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Unplanned Pregnancy and Abortion Care

Introduction

For many women, getting a positive pregnancy test can be great. But for others an unexpected and unplanned pregnancy is not welcome news. The aim of this leaflet is to help you consider your options and know your rights when pregnancy is not planned. It also deals with some of the questions that are frequently asked about having an abortion. Despite the fact that around 160,000 abortions are performed in England and Wales every year, there is still very little good information and a lot of misinformation about abortion.

Emergency contraception

If you have had sex without using contraception, or if the condom broke, pregnancy can be prevented if you act quickly. Emergency pills can be taken up to three days after unprotected sex, or an IUD can be fitted up to five days after. Emergency contraception is available from your GP, family planning clinics, and most genito-urinary medicine (GUM) clinics or sexual health clinics.

Missed a period?

If you've missed a period and think you might be pregnant, you need to have a pregnancy test as soon as possible. You may be experiencing some of the early signs of pregnancy such as swollen breasts, tiredness, or feeling ill, particularly in the morning, but not all pregnant women have these symptoms. You also can have these symptoms if you're not pregnant. And sometimes when you are pregnant there is still some spotting or bleeding at the time of an expected period. It is important to have a pregnancy test done so you can start thinking about what to do.

Pregnancy Tests

Pregnancy tests vary in how soon they can detect a pregnancy. Some tests can tell when your period is one day late (although it is recommended to wait for five days). You can get pregnancy tests done at a variety of places:

• Your GP should be able to provide a same day pregnancy testing service. Some health authorities no longer do pregnancy tests unless there is a medical reason to do so. Make sure you know how long it will be before you get the result.
• Your local charitable clinic (see Resources section). The fee is £10-£12, but under 25s can get a free test at Brook centres.
• You can buy a home kit from the pharmacist. These cost £8-£10. It is best to buy one that provides two tests. The tests are reliable if instructions are followed carefully. If a test proves negative but you still haven't had a period a week later, repeat the test.

If You're Pregnant And Unsure What To Do

Even if you've been expecting it, a positive can be quite a shock. Deciding what to do may not be easy. You may want to talk about it with someone - your friends, your family, your partner or GP might help. If you'd rather not talk to any of them, you can get advice and counselling from various information and community centres, including the organisations listed in the Resources section. At this point, there are three possibilities open to you:

1. You may want to continue the pregnancy. The Department of Social Security and/or Council Housing Department can give you advice about housing and benefits. You need to arrange things early. It's important to see your doctor to arrange antenatal care. There is a helpful booklet called Who's having your baby?, which explains what you are entitled to. (See the Resources section.)
2. You may decide to continue the pregnancy but want to consider offering the baby for adoption. Your GP or local Social Services Department can advise you. You can also get information and help from the British Agencies for Adoption and Fostering, Skyline House, 200 Union Street, London SE1 0LX. Tel: 020 7593 2000.
3. You may want an abortion. The rest of this leaflet gives you basic information about having an abortion, and where to go to get help if this is your decision.

Risks and Complications of Abortion

Before abortion was legalised in 1967, women had to go to the backstreets for abortions. They faced serious risk to their lives and health from dangerous potions and instruments. Following the 1967 Abortion Act, abortion became a safe surgical operation with a low incidence of complications. But it must still be seen in the context of all operations - any medical operation carries some element of risk.

The majority of abortions are done early; 88% were done under 12 weeks in 1995. Early abortions (up to 12/14 weeks by vacuum aspiration or medical abortion using mifepristone) are safe, simple and quick and have a low complication rate.

The risk associated with abortion depends on many factors: how many weeks pregnant the woman is, her age, the type of operation, whether, and how often, she has been pregnant before and her general health. Another important factor is the skill of the doctor performing the operation. If abortions are performed by experienced staff committed to providing a comprehensive abortion service, the likelihood of complications is much reduced.

