The rise in recent years of medical abortion has transformed abortion care. Katy Footman identifies some of the main obstacles still undermining the provision of adequate patient-centred abortion care and sets out key measures to improve the quality and fairness of this care.

Abortion is a critical health need experienced by one in three women in their lifetime in England and Wales. Over the past decade, medical abortion using pills has become the most common type of abortion service in England and Wales. Although patient satisfaction with medical abortion is very high, new research highlights that the choice of abortion treatment options has been constricted due to under-funding of services and archaic laws.

Abortion treatment options

There are two main treatment options in abortion services: women and pregnant people generally have the option to take a set of medications and expel the pregnancy at home (medical abortion), or to have a gynaecological procedure in a clinic (surgical abortion). The proportion of medical abortions rose from 47 per cent in 2011 to 87 per cent in 2021.

A lack of treatment choice may create inequalities in patient-centredness of abortion care.

Medical abortion suits most people and both treatment options are very safe and acceptable. However, choice is important because the experience of each treatment is very different so acceptability will vary depending on personal circumstances. For example, patients’ needs vary depending on whether they have privacy and comfort at home, their childcare responsibilities, whether they have support around them, and their working hours and flexibility. A lack of treatment choice may therefore create inequalities in patient-centredness of abortion care.

For these reasons, having a choice of treatment options is one of six national standards for quality abortion care.

Restrictions on treatment choice

New research has highlighted that abortion treatment choice is constrained in England and Wales, and that the rise in medical abortion use over the past decade may not be entirely down to patient preference. Through an analysis of national abortion statistics and interviews with abortion care providers, managers and commissioners, this research has identified how structural constraints within the health system are limiting patient choice. These constraints include inadequate funding, poor health system integration and archaic laws that continue to govern abortion.

The rise in medical abortion use over the past decade may not be entirely down to patient preference.

Most abortion care in England and Wales is provided by private, non-profit organisations, under contract with NHS commissioners. Over the past decade, abortion services have been financially squeezed by commissioning practices, as competitive tendering has driven down the tariffs used to reimburse abortion providers below NHS standards. The resulting under-funding of abortion care makes it very difficult to offer timely, local surgical options while medical abortion provision can be delivered at less of a financial loss.

Reliance on private, non-profit organisations to provide abortion was also found to limit choice. These organisations are more heavily impacted by the cost of delivering different services as they must remain financially viable. The historical outsourcing of abortion care therefore makes these services particularly vulnerable to the negative impacts of competition-focussed health reform. Additionally, commissioners are not legally required to reimburse private, non-profit organisations at NHS standard rates.

Dependence on the private, non-profit sector also enables a continuing lack of engagement with abortion and low capacity to provide surgical abortion within the NHS. Treatment choice could be strengthened through collaboration and referrals between services, but the highly competitive commissioning environment for abortion harms collaborative working between service providers.

Additionally, although many legal restrictions on medical abortion have been removed, policy progress for surgical abortions is lacking. Nurses and midwives cannot legally provide surgical abortions, although they can provide the exact same procedure in this country to manage a miscarriage. Provision of surgical abortions by nurses and midwives is recommended by the World Health Organization and is standard practice in many countries. The requirement for doctors to provide abortion procedures drives up the cost of delivering these services, making them more difficult to provide.

As a result of these constraints on patient choice, the research finds patients are required to inform and advocate for themselves, and often have to travel further, if they want a surgical abortion. This can further exacerbate inequalities in patient-centred abortion care.

Implications for policy and practice

There is an urgent need to strengthen patient choice of surgical and medical abortion care, which will involve increasing access to surgical options. There will always be a clinical need for surgical abortion, and it is vital to ensure this option is accessible for those who are not clinically eligible for medical abortion or who prefer a surgical option.

This could be achieved through clearer standards for reimbursement of abortion service provision in the private non-profit sector, based on a transparent and fair costing of each treatment option. Separate commissioning processes for medical and surgical abortion may also help to negate some of the impact of commissioning practices on treatment choice.

Improved collaboration between the private non-profit sector and NHS is required to safeguard access to surgical abortion in the long-term, if it is more cost-effective to deliver surgical options through NHS staff and infrastructure.

Treatment choice could also be improved by strengthening training and workforce planning to protect and expand surgical abortion skills, and by clarifying that nurses and midwives can legally provide surgical abortion procedures.

Finally, the financial pressures that have been placed on abortion services have implications that go beyond the issue of treatment choice. This research highlights the fragility of abortion services owing to under-funding, poor health system integration and fragmentation of sexual and reproductive health. Adequate investment in these services is essential to ensure that experiences of abortion care are high quality and de-stigmatising, and to avoid inequalities in patient-centred care.

All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science.

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