+1 and 23+6 weeks' gestation and who have taken 200 mg mifepristone, offer an initial dose (36 to 48 hours after the mifepristone) of:

  • 800 micrograms misoprostol[4], given vaginally, or

  • 600 micrograms of misoprostol[4], given sublingually, for women who decline vaginal misoprostol.

    Follow the initial dose with 400 microgram doses of misoprostol[4] (vaginal, sublingual or buccal), given every 3 hours until expulsion.

1.10.2 Use a shorter interval between mifepristone[3] and misoprostol[4] if the woman prefers this, but explain that it may take a longer time from taking the first misoprostol dose to complete the abortion.

To find out why the committee made the recommendations on medical abortion between 10+1 and 23+6 weeks and how they might affect practice, see rationale and impact.

1.11 Medical abortion after 23+6 weeks

1.11.1 For women who are having a medical abortion between 24+0 and 25+0 weeks' gestation, consider 200 mg oral mifepristone[3], followed by 400 micrograms misoprostol[4] (vaginal, buccal or sublingual) every 3 hours until delivery.

1.11.2 For women who are having a medical abortion between 25+1 and 28+0 weeks' gestation, consider 200 mg oral mifepristone[3], followed by 200 micrograms misoprostol[4] (vaginal, buccal or sublingual) every 4 hours until delivery.

1.11.3 For women who are having a medical abortion after 28+0 weeks' gestation, consider 200 mg oral mifepristone[3], followed by 100 micrograms misoprostol[4] (vaginal, buccal or sublingual) every 6 hours until delivery.

1.11.4 Be aware that:

  • the uterus is more sensitive to misoprostol as pregnancy advances

  • risk factors for uterine rupture include a pre-existing uterine scar, increased gestational age and multiparity.

To find out why the committee made the recommendations on medical abortion after 23+6 weeks and how they might affect practice, see rationale and impact.

1.12 Cervical priming before surgical abortion

Up to and including 13+6 weeks

1.12.1 For women who are having a surgical abortion up to and including 13+6 weeks' gestation, offer cervical priming with:

  • 400 micrograms sublingual misoprostol[4], given 1 hour before the abortion or

  • 400 micrograms vaginal misoprostol[4], given 3 hours before the abortion.

    If misoprostol cannot be used, consider cervical priming with 200 mg oral mifepristone[3], given 24 to 48 hours before the abortion.

1.12.2 Explain to women that cervical priming:

  • reduces the risk of incomplete abortion for women who are parous

  • makes dilation easier for women who are parous or nulliparous

  • may cause bleeding and pain before the procedure.

Between 14+0 and 23+6 weeks

1.12.3 For women who are having a surgical abortion between 14+0 and 23+6 weeks' gestation, offer cervical priming.

1.12.4 For women who are having a surgical abortion between 14+0 and 16+0 weeks' gestation, consider:

  • osmotic dilators or

  • buccal, vaginal or sublingual misoprostol[4]or

  • 200 mg oral mifepristone[3], given the day before the abortion.

1.12.5 For women who are having a surgical abortion between 16+1 and 19+0 weeks' gestation, consider:

  • osmotic dilators or

  • buccal, vaginal or sublingual misoprostol[4].

1.12.6 For women who are having a surgical abortion between 19+1 and 23+6 weeks' gestation, offer osmotic dilators. In addition, consider:

  • 200 mg oral mifepristone[3] the day before the abortion and

  • inserting osmotic dilators at the same time as the mifepristone.

1.12.7 For women who are having a surgical abortion between 14+0 and 23+6 weeks' gestation and are having cervical priming with osmotic dilators, consider inserting the osmotic dilators the day before the abortion.

1.12.8 Do not offer misoprostol for cervical priming if the woman has had an osmotic dilator inserted the day before the abortion.

To find out why the committee made the recommendations on cervical priming before surgical abortion and how they might affect practice, see rationale and impact.

1.13 Anaesthesia and sedation for surgical abortion

1.13.1 For women who are having surgical abortion, consider local anaesthesia alone, conscious sedation with local anaesthesia, deep sedation or general anaesthesia. To help women make an informed choice, discuss the options with them and explain that:

  • having local anaesthesia alone means they will be able to spend less time in hospital

  • intravenous sedation plus local anaesthesia will help if they are anxious about the procedure

  • with deep sedation or general anaesthesia they will not usually be aware during the procedure.

1.13.2 When using conscious sedation for a surgical abortion, use intravenous rather than oral sedation.

1.13.3 When using general anaesthesia for a surgical abortion, consider intravenous propofol and a short-acting opioid (such as fentanyl) rather than inhalational anaesthesia.

To find out why the committee made the recommendations on anaesthesia and sedation for surgical abortion and how they might affect practice, see rationale and impact.