The most usual complication is infection. Other, less common, problems include retained fetal tissue and perforation of the womb (uterus). On average, women have a 1 in 50 chance of a minor infection and a 1 in 200 chance of a more major infection. Two to three per cent of women have a problem that results in readmission to the hospital or clinic. In the majority of cases, abortions after 14 weeks in the NHS and after about 18 weeks in non-NHS clinics are carried out by bringing on (inducing) labour. Later abortions have a higher complication rate. Between 13 and 18 weeks the risks are double those of early abortion and those done after 18 weeks carry three times the risk.

The incidence of problems has been greatly reduced in recent years by the use of prostaglandins. These are hormones which cause the uterus to contract and open the cervix. In young women, 15-16 year olds, a prostaglandin abortion can be less risky to the cervix than a surgical abortion (called a D&E) because the cervix is much more difficult to dilate surgically. The main risks of later abortions are bleeding, injury to the uterus and infection.

The rate of deaths from early abortions is about 1 in 100,000 in this country. Comparing this to the maternal death rate, abortion is eight to ten times safer than childbirth.

Abortion and Infertility

Unless a major infection occurs, there is no evidence that abortions affect future fertility, cause stillbirths, ectopic pregnancies, low birth weight babies or birth defects. Some studies suggest a slightly increased risk of late miscarriage in subsequent pregnancies, caused by 'cervical incompetence' - the cervix not being able to remain tightly closed during pregnancy. But as techniques for abortion are improved, this should happen less and less. There is also no evidence that repeat abortions carry an increased risk of most problems, although some studies show a slightly higher risk of miscarriage. There is now greater awareness about sexually transmitted diseases such as chlamydia (a bacterial infection) and their effect on fertility. Screening before abortions, and a course of antibiotics if necessary, can cut down the incidence of infection-related infertility.

Taking care of yourself after an abortion is important and any problems should be reported to your doctor or clinic immediately to reduce long term effects on your reproductive health.

Anti-abortionists claim that abortions have grave side effect, in order to deter women from ending an unwanted pregnancy. This is scaremongering and very unethical. The relatively few risks associated with abortion must always be considered in relation to the risks of continuing with an unwanted pregnancy. Only the woman herself can assess this.

Getting an Abortion

Who to See About Getting an NHS Abortion

Go to your own GP as soon as possible. Be clear and firm about explaining your reasons for wanting an abortion. Not all doctors have the same policy on abortion. You should be able to find out your doctor’s attitude to abortion from the practice leaflet. Doctors with specific religious views may be against abortion, except in certain circumstances, but in this case they are obliged to refer you to another GP. Other doctors, holding other views, may be more immediately sympathetic. Be prepared to answer a few questions about why you want an abortion. Even if your GP is sympathetic, s/he needs a clear indication that you've considered all the options and have come to a firm conclusion.

If you would rather not go to your own doctor, or if s/he will not help you to get an NHS abortion, you can:

• Try to see another doctor who might be more sympathetic (this may take up valuable time).
• Try your family planning clinic. Some can refer you to your local hospital.
• Go to your local BPAS or Brook Advisory Centre. They refer women to the NHS for free abortions whenever possible and desirable.

NHS or Private?

The percentage of abortions done on the NHS in each health district varies considerably. You may live in an area where it is relatively easy to obtain an NHS abortion. Or you may live in an area that has poor NHS facilities. Taking the country as a whole, just over two thirds of all abortions are done on the NHS, the rest being done in the private and charity sectors. NHS abortions are becoming easier to get, but most regions of Britain still trail behind the 1979 royal commission recommendation that the NHS should provide 75% of abortions.

Once you've seen a doctor who has agreed to refer you to a hospital, the earlier you can see the gynaecologist there the better. This appointment can take anywhere from a few days to up to four weeks and then you may have to wait for the actual operation for up to several weeks. (See below, Problems)

To sum up, whether or not you get an NHS abortion depends on a combination of factors: your GP or local gynaecologist's attitude, local facilities, how many weeks pregnant you are, waiting lists, whether you have had an abortion before (some areas will not do repeat abortions), and your current situation.

