Termination of Pregnancy

SPECIFICATION

Care Pathway/Service / Termination of Pregnancy
Commissioner Lead
Provider Lead
Period / 1 April 2010 to 31 March 2013
1. Purpose
The purpose of a termination of pregnancy service is to provide termination of pregnancies which are speedy and safe depending on the personal health and circumstances of the individual service user, to reduce repeat abortions and unintended pregnancies, and to promote better sexual health among service users.
1.1 Aims
To provide a consistent, comprehensive, effective, accessible, legal and appropriate termination of pregnancy service to service users.
To provide a quality service informed by the Royal College of Obstetricians and Gynaecologists Guideline for the “Care of Women Requesting Induced Abortion” (the RCOG Guideline), the MEDFASH standards for sexual health services, and current best evidence.
To ensure that risk of infection and other complications to service users is minimised.
To ensure that opportunities for contraceptive information and supply and sexual health screening are maximised
1.2 Evidence Base
The Royal College of Obstetricians and Gynaecologists produced guidance on termination of pregnancy services (The Care of Women Requesting Induced Abortion, RCOG, 2004) and this sets out best practice in delivering termination of pregnancy services. A copy can be accessed using the link below:-

The Medical Foundation for AIDS and Sexual Health (MedFASH) produced standards on sexual health services (Recommended Standards for Sexual Health Services, MedFASH, March 2005), setting out best practice across the whole field of sexual health for both providers and commissioners. A copy can be accessed using the link below:-

The National Institute for Health and Clinical Excellence (NICE) has produced a clinical guideline on long acting reversible contraception (The effective and appropriate use of long-acting reversible contraception, NICE, October 2005) which discussed the efficacy of contraceptive methods and the efficacy in particular of long acting reversible contraception. A copy can be accessed using the link below:-

The British Association for Sexual Health and HIV(BASHH) produce a number of guidelines on best practice and evidence-based treatment of a number of Sexually Transmitted Infections. The most up to date BASHH guidelines can be accessed using the link below:-

