Towards comprehensive early abortion service delivery in high ...

RESEARCH ARTICLE Open Access

Towards comprehensive early abortionservice delivery in high income countries:insights for improving universal access toabortion in AustraliaAngela Dawson1* , Deborah Bateson2, Jane Estoesta3 and Elizabeth Sullivan4

Abstract

Background: Improving access to safe abortion is an essential strategy in the provision of universal access toreproductive health care. Australians are largely supportive of the provision of abortion and its decriminalization.However, the lack of data and the complex legal and service delivery situation impacts upon access for womenseeking an early termination of pregnancy. There are no systematic reviews from a health services perspective tohelp direct health planners and policy makers to improve access comprehensive medical and early surgicalabortion in high income countries. This review therefore aims to identify quality studies of abortion services toprovide insight into how access to services can be improved in Australia.

Methods: We undertook a structured search of six bibliographic databases and hand-searching to ascertain peerreviewed primary research in English between 2005 and 2015. Qualitative and quantitative study designs weredeemed suitable for inclusion. A deductive content analysis methodology was employed to analyse selectedmanuscripts based upon a framework we developed to examine access to early abortion services.

Results: This review identified the dimensions of access to surgical and medical abortion at clinic or hospital-outpatient based abortion services, as well as new service delivery approaches utilising a remote telemedicineapproach. A range of factors, mostly from studies in the United Kingdom and United States of America were foundto facilitate improved access to abortion, in particular, flexible service delivery approaches that provide women withcost effective options and technology based services. Standards, recommendations and targets were also identifiedthat provided services and providers with guidance regarding the quality of abortion care.

Conclusions: Key insights for service delivery in Australia include the: establishment of standards, provision ofchoice of procedure, improved provider education and training and the expansion of telemedicine for medicalabortion. However, to implement such directives leadership is required from Australian medical, nursing, midwiferyand pharmacy practitioners, academic faculties and their associated professional associations. In addition, politicalwill is needed to nationally decriminalise abortion and ensure dedicated public provision that is based oncomprehensive models tailored for all populations.

* Correspondence: [email protected] of Health, University of Technology, Sydney (UTS), P.O. Box 123,Ultimo, NSW 2007, Sydney, NSW, AustraliaFull list of author information is available at the end of the article

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Dawson et al. BMC Health Services Research (2016) 16:612 DOI 10.1186/s12913-016-1846-z

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http://creativecommons.org/publicdomain/zero/1.0/

BackgroundAccess to a safe, early induced abortion, or the termin-ation of an unplanned pregnancy (up to and including13 weeks [1] can potentially prevent the death of nearlyhalf a million women and the associated morbidity ofanother five million women worldwide [2]. Improvingaccess to safe abortion is an essential strategy in theprovision of universal access to reproductive health andachieving the sustainable development goals [3].Comprehensive safe abortion care encompasses the

provision of elective abortion services at the request ofthe woman, along with counselling for contraceptiveuse, medical after-care, and attention to other issuesthat are relevant to the woman’s health [4]. Theprovision of safe medical and/or surgical abortion re-quires an enabling legal, regulatory and policy envir-onment that is responsive to women’s needs andcommunity demands for quality care, services and in-formation. The legal grounds upon which a woman ispermitted to have an abortion differ across and withincountries. However, a woman’s access can also be affectedby the: availability and quality of health services, geo-graphical access to services, financial affordability andsocio-cultural acceptability of the procedure/s and as-sociated care.Planning, delivering and evaluating legal and safe,

comprehensive abortion services that enable women tomake a choice about the use of such services requires at-tention to a number of principles that were developedby the World Health Organization (WHO) through ahigh level consultative process. These quality servicedelivery principles include the establishment of nationalstandards and guidelines, integrated multidisciplinaryservices, ensuring health-care provider skills and perform-ance, the costing and financing of services, and a systematicapproach to policy and programme development.Despite numerous guidelines and recommendations

there has been little research from a health services ap-proach to help direct health planners and policy makersto increase access to abortion. Souza et al. have notedgaps in best practice with regard to integrating abortionservices into existing family planning services and opti-mizing the workforce [5]. However, although task shift-ing from doctors to nurses and midwives in high incomecountries (HIC) (countries with a gross national incomeper capita of $12,476 or greater) [6] shows promise [7],there is a lack of evidence in this area [8]. The few sys-tematic reviews that are available in the area of servicedelivery include an examination of the acceptability ofhome and clinic based medical abortion by Ngo et al. [9]in largely low and middle income countries (LMIC) withthe exception of one study from France. Another reviewcomprising three studies from Italy, Scotland andIceland found no evidence of increased acceptance and

use of contraceptive methods after an abortion [10].The review by Doren at al. [11] examines factors thatfacilitate or constrain access to abortion from the per-spective of women and providers. Despite these studiesthere are no systematic reviews that provide insightinto models of comprehensive medical and surgicalabortion services. This review therefore aims to identifyquality studies of abortion services to provide insightinto how access to services can be improved inAustralia.