If you fail to get an abortion on the NHS, the alternative is paying for one at one of the private or charitable clinics. The charitable clinics tend to be more aware of your problems, will talk to you about your abortion and will help as much as possible.

The cost at a charitable clinic varies but you can expect to pay about £275 to £310 (1998) for an abortion up to 12/14 weeks. A later abortion (after 14 weeks) costs more depending on how many weeks pregnant you are and what the clinic offers.

Late Abortions
In theory, the law allows abortion up to the 24th week of pregnancy (except in circumstances outlined above). However, abortion practice is different. Many NHS hospitals will only do abortions up to 12 weeks, and later ones only in exceptional circumstances. If you are turned down because you are considered "too late", it is worth looking around in case another hospital or clinic will accept you.

It is essential that you visit your doctor or a clinic as soon as possible.

Problems

If you suspect that for some reason there is undue delay in the process of organising an abortion, for example if there seems to be excessive delays in getting your pregnancy test results, getting an appointment at the hospital, your doctor says you should go home and think about it and come back in a couple of weeks, or your doctor says you are too late even though you are less than 24 weeks pregnant, don't delay. Time is crucial. Contact one of the advisory centres for advice.

The Law On Abortion

Before the 1967 Abortion Act, abortion was illegal, except to save the life of the pregnant woman.

The 1967 Abortion Act
Under the 1967 Act, which covers England, Wales and Scotland, abortion is legal in certain circumstances. Women do not have the right to abortion on request. Two doctors (normally your own GP and a hospital gynaecologist) have to agree that you are entitled to an abortion under the grounds of the Act. This applies to both the NHS and the private sector. The law states that you can get an abortion if continuing with the pregnancy would involve:

• risk to your life
• risk of injury to your mental and physical health
• risk of injury to the mental and physical health of your existing children
• substantial risk that the child would be born severely mentally or physically handicapped

These grounds can be interpreted quite widely, depending on your doctor's views on abortion. Some may be very unhelpful, others very helpful.

The 1990 Amendment
The Abortion Act 1967 was amended in 1990 by Section 37 of the Human Fertilisation and Embryology Act. The main change is that there is now an upper time limit of 24 weeks for legal abortion. There is no upper time limit in a very few extreme cases, which are: risk to the life of the mother, risk of grave permanent injury to the mother and risk of serious fetal handicap.

For Those Under 16 Years
Women over 16 years do not need their parents' consent to have an abortion. If you are under 16, you normally need your parents' consent. However, the law does say that a girl under 16 can give consent to her own treatment if her doctor considers her to be mature enough to make the decision. But very few doctors are prepared to give medical treatment under these circumstances. The best thing to do in this situation is to contact one of the organisations listed in the Resources section of this leaflet. They will be sympathetic and help as best they can.

Before the Operation

Consultation

An abortion consultation involves a number of procedures. These include a physical examination (including an internal examination where the doctor places her/his fingers in the vagina and feels the uterus), a blood test to find out blood group and check for anaemia, and a review of medical history to establish physical fitness and general health. Sometimes an ultrasound scan is done to confirm your dates.

The quality of the consultation depends mainly on the attitude of the doctor or counsellor - some may be judgmental, but many are sympathetic and understanding.

Practical information

You should get an explanation about how the operation will be performed (with as little or as much detail as you want), the type of anaesthetic and possible risks, the length of stay, when your period is expected to return, and follow up appointments. These are usually two to six weeks later, at the hospital, clinic, doctor's surgery or family planning clinic.

Many abortions are done as day surgery so you may go home the same day.

Advice about problems

You should be told how to recognise possible complications and who to contact if they rise.