1.3 General Overview
This service provides termination of pregnancy care to the Co-ordinating PCT and any Associate PCTs.
1.4 Objectives
To offer high quality, impartial support and advice to all service users who request an termination of pregnancy, regardless of age, ethnicity, language, disability, sexual orientation, religious or personal circumstances.
To provide service users with access to a termination of pregnancy as early as possible.
To provide termination of pregnancy methods clinically appropriate for a service user’s gestation and clinical circumstances.
To improve the sexual health of service users through providing sexual health screening and treatment as appropriate for Chlamydia, other sexually transmitted infections (STIs) and HIV.
To provide information and advice on all methods of contraception, and the supply of the full range of reversible contraceptive methods.
1.5 Expected Outcomes including improving prevention
Improved access to termination of pregnancy
Reduction in the number of subsequent unintended pregnancies among service users
Reduction in the numbers of repeat termination of pregnancies among service users
Reduction in the rate of pelvic infection among service users
Reduction in the rate of any subsequent sexually transmitted infections among service users
Reduction in onward transmission of any existing STIs by service users
2. Scope
2.1 Service Description
The provision of termination of pregnancy and related services.
2.2 Accessibility/acceptability
[Describe the Service Provider’s policy and practices for ensuring that its services are accessible to all, regardless of age, disability, race, culture, religious belief or sexual orientation, income levels or previous termination of pregnancies, and deals sensitively with all service users, potential service users and their family / friends and advocates.]
2.3 Whole System Relationships
[Describe how the service fits into the local health economy, in particular its relationship with the Co-ordinating PCT and any Associate PCTs, local hospitals, local GPs, GU and contraceptive services, Sexual Assault Referral Centres and the police, social services and any relevant services operated by third sector organisations].
Describe how the Service Provider works with other services to ensure that service users are referred for follow-up care, and how the Service Provider participates in any initiatives or care pathways operated by the Co-ordinating PCT and any Associate PCTs
Describe how the Service Providers ensures that staff and other workers keep up-to-date with the continuing professional development requirements of their respective professions]
2.4 Interdependencies
[Describe any relationships between the service and other providers of health and other services in which a relationship of “dependency” exists. For example, is the service dependent on certain GPs for a proportion of its referrals? And is the service “dependent” on certain local hospitals to provide urgent emergency care? What arrangements are in place to allow for the speedy onward referral of service users who may need additional or different treatment, for example where service users have significant concurrent medical conditions, or are at a later gestation than gestation accommodated by the Service Provider ? What arrangements are in place to work with Sexual Assault Referral Centres, the police and other services offering support to women who are victims of rape or domestic violence? And how does the service make links with providers of other sexual health services in service users’ home areas?]
2.5 Relevant networks and screening programmes
[Describe the service’s membership of local clinical networks and support for screening programmes. As a minimum this should include membership of local sexual health networks (including the local Teenage Pregnancy Partnership) and support for the National Chlamydia Screening Programme]
3. Service Delivery
3.1 Service model
Note.
  • This specification is designed to sit alongside the legislative provisions of the Abortion Act and the Care Standards Act, and is not designed to replicate these provisions, or to duplicate, replicate or supercede the work undertaken by the Care Quality Commission or the Secretary of State for Health to register or approve independent sector termination of pregnancy clinics. However, there many be some areas where the requirements of legislation appear in this specification – but duplication has been kept to a minimum.
  • This service model is based on the RCOG Guideline on “The Care of Women requesting Induced Abortion” published in 2000 and updated in 2004, and current best practice. This specification should be amended in line with any future guidance produced by the College.
Safety, Confidentiality and Safeguarding
Aim: Confidentiality and safety are of paramount importance to women seeking to discuss their pregnancy options and undergo termination of pregnancy. The aim of the specification is to ensure that confidentiality can be maintained while also recognising the need on occasion to share information in the interests of patients, and to ensure that guidelines on dealing with young people under 18 are observed.
The aim of the specification is also to ensure that service users who seek a termination of pregnancy following rape receive services which acknowledge and respond sensitively to their situation.
General provisions
3.1.1A written confidentiality policy should be prominently displayed and made available to service users. The policy needs to clearly state the circumstances in which other agencies may need to be informed. Staff should be able to demonstrate an understanding of the policy and process and be able to communicate this to service users.
3.1.2Confidentiality must be maintained throughout the visit, including the minimal use of names in public areas, such as the reception or waiting areas.
3.1.3In order to maintain confidentiality, the Provider should not send information to the service user’s home address unless the user expressly wishes this.
3.1.4The Provider should ensure that information is not shared with anyone else, including the service user’s General Practitioner, without her consent. However, this does not apply to information which must be sent to other agencies to comply with the Abortion Act and the Care Standards Act.
Additional provisions on young people
3.1.9Providers providing services to service users under the age of 18 shall hold or be working towards accreditation against the “You’re Welcome” service standards for young people’s services.
3.1.10In dealing with service users under the age of 16, Providers must ensure that they adhere to the Department of Health’s guidance document “Best practice guidance for doctors and other health professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health” (2004, Gateway reference 3382). This guidance sets out what Service Providers should do to ensure that they protect the confidentiality of young people. It also sets out the good practice contained in the Fraser Guidelines, which detail the circumstances in which treatment can be provided to young people under 16 without parental consent.
Referrals
Aim: Evidence shows that the earlier a termination of pregnancy is performed, the less the risk and the better the likely outcome for the service user. The aim of the specification is to ensure that women are aware of local termination of pregnancy services and are able to access these services speedily.
3.1.11The Provider will take referrals from a wide range of sources, including but not limited to health professionals, community contraceptive services, GUM clinics and from services run by third sector organisations, the Local Authority, including schools and colleges, young people’s services and social services.
