How health services can improve access to abortion

Previous editorials have dealt with unsafe abortion in Africa [1] and the law in Spain.[2] This editorial will confine itself to factors within health services that affect access to abortion in high-income countries. Factors that either obstruct or facilitate access to abortion in such countries have recently been reviewed.[3] The quality of the health services of the country in which a woman resides will affect her access, both generally and more specifically, to abortion services. Health ministries often fail to take a lead in abortion care. Where there is not enough confidence in how the law should be interpreted, there may be unnecessary restrictions, as is the case in Northern Ireland.[4] World Health Organization (WHO) guidance recommends that policy-makers and health care managers should ensure that safe abortion is readily accessible and available to the full extent of the law.[5] Abortions are already being provided by general practitioners (GPs) in countries such as France, Switzerland and the Netherlands; WHO supports more abortion care at primary care level. Information on local abortion services should be widely available on websites, in telephone directories, in public libraries, in pharmacies and in GP premises. A system of direct access (self-referral) to abortion services avoids any delays associated with the need for referral. Central booking systems have been shown to facilitate access.[6] In many countries fees are charged for abortion.[7] Some countries subsidise abortions performed for medical reasons, rape and in the case of minors. In the USA, under the Hyde Amendment, 32 out of the 50 states do not provide Medicaid funding for abortion, and federal funding is prohibited.[8] For individuals without health insurance in systems in which charges for health care apply, an abortion may be simply unaffordable. In other countries abortion procedures are free, although there may be some charges for hospital stay and investigations. More needs to be done to assist women in countries that charge fees for abortion which cannot be reimbursed. Where fees are charged for abortion, such fees should be matched to women’s ability to pay, and procedures should be developed for exempting the poor and adolescents from paying for services.[5] As far as possible, abortion services should be mandated for coverage under insurance plans. The barrier of high costs to women is likely to generate much higher costs for the health system, by increasing the number of women who attempt to self-induce abortion or go to unsafe providers and, as a result, require hospitalisation for serious complications.[5] Depending on whether a referral is needed by the provider, the responsiveness of health services generally to booking appointments can affect a woman’s pathway to the appropriate provider. The need for a referral from a GP can cause a delay if that doctor has a negative attitude or is a conscientious objector. About one-quarter of GPs do not refer women for abortions.[9,10] Professional guidelines on maximum acceptable waiting times between referral and assessment [11,12] and assessment and treatment [12] will tend to be incorporated into local service delivery and should be encouraged. There may or may not be a choice of provider. Some individuals may prefer not to go to a hospital. Choice is a highly valued element of services by women.[13] Negative staff attitudes and imposition of artificial requirements such as gestational limits will tend to deter women seeking abortion.[3] Unregulated conscientious objection results in high conscientious objection prevalence areas where abortions are hard to access.[14] The system operated in Norway is the best example of how conscientious objection can be overseen to ensure proper service delivery in all regions of the country. Regulations on conscientious objection ensure that all conscientious objectors are known about and that local providers have enough non-objectors to ensure the availability of adequate services.[14] Availability of abortion depends on adequate equipment; adequate availability of theatre time for surgical procedures;[15] necessary drugs being licensed for use; and trained, experienced health personnel. Furthermore, for surgical abortion in the second trimester, access to abortion depends on doctors having the necessary skills, which can become a problem unless younger doctors have the motivation and training to acquire these skills.[15] Abortion care is not usually integrated into doctors’ residency programmes.[16] Insistence on all women having an ultrasound scan can limit availability of services. WHO policy is that ultrasound scanning is not routinely required for the provision of abortion.[5] This should be kept in mind in the organisation of abortion services particularly in more rural areas.[17] In some countries there is no access to mifepristone. This limits what can be offered in primary care and greatly