Screening for Chlamydia

Chlamydia is the most common sexually transmitted disease in Britain. The majority of women who are infected don't know they are carrying it. If it spreads from the vagina into the uterus, fallopian tubes or ovaries it can cause a serious infection (called pelvic inflammatory disease) which may lead to fertility problems in the future. If caught early, treatment is simple: a course of antibiotics. This will clear up the infection very quickly and the operation need not be delayed. If chlamydia is present, it can be spread by surgery. We recommend that women are tested for it before an abortion (or any procedure where the cervix is opened, such as insertion of an IUD or a D&C). This is a sensible precaution to prevent serious infection. You may not be offered this test as a matter of routine so you may have to ask for it, or organise it yourself. You can have it done at your local genito-urinary medicine (GUM) clinic. There should be one at your local hospital. You do not need a referral from your GP, and at many you don't need an appointment. If you are found to have chlamydia, your partner(s) must also be tested and given treatment, otherwise you will be re-infected. Your local GUM clinic will help you.

Rhesus Immunisation

Women who have a blood type known as Rhesus negative and who have a Rhesus positive fetus can develop blood antibodies at the time of an abortion. These antibodies may harm future wanted pregnancies. Make sure you know your blood group at the start of the operation. If you are Rhesus negative you should be given an injection of anti D gamma globulin before you leave the clinic. This will prevent the formation of antibodies.

Contraceptive Advice

It is possible to become pregnant again very soon after an abortion, even before you get your next period, if you have unprotected intercourse. You should be offered contraceptive advice before the operation. You may feel pressured into making decisions about using one particular method over another. It should be your choice. It might be a good idea to wait until you are completely recovered physically and no longer under the stress of an unwanted pregnancy before making a permanent decision about birth control. If you have already planned to use the pill, you can start taking it the day after the abortion.

The Operation

There are several different ways of doing an abortion. These are explained below. The pregnancy is dated from the first day of your last menstrual period. This is called your LMP.

First Trimester Abortions (up To 12 Weeks)

Vacuum Aspiration or Suction
This is the most common method of abortion. It is usually done between 7 and 12 weeks, but some doctors are skilled enough to perform it up to 14 weeks. The cervix is dilated in stages and then a tube is passed into the uterus and the contents are removed by the use of an electric pump. Some clinics combine suction with a scrape of the uterus, using a spoon like instrument. The procedure usually takes about 10 minutes and is most often done under a general anaesthetic (the woman is not awake). Some clinics will do this type of abortion using local anaesthetic (the woman is awake).

Abortions up to 14 weeks are usually done on a daycare basis. This means that you go into the hospital/clinic about an hour before the termination and go home up to two hours after the procedure. You must have a responsible adult escort and you must have fasted beforehand if you are having a general anaesthetic. Your GP must also be available to call if needed, and must be informed of the abortion. If you are not having a daycare abortion, you will be required to stay overnight in hospital/at the clinic and you can go home the following morning.

Second Trimester Abortions (after 12/14 Weeks)

There are different techniques for performing abortions after the 12/14-week stage. Each is used according to the skill and/or preference of the gynaecologist doing the operation. Time limits vary too, with each hospital/clinic setting its own guidelines. Some clinics won't do abortions between 14 and 17 weeks, but may refer you to one which does. There are three main methods in use at the moment:

Dilatation And Curettage (D&C)
This technique is used between 12 and 16 weeks and is often combined with a vacuum aspiration. The contents of the uterus are removed with a scraping instrument called a curette, after the cervix has been dilated. A general anaesthetic is used.

Dilatation and Evacuation (D&E)
This technique is usually used between 12 and 16 weeks, but some skilled clinicians can perform it up to 24 weeks. The cervix is dilated and the doctor uses forceps, a curette and vacuum suction to remove the contents of the uterus.

The BPAS offers a two-stage procedure for late abortions. This takes two days. Under general anaesthetic the fluid sac around the fetus is broken and a substance derived from seaweed is inserted into the cervix. This gradually expands over the following day, opening the cervix. The evacuation of the uterus is then carried out under a second general anaesthetic.