3.1.12The Provider will accept self referrals as commissioned by the Commissioner(s).
3.1.13Where the referring doctor has not provided a signed form HSA 1, or in the case of self referral it has not been possible to complete the Form, the Provider will make the necessary arrangements and bear overall responsibility for completion of the forms required under the Abortion Act. This should comply with the legal requirement for two separate signatures from two separate doctors
3.1.14Referral arrangements operated by the Provider will be simple and streamlined and will promote speedy access to termination of pregnancy.
3.1.15The Provider will ensure that it provides locally available information about the services it provides, including details as set out in section 4 of this specification. This information will be sent to GPs, community contraceptive services, GUM Clinics, young people’s services, the school nursing service and any relevant third sector organisations., to be made available to people using these services.
3.1.16Locally available information prepared by the Provider will also include details of local GU clinics, community contraceptive/ family planning clinics, HIV support services and sexual assault support services.
3.1.17The Provider shall work pro-actively with the Commissioner, making use of a variety of local media, to ensure that women are aware of how termination of pregnancies funded by the NHS can be accessed, and that termination of pregnancies performed on the NHS are free to service users.
3.1.18The Provider will participate in any local or national centralised booking system.
Assessment and advice on pregnancy options
Aim: As stated above, evidence shows that the earlier women can access termination of pregnancy, the less the risk and the better the outcome is likely to be. The aim of the service specification is to ensure that women seeking termination of pregnancy or discussion of their pregnancy options receive an early assessment appointment and can access impartial advice and support at that appointment, in surroundings which promote confidentiality and well-being, and which reflect any particular personal circumstances (eg if a service user is seeking an termination of pregnancy as a result of rape).
3.1.19All service users should be offered an assessment appointment within 5 calendar days of referral or self-referral.
3.1.20The content of the assessment, the standards to which the assessment is carried out and confidentiality service users can expect to receive should be the same regardless of which setting or settings are used to carry out the assessment.
3.1.21The assessment appointment should be within clinic time dedicated to service users requesting termination of pregnancy.
3.1.22Waiting areas should have sufficient seating to accommodate the number of service users and an appropriate number of their family / friends or advocates.
3.1.23 Service users should be seen within half an hour of their appointment time.
3.1.24Where possible service users who have not yet had an termination of pregnancy should be kept separate from those who have already undergone the procedure, or who are undergoing routine antenatal, miscarriage or sub fertility care.
3.1.25Clinical staff undertaking assessment must be appropriately trained and experienced and the assessment should be undertaken in accordance with the RCOG Guideline and any other appropriate clinical evidence or guidance.
3.1.26Advice provided on pregnancy options should cover the benefits and risks of continuing with the pregnancy or opting for an termination of pregnancy, and should be provided by staff who are competent to advise on these benefits and risks.
3.1.27All service users should be offered a screening test for chlamydia and will be advised of the results, whether positive or negative. Any service user whose test result is not available prior to the procedure should be treated prophylactically, and service users whose positive test result is available before the procedure should receive treatment. The treatment given should conform to prevailing BASHH guidelines on treatment for chlamydia. Any service user testing positive will also be advised to attend their local GUM clinic for a further discussion about their general sexual health, including the need to notify their sexual partner(s) about their positive result.
3.1.28Partners who attend with service users will also be offered screening for chlamydia, and will be advised of the result whether positive or negative. Partners who test positive for chlamydia will be offered treatment (if the test results are available before the service user’s procedure is carried out) and will also be advised to attend their local GUM clinic for a further discussion about their general sexual health, including the need to notify their sexual partner(s) about their positive result.
3.1.29Service users will be offered an HIV test. At the time of offering this test the Provider will make it clear that a negative result will be notified to the user by the Provider, but that if the result is inconclusive then the service user’s details will be passed to their local GU service who will contact the user for a discussion about further testing and any necessary further care and treatment.
3.1.30[Providers will offer testing for gonorrhoea and syphilis and will advise users of a negative result. If the result is positive or inconclusive then the service user’s details will be passed to their local GU service who will contact the user for a discussion about further testing and any necessary further care and treatment]. It is expected that this clause of the specification will only be used in areas where the prevalence of gonorrhoea/ syphilis is high, and in those areas testing will be commissioned by the Commissioner.
3.1.31All service users should be offered a chaperone for any examination. If a chaperone is present a record should be made of their identity.
3.1.32At no time during the assessment or procedure should a service user be shown an image or scan of the foetus, unless she (not her accompanying person(s)) specifically requests this.
3.1.33If the Provider feels that a service user could benefit from services of other agencies to support and help them either in coming to a decision about whether to proceed to termination of pregnancy, or to support them in continuing with the pregnancy, then the Provider with the consent of the service user should refer the user to a designated agency offering impartial advice with an arrangements for a rapid return if she wishes to have an termination of pregnancy, or rapid entry to antenatal care is she wishes to continue the pregnancy. Service users should ensure that they complete any referral procedures within two calendar days.
3.1.34If the service user is not pregnant, then she should be offered advice on contraception together with the supply of an appropriate contraceptive method (see Contraception below).
3.1.35Service users who do not wish to proceed with an termination of pregnancy will be referred back to the original referrer (if any) and the referrer will be notified of the reason for this, in writing, providing the user consents to this action, and advised of the need for prompt access to antenatal care.
3.1.36Service users who choose to proceed with a termination of pregnancy should be advised on appropriate termination of pregnancy methods depending on their gestation and health and other circumstances. The service user’s wishes must be taken into account, and the Service Provider should transfer the user to another service or agency if they are unable to undertake the chosen termination of pregnancy method.