Choice is now an integral part of abortion care and information; coupled with sensitive counselling, it is essential to help the woman in selecting an abortion method that is right for her and to optimize the abortion experience. The factors that determine an individual woman’s choice for medical or surgical abortion are complex, but in brief, the chief advantages of surgical methods are that they are simple and quick and associated with a low risk of complication or failure. Medical methods are often favoured because they appear more physiological, like a miscarriage, and avoid the need for uterine instrumentation; they also have low rates of complication and failure. Some women can feel a lack of control over a surgical procedure, whereas others prefer that they remain unaware and that the procedure is undertaken by their clinician.
The late 1980s and 1990s saw exciting new developments in medical methods for early abortion and improvement of the medical methods for mid-trimester abortion. It is these developments that have extended patient choice and diversified the provision of abortion services. In 1991 the anti-progestogen mifepristone was licensed for termination of pregnancy up to 9 weeks’ gestation, and since then an extensive literature has built up to support the safety, efficacy and acceptability of the medical regimen for early first-trimester abortion. In 1995 the licence was extended to include pregnancies of over 13 weeks’ gestation. At present, the medical regimen is not licensed for use in women with pregnancies over 9 and less than 13 weeks’ gestation, and the majority of abortions at these gestations remains surgical. A randomized trial has compared medical and surgical termination at 10-13 weeks’ gestation and shown the medical regimen to be an effective alternative to surgery with high acceptability, and some units offer medical termination at these gestations.
Clinical practice in three larger Scottish units indicates that more than half of eligible women opt for medical methods when given a choice at early gestations of up to 9 weeks, and Scottish abortion statistics reveal that over 50% of all terminations in Scotland are now performed medically. Interestingly, the introduction of medical termination has not affected abortion rates overall. The introduction of medical abortion has been slower in England and Wales and there is significant variation in its provision across Health Authorities. Patient surveys further confirm that women value being offered a choice of method appropriate to the gestation of their pregnancy.
RCOG guidelines recommend that conventional suction termination should be avoided for gestations of less than 7 weeks on the basis that for these very early gestations the procedure is three times more likely to fail to remove the gestation sac than those performed at between 7 and 12 weeks. Although medical termination is advocated for these very early gestations of less than 7 weeks, current research is evaluating manual vacuum aspiration (MVA) under local anaesthetic using strict protocols.
Selection of the medical or surgical method for later abortion, particularly beyond 15 weeks, is usually dependent on the availability of health care personnel who are trained and willing to participate in late dilatation and evacuation (D+E). It is certainly true that as gestational age increases, the safety of second-trimester surgical abortion depends highly on the operator’s skill and experience and the current situation is that clinics and clinicians usually set their limits for operative care based on these considerations. Regrettably, there has been no formal comparison in clinical trials between second-trimester dilatation and evacuation and the modern methods of medical mid-trimester termination. It should be noted that hysterotomy, with its associated high morbidity and mortality, has virtually disappeared from practice.
Increasingly, women are referred to dedicated abortion services offering care separately from other gynaecological patients but with full gynaecological support should that be required. There is good supporting evidence that the earlier in pregnancy that an abortion is performed, the lower the risk of complications. Services should therefore be organized to offer arrangements which minimize delay for the patients. It is helpful if the referring doctor is able to provide the first signature on Certificate A. Day care is recognized as a cost-effective model of service provision and a typical service will be able to manage 90% of its patients on a day-care basis. Obviously, this will be influenced by pre-existing medical problems, social factors, geographical distance and the possibility of a planned day case requiring an overnight stay because of surgical or medical problems. Women undergoing mid-trimester termination, in particular, should be advised of the possible need for an overnight stay.