Prostaglandins
Prostaglandins are normally used from 15 weeks onwards, especially in NHS clinics.

Prostaglandins are hormones, similar to those produced during labour, which cause the uterus to contract. The drug is given either as a vaginal pessary or as an injection either through the cervix into the uterus or through the abdomen. The fetus is delivered in the same way as a woman gives birth. This method can be quite painful and no anaesthetic is used although women can receive sedatives and pain relief tablets. A D&C usually follows this, with anaesthetic.

Whether you have an early or late abortion, you may want to have a friend come with you to the clinic or meet you after the operation.

The Abortion Pill - RU486 "Medical Abortion"

In 1991 a drug called mifepristone, also known as RU486, was licensed for use in abortions up to 63 days (nine weeks) of pregnancy. In mid-1995 it was licensed for use up to 20 weeks. When using mifepristone for abortion, doctors must still follow all the rules of the 1967 Abortion Act. It is not available from a GP surgery or a chemist.

Progesterone is the hormone which maintains early pregnancy. Mifepristone stops progesterone from working. Not all women are medically suitable for a mifepristone abortion and a detailed medical history will be taken before proceeding.

Studies show that mifepristone abortions have a success rate of 94%. A follow up suction abortion is done for the small percentage of women who do not have a complete abortion with mifepristone.

Abortion using mifepristone involves three visits to a hospital/clinic, except when going to a private clinic, when there often is another initial appointment for counselling and medical examination. Some centres may also require you to have an ultrasound scan before proceeding. This is to date the pregnancy and to make sure the pregnancy is not ectopic (occurring outside the womb), in which case mifepristone would not be used.

At the first visit for the actual abortion, three mifepristone pills are taken. You will need to rest in the clinic for a couple of hours to make sure that the tablets are properly absorbed. Forty eight hours later, you return to have a vaginal pessary of prostaglandin inserted. Prostaglandin causes the uterus to contract and expel the contents. Bleeding can begin any time after the pills are taken. It is usually like a heavy period. Some women may have period like pains at this time. Sometimes bleeding does not start until the prostaglandin pessary is given.

After the pessary is inserted, uterine contractions start. Women must remain in the hospital/clinic for four to six hours after pessary insertion. Differing amounts of pain are experienced with these contractions. Pain medication will be offered. The majority of women will abort within this time, expelling a large blood clot.

The last visit involves having a medical exam to make sure the abortion is complete and there are no problems.

Following abortion with mifepristone, bleeding usually continues for ten to twelve days. A small percentage of women bleed very heavily.

It is important to note that once the mifepristone tablets are taken, women are strongly advised to carry through with the entire procedure. This is because the effects of the drugs on the outcome of any continuing pregnancy have not been fully evaluated.

Clinical studies have been done to find out how women feel about having a mifepristone abortion. Some women experience heavy bleeding and considerable pain while others do not. Some women have also experienced side effects such as nausea, vomiting and diarrhoea.

When asked why the choice was made to have mifepristone, reasons given included:

• feeling more in control of what was happening to them
• mifepristone seemed more natural and more private than surgical abortion
• avoiding general anaesthetic

Studies have found that medical abortion is no more distressing psychologically than suction abortion.

After the Operation

Check Up

You should have a check up two to six weeks after the abortion. (The time varies from hospital to hospital). This is important to make sure that there are no complications such as pelvic infection or continued vaginal bleeding. A pelvic examination should be carried out to make sure that the uterus is empty as, very occasionally, pregnancy does continue after the procedure. A repeat procedure would then be needed.

General advice

It is best to avoid tampons immediately after the operation because of the risk of infection while the cervix is open. You should use sanitary towels. For the same reason, it is advisable not to have intercourse for four weeks or a week after the bleeding has stopped, whichever is sooner. You may also be advised to take showers instead of baths and to take it easy for a few days after the operation. You can go back to work as soon as you feel like it.

