Title: Evidence base to inform health service configuration for abortion provision
Funder: Department of Health and Social Care

Abstract: Roughly one in three women in the UK have an abortion in their lifetime. Making sure that abortion is a safe, effective and acceptable experience is an important part of good reproductive health care. In the UK, the drive for abortion to be brought into line with modern health care practice is gathering pace. Many people have called for abortion to be decriminalised. That means removing the need for two doctors to approve certain reasons for having the abortion, and for women to attend to attend certain health services to access abortion care. At the same time, medical scientists have produced new safe and effective methods involving taking two pills. Researchers have also shown that it is safe for a woman to receive the pills through a telemedicine consultation, and to take both pills at home rather than having to travel to an approved health service._x000D_ New methods are being used and new regulations are likely to set out who can carry out abortions and where. Some of these changes have already happened. In Northern Ireland, the law was changed in 2019 so that women and health care workers no longer face prosecution if they end a pregnancy without the permission of two doctors. The same may well happen in the rest of the UK. _x000D_ These changes could have real benefits. Abortion would happen earlier in pregnancy, when it is easier and safer. Women would be able to have more control over what happens to them. The National Health Service could save money by supporting nurses and midwives carry out abortions , and by cutting the time it takes to arrange an abortion, so that more could be done at an earlier stage by taking medicines rather than carrying out a surgical operation. _x000D_ At present, health services are not ideally prepared to benefit from these changes. There are too few staff with the right training to provide abortions. We don’t know enough about how nurses and midwives feel about providing abortion, or how women themselves feel about them doing so. Not enough is known about the help and support women may need or want when they take abortion pills at home. Efforts are being made to develop new ways to improve abortion care in other parts of the world, but more needs to be known before deciding what is right for the UK. _x000D_ The aim of this study is to gather facts which will help health services and systems in the UK to take advantage of new ways of providing abortions to improve standards. To do this we will:_x000D_ i) look for new ideas about how to carry out abortions and care for women having them;_x000D_ ii) collect information from countries where it is purely a woman’s choice whether she has an abortion about how this works; _x000D_ iii) ask healthcare practitioners, such as pharmacists, GPs, and nurses, about what effect new ways of providing abortion might have on them, and what they think about it; _x000D_ iv) ask women with recent experience of abortion about their care and how it might have been improved;_x000D_ and v) ask people with a work interest in abortion what they think would work well in the UK. _x000D_ The research will be carried out by a team from universities and health services in London, Kent, Oxford, Cornwall, Scotland, Canada, Sweden and Australia. The team will take advice of how to carry out the research from users of abortion services, practitioners, policy makers and members of associations representing doctors and members of the public. We will prepare reports of the findings for different audiences.

Lay abstract: Research question: How can health services be best configured in response to the decriminalisation, deregulation and de-medicalisation of abortion to provide quality, evidence-based care for women in the UK?_x000D_ Background: One in three women in the UK have an abortion at some point in their lives. Significant changes to the nature and context of abortion provision are taking place in the UK which will impact on patients, practitioners and policy makers. Challenges persist in relation to abortion provision, even in countries with few legal constraints, including insufficient human resources and suboptimal training, and for women, experience of stigma, delay in obtaining appointments and negative staff attitudes.17,19,25,36_x000D_ Aims and objectives: Our aim is to provide an evidence base to inform optimal configuration of health services and systems in response to current and future changes in the legal and regulatory context of abortion provision in the UK. The objectives are to: i) collate, synthesise and summarise recent evidence for innovative models of abortion care with the potential to enhance access, quality of experience and cost-effectiveness; ii) explore the potential for beneficial and harmful consequences of current trends in abortion provision and identify implementation strategies to harness positive outcomes of current developments and mitigate adverse outcomes; iii) assess the potential of GPs and non-clinician providers in abortion provision, their education and training needs and their views on innovations in care; iv) elicit women’s views on current experiences of abortion and on preferences for abortion techniques, models of care and sources of support; v) consult decision-makers on the range of innovative abortion practices and procedures and on the potential feasibility, acceptability and sustainability of their adoption in UK health services and systems. _x000D_ Methods; The study will be guided by ‘Diffusion of Innovation’ theory which focuses attention on the qualities of novel strategies, the characteristics of potential adopters, and their ‘fit’ with the context in which they might be introduced.77,78 A horizon-scanning study is planned with five integrated components: i) a realist review to generate evidence to guide the effective choice and implementation of novel approaches to abortion provision; ii) Country-based case studies (Canada, Australia and Sweden) identifying transferable lessons for UK policy and practice; iii) A survey exploring attitudes, receptivity to and preparedness for changes in abortion provision amongst healthcare practitioners; iv) Qualitative research with women with recent experience of different methods of abortion and service delivery models to explore their views and experiences of abortion provision, care and support; v) Round table discussion groups with key stakeholders to generate/share expert knowledge on the optimal configuration of abortion services, and the feasibility and applicability of novel strategies and interventions in the UK._x000D_ Timelines for delivery: 2 years_x000D_ Anticipated impact and dissemination: The proposed research has the potential to improve the health and well-being of women seeking abortion, cut NHS costs, improve NHS services and increase job-satisfaction amongst practitioners. Dissemination will be guided by the needs of different audiences, including the general public, healthcare professionals, academics, policy makers and commissioners, and NGOs.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: REPRODUCTIVE HEALTH AND CHILDBIRTH