1.14 Follow-up and support after an abortion

Follow-up after medical abortion up to and including 10+0 weeks

1.14.1 For women who have had a medical abortion up to and including 10+0 weeks' gestation with expulsion at home, offer the choice of self-assessment, including remote assessment (for example telephone or text messaging), as an alternative to clinic follow-up.

1.14.2 Provide women with a low-sensitivity or multi-level urine pregnancy test to exclude an ongoing pregnancy.

Support after an abortion

1.14.3 Explain to women:

  • what aftercare and follow-up to expect

  • what to do if they have any problems after the abortion, including how to get help out of hours

  • that it is common to feel a range of emotions after the abortion.

1.14.4 Advise women to seek support if they need it, and how to access it (if relevant). This could include:

  • support from family and friends or pastoral support

  • peer support, or support groups for women who have had an abortion

  • counselling or psychological interventions.

1.14.5 Providers should be able to provide emotional support after abortions. They should tell women this support is available if they need it.

1.14.6 Providers should provide or refer women for counselling if requested.

To find out why the committee made the recommendations on follow-up and support after an abortion and how they might affect practice, see rationale and impact.

1.15 Improving access to contraception

1.15.1 Commissioners and providers should ensure that the full range of reversible contraceptive options (depot medroxyprogesterone acetate [DMPA], contraceptive implant, intrauterine methods, oral contraceptives, contraceptive patches, vaginal rings or barrier contraception) is available for women on the same day as their surgical or medical abortion.

1.15.2 Providers should ensure that healthcare professionals have the knowledge and skills to provide all contraceptive options.

1.15.3 Providers should ensure they can provide the contraceptive implant, and that women who choose this method are offered it on:

  • the day of the surgical abortion or

  • the day they take mifepristone (for medical abortions).

1.15.4 Providers should ensure they can provide intrauterine methods of contraception, and that women who choose this method are offered this:

  • at the same time as the surgical abortion or

  • as soon as possible after expulsion of the pregnancy (for medical abortions).

1.15.5 For women who are having a medical abortion and who choose DMPA intramuscular injection for contraception:

  • consider providing it at the same appointment when they take the mifepristone

  • explain that having the injection at this stage may increase the risk of ongoing pregnancy, although overall the risk is low.

To find out why the committee made the recommendations on contraception after abortion and how they might affect practice, see rationale and impact.

Terms used in this guideline

Fetal anomaly

Defined as pregnancies falling within section 1(1)(d) of the 1967 Abortion Act. This covers pregnancies where 2 medical practitioners are of the opinion that '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'. This is referred to as ground E in the HSA1 form.

Feticide

Feticide is the injection of digoxin or potassium chloride into the fetus, or an injection of digoxin into the amniotic cavity, to stop the fetal heart before an abortion.



[1] Surgical abortion can be performed shortly after 23+6 weeks' gestation only if feticide is given at or before 23+6 weeks' gestation, according to the 2019 clarification of the time limits in the Abortion Act.

[2] This recommendation is based on the evidence for the safety of home expulsion. The legal limit for the gestational age at which misoprostol can be taken at home is specified in the Secretary of State's approval order of December 2018.

[3] At the time of publication (September 2019) mifepristone for abortion only has a UK marketing authorisation for:

600 mg orally for medical abortion of developing intrauterine pregnancy, followed 36–48 hours later by 400 micrograms misoprostol orally or 1 mg gemeprost vaginally, up to and including 49 days of amenorrhoea

600 mg orally for medical abortion of developing intrauterine pregnancy, followed 36–48 hours later by 1 mg gemeprost vaginally, between 50 days' and 63 days of amenorrhoea

200 mg orally for medical abortion of developing intrauterine pregnancy, followed 36–48 hours later by 1 mg gemeprost vaginally, between 50 days' and 63 days of amenorrhoea

200 mg orally for medical abortion of developing intrauterine pregnancy, followed 36–48 hours later by 800 micrograms misoprostol vaginally, up to and including 63 days of amenorrhoea

600 mg orally for medical abortion for medical reasons, followed 36–48 hours later by prostaglandin administration, beyond the first trimester

200 mg orally for cervical priming, 36–48 hours before first trimester surgical abortion.

All other uses of mifepristone are unlicensed. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

[4] At the time of publication (September 2019), misoprostol for medical abortion only has a UK marketing authorisation for:

400 micrograms orally as an initial dose for medical abortion of developing intrauterine pregnancy, 36–48 hours after 600 mg mifepristone orally, up to and including 49 days of amenorrhoea

800 micrograms vaginally as an initial dose for medical abortion of developing intrauterine pregnancy, 36–48 hours after 200 mg mifepristone orally, up to and including 63 days of amenorrhoea.

All other uses of misoprostol (including for cervical priming and for abortion at later gestations) are unlicensed. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Prescribing guidance: prescribing unlicensed medicines for further information.

  • National Institute for Health and Care Excellence (NICE)