After an anaesthetic, tolerance of drugs (including alcohol) is impaired. Avoid alcohol and other drugs for at least 24 hours.

Bleeding
Women bleed in varying amounts after an abortion. Slight bleeding for up to three weeks is considered normal but heavy bleeding or clots should be investigated, as well as any pain, feverishness or feeling unwell. Most problems show up within two to three weeks after the operation.

Coping

Many women feel relieved after an abortion, but some may need time to adjust to the experience of having had an unplanned pregnancy. An abortion may not be an easy decision and each woman will have different feelings, depending on her circumstances. While the medical side of things may be taken care of, the emotional side may be neglected. It's important to acknowledge difficult feelings when they exist. It's often helpful to talk over your feelings with a close friend or other women who have also had abortions.

Support

Some women feel they have all the support they need from their friends, family and/or partners. Other women may feel more isolated, have no one to talk to, or feel that they can't bother their friends any more. For this reason post-abortion support has been set up to provide a place where women can talk about their experiences, good and bad, without feeling judged or criticised in any way.

Contact Women's Health or one of the organisations in the Resources section for details of abortion support.

Resources and links

Organisations offering abortion referral and counselling

British Pregnancy Advisory Service (BPAS)
Head Office:
Austy Manor
Wootten Wawen
Solihull
West Midlands B95 6BX
Actionline tel: 08457 304030

BPAS is a non-profitmaking charity which provides a counselling service and NHS-approved abortion facilities. BPAS operates nine clinics and 32 branches in England, Wales and Scotland. Contact the Actionline for details of your nearest centre.

Brook Advisory Centres
National Office
165 Grays Inn Road
London WC1X 8UD
Tel: 020 7713 9000

Brook Advisory Centres offer advice and information to people under 25 on relationships, contraception, pregnancy (including testing), and abortion referral (to the NHS if possible). Services are free. Brook has 33 branches in England and Scotland, and one in Belfast. Contact the National Office for details of the one nearest you.

Marie Stopes International
Free phone 0800 716 390

Marie Stopes International provides counselling, abortion services and referral for people of all ages. Fees are charged for services. Centres in London, Leeds, Manchester and Essex. For all enquiries ring the free phone number.

Campaigning organisations

National Abortion Campaign (NAC)
The Print House
18 Ashwin Street
London E8 3DL
Tel: 020 7923 4976

NAC campaigns on abortion rights, provides information and publishes a newsletter.

Pro-Choice Alliance
11-13 Charlotte Street
London W1P 1HD
Tel: 020 7636 4619

The Pro-Choice Alliance is a national umbrella group of organisations and individuals campaigning for a more liberal abortion law and better NHS provision.

Reading

Understanding abortion by Mary Pipes, (The Women’s Press, second edition 1998).
A comprehensive and supportive guide to the medical, legal, emotional and practical aspects of abortion. Available from Women’s Health at a special price of £5, including postage.

Coping with a termination: advice on the emotional and practical difficulties of an unwanted pregnancy by Dr David Haslam (1996).

Sympathetic explanation of each stage of the process from initial reactions to an unplanned pregnancy, through the experience of abortion and afterwards. Includes women’s personal accounts.

Who’s Having your Baby – A Health Rights Handbook for Maternity Care by Beverley Beech, (Bedford Square Press, 1991).

Unplanned Pregnancy – Making the Right Choice for You by Debby Klein and Tara Kaufmann, (Thorsons, 1996).

SOME OF THE INFORMATION ON THESE PAGES HAS NOW BEEN SUPERSEDED

Based on leaflets written by Lesley Dike
and Women’s Reproductive Rights Information Centre. This edition revised by Women’s Health 1999.

This leaflet is protected by Copyright © Women's Health. You may print off one copy for personal use only.