Disclaimer (legal content):
- The legal framework surrounding termination of pregnancy is complex and context-dependent.
- This article provides a simplified overview for educational purposes and does not represent the full detail or exact wording of the Abortion Act 1967 or related legislation.
- Content has been reworded, restructured, and simplified to support understanding and exam preparation.
- For clinical practice or legal decision-making, always refer to official legislation and local guidance.
Definition
Termination of pregnancy or abortion is defined as an intervention intended to terminate a pregnancy so it does not result in live birth.
Legal Considerations
Abortion Act 1967
In England, Scotland and Wales, abortion is NOT legal on demand. It is only lawful when:
- A registered medical practitioner performs it, and
- TWO doctors certified that it is justified under at least ONE statutory ground, and
- The procedure must take place in an NHS hospital or Secretary of State-approved premises
The key statutory grounds to be aware of:
| Ground | Statutory wording (simplified) | Gestational age limit | Notes |
|---|---|---|---|
| C | Continuance of the pregnancy would involve risk, greater than if terminated, of injury to the physical or mental health of the pregnant woman | Treatment must be completed by 23 weeks 6 days (“up to 24 weeks”) | This ground is used in 98% of all abortions in England and Wales. [Ref]
Does NOT require a diagnosed mental health condition, risk to mental well-being is sufficient. |
| E | There is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped | No gestational age limit | There is no legal definition of “substantial risk” or “serious handicap”. An assessment of the seriousness of a fetal abnormality should be considered on a case-by-case basis, taking into account all available clinical information.
Some classic examples include:
|
| Emergency (F and G) | F: To save the life of the pregnant woman
G: To prevent grave permanent injury to the physical or mental health of the pregnant woman |
ONE doctor’s opinion is sufficient (exception to the two-doctor rule) |
Disclaimer: In Northern Ireland a slightly different legal framework is used – Abortion (Northern Ireland) (No. 2) Regulations 2020. The key difference is that abortion is unconditionally legal up to 12 weeks.
Conscientious Objection (Abortion Act 1967)
Healthcare professionals have a legal right to conscientiously object to participating in the termination of pregnancy.
Key principles:
| Right to object | No person is under a duty to participate in abortion treatment if they have a conscientious objection |
| Applies to | Doctors, nurses and other healthcare professionals who are directly involved |
| Scope of objection | Applies to direct participation in the procedure
Does NOT include:
|
| Duty of care |
|
Consent
Consent for adults and young people:
- Adults (18+): capacity should be presumed, unless there is evidence of impairment or disturbance in the functioning of the mind or the brain
- Young people (16-17): capacity should be presumed, a competent young person can provide valid consent without parental knowledge
- Children (under 16): under the Gillick ruling, any young person who is “competent” (meaning they have sufficient understanding and intelligence to understand the nature and consequences of the treatment) can give valid consent regardless of their age
- Important safeguarding rule: if a child is under 13 they are NOT considered capable of consenting to sexual intercourse. Doctors have a duty to disclose such cases to social care or the police ot protect the child
Rights of partners:
- The woman’s spouse and/or the putative father of the child has NO right to demand or refuse an abortion
- The decision to have an abortion rests solely with the woman and her doctors
If necessary, capacity is assessed based on the patient’s ability to:
- Understand the information relevant to the decision
- Retain that information
- Use or weigh that information as part of the decision-making process
- Communicate their decision by any means
Methods of Termination / Abortion
There are 2 methods: 1) medical abortion and 2) surgical abortion.
Key principles to take into account when choosing between medical vs surgical abortion:
- NICE emphasises that women should be offered a choice between medical and surgical methods up to and including 23+6 weeks, provided they are clinically appropriate
- Late terminations (after 23+6 weeks) are almost exclusively medical abortion
- For terminations involving fetal abnormalities, medical abortion is preferred by clinicians as it allows the delivery of an intact fetus for pathological examination
- Surgical methods generally have higher “complete” abortion rates (~98%) compared to medical methods (~94%)
| Gestational timing | Setting | Medical abortion details | Surgical abortion details |
|---|---|---|---|
| Up to 10+0 weeks (early 1st trimester) | Home expulsion is an option for medical abortion
Surgical abortion occurs in hospital / clinic |
Mifepristone followed by misoprostol
Note that timing and dosing vary depending on the gestational age. |
Vacuum aspiration (electrical or manual)
Cervical priming with misoprostol is offered in late 1st trimester |
| 10+1 to 13+6 weeks (late 1st trimester) | Usually as day cases in hospital / clinic | ||
| 14+0 to 23+6 weeks (2nd trimester) | Inpatient | Mifepristone followed by multiple doses of misoprostol
Feticide is routinely offered from 21+6 weeks to ensure no risk of a live birth |
Dilation and evacuation (D&E) under ultrasound guidance
Requires cervical preparation with osmotic dilators or misoprostol |
| After 23+6 weeks (late terminations)* | Mifepristone followed misoprostol
Lower doses of misoprostol are necessary as the uterus becomes significantly more sensitive |
Rarely performed |
*Note that late terminations are NOT legal if they are based on statutory ground C (the most commonly used one).
Preventing Infection
NICE recommends:
- Routinely offer and recommend a HIV test to women at their first appointment with abortion services
- Offer antibiotic prophylaxis to women who are having surgical abortion
Anti-D Prophylaxis
Largely depends on the gestational age:
| Gestational age | Recommendation on Anti-D prophylaxis |
|---|---|
| <12 weeks (up to 11+6 weeks) | NO anti-D needed for ALL patients
There is NO need to test for Rhesus status |
| ≥12 weeks | Offer anti-D prophylaxis to ALL Rhesus D-negative patients (regardless of medical or surgical abortion)
To be given ideally at the time of the abortion, and certainly within 72 hours |
Important rule regarding anti-D prophylaxis.
In addition to those above, 2 important factors must be fulfilled before offering anti-D prophylaxis:
- Rhesus D-negative (confirmed on blood group testing)
- Not previously sensitised (confirmed with antibody screen / indirect Coombs test)
Dosage:
- Fixed doses
- 12+0 to 19+6 weeks → 250 IU
- ≥20+0 weeks → 500 IU
- For abortions performed at 20+0 weeks or over, fetomaternal haemorrhage should be assessed using the Klehauer test or flow cytometry
- Anti-D dose should be increased if a large fetomaternal haemorrhage is detected
Complications
Abortion is a very safe procedure where major complications and mortality are rare across all gestations
Medical vs surgical complications:
- Medical abortion is associated with
- More intense pain
- Heavier and longer duration of bleeding
- More frequent GI side effects (e.g. nausea, vomiting, diarrhoea)
- Surgical abortion is associated with
- Less pain and shorter duration of bleeding
- Increased bleeding (associated with inhalational anaesthetics used in GA)
- Higher risk of infection
- Surgical abortion-specific complications
- Uterine perforation
- Cervical trauma
Important red flags to advise patients on:
- Persistent or worsening abdominal pain
- Very heavy bleeding / non-stopping
- Fever / systemically unwell
- Offensive vaginal discharge
References
RCOG The Care of Women Requesting Induced Abortion (Evidence-based Clinical Guideline No. 7).
RCOG Termination of Pregnancy for Fetal Abnormality in England, Scotland and Wales