The Australian contextThere is no national data collection on the incidence ofinduced abortion in Australia. Notification of abortionsis mandatory in the States of South Australia, WesternAustralia and the Norther Territory but only SouthAustralia and Western Australia publish data on inducedabortions [12, 13]. Several studies have estimated thenumber of abortions in Australia of over 80,000. The esti-mated number of induced abortions adjusted for patientswho do not claim Medicare (National ReimbursementServices) were 84218 and 83210 in 2013 and 2014, re-spectively. The national age-standardised abortion ratewas 19.7 per 1000 women in 2003 and 19.3 per 1000women in 2004. However, the latest information was from2004 [14–16].The situation in Australia is further complicated with

marked differences in abortion legislation between statesand territories. Of the nine laws that govern abortion inthe country, restrictions exist in all with the exception ofthe Australian Capital Territory. This highlights the ur-gent need for reform [17]. The recent focus at the na-tional level has been on new Medicare Benefit paymentsfor pregnancy support counselling that has been poorlyaccessed by women with unplanned pregnancies [18].The Australian public including health professionals

are largely supportive of the provision of abortion [19, 20]and its decriminalization [21]. However, the lack of dataand the complex legal and service delivery situation im-pacts upon access for women seeking an early terminationof pregnancy. Recent literature cites issues related to geo-graphical and financial access [22, 23] and considerablegaps in women’s knowledge [24]. Services are providedacross a myriad of public and private contexts where thereis no accepted and standardized approach for service de-livery that facilitates universal access to comprehensiveabortion care. This paper therefore aims to identify servicedelivery models of comprehensive abortion care, bothmedical and surgical, that has been effective in increasingaccess to early abortion care in high income country set-tings. Such insights may provide Australia with practicalevidence-based policy options for improving access toabortion services.

Dawson et al. BMC Health Services Research (2016) 16:612 of 23

A framework for understanding the factors contributingto universal access to comprehensive abortion servicesAccess can be understood from supply and demand sideperspectives [25]. Demand for a service is influenced byfactors that determine whether a woman is willing andable to seek appropriate abortion care. Supply is deter-mined by factors that include availability, technology,management, and price that interact to produce effectivehealth care. These perspectives can be considered undervarious dimensions of access that are well described inthe literature [26, 27]. We have summarised these dimen-sions in a framework adapted from existing literature[28, 29] (see Table 1) in order to conceptualise ques-tions that can be used to examine the extent of accessto abortion services.

MethodsSix bibliographic databases (Medline, PubMed, Web ofScience, ProQuest Health and Medicine, Scopus, ScienceDirect), Google Scholar and the reference lists of identifiedpapers were methodically searched to retrieve research lit-erature. A deductive qualitative content analysis method-ology was employed to analyse selected primary researchmanuscripts [30].A Population, Interventions, Comparators, Outcomes,

Study design question guided the development of the

review question [31]. The question we sought to answerwas: for services providing first trimester abortion inhigh income country settings, what approaches to servicedelivery have been found to be effective in increasing ac-cess? We aimed to include studies with demonstrable out-comes from both supply and demand perspectives whileacknowledging important health systems factors that en-able service delivery. We sought studies examining com-prehensive abortion services, as well those investigatingcomponents of abortion services with a focus on under-standing new or existing delivery systems and key pro-cesses as defined by Donadedian [32]. Outcomes ofinterests include the abortion service delivered, changesin behaviour such as contraception uptake, change inhealth status such as complete terminations and women’saccess to abortions services as defined in Table 1 includingsatisfaction and uptake of services.We defined comprehensive abortion service delivery

as the provision of legal, safe, stigma free, high qualityservices that include abortion, post abortion care,contraception and referral. This also involves attentionto issues concerning information provision, initial as-sessment and arrangements for the procedure as out-lined in the recent best practice paper by the RoyalCollege of Obstetricians and Gynaecologists (RCOG)[33] and service factors identified by IPAS [34].

Table 1 A framework for examining access to early abortion services

Access Dimensions Questions to establish extent of access to comprehensive abortion services-what isdone and how

Availability: The number of existing abortion services meetwomen’s needs

How many and what types of abortion services exist? Which organizations offer theseservices? Are there enough willing and skilled personnel to deliver abortion services?Do the services offer choices that correspond with the needs of financiallydisadvantaged women? Are the services and supplies of abortion drugs andassociated equipment and tests sufficient to cover the demand?

Accessibility: Abortion services are near where women live, oraccessible in their homes and referral timely

What is the geographical distance between abortion services and the homes ofwomen? Can services be reached and women referred in a timely and stress-freemanner? How has technology been employed to address issues of distance?

Affordability: The prices of terminations are aligned withwomen’s income and ability to pay

What are the direct costs of abortion services and the associated commodities? Whatare the indirect costs in terms of transportation, childcare, lost time and income? Arepayment options available for women? What are the costs to the health system andare they affordable?

Adequacy: The organization of abortion services meetwomen’s expectations

How are/is the abortion service/s organized? Does the organizational structure meetwomen’s expectations? Do opening hours match the schedules of women? Arefacilities clean, organized and well managed?

Acceptability: The services are satisfactory and used bywomen

Does the information, explanation, and service provided accommodate social normsand values? Do women find self-management aspects such as drug taking and pregnancytesting satisfactory and easy to use? Do women feel welcome and cared for? Do womentrust in the competence and character of the health care providers?

Quality: The services are scientifically and medicallyappropriate and of good quality

Are there service delivery standards and quality management systems? How arewomen’s complaints dealt with? What quality assurance, control and improvementmechanisms are in place? Quality also extends to the manner in which women aretreated, and how underlying determinants of health are addressed. Is there providersensitivity training (i.e. in appropriate language use, cultural safety, privacy) or/andincentive schemes for providers to offer services? Are providers accredited, andregulated? Do providers collect accurate data? Is family planning/contraceptive adviceprovided? How are abortifacient drugs packaged? Is treatment observed if required?What family planning training and peer support is available for providers?


In line with other systematic reviews in the field [35, 36]a structured search of contemporary research literaturewas conducted between 2005 and 2015 using key words:“abortion” OR “termination of pregnancy” AND “servicedelivery” OR “model of care”. We sought to assess the re-sults of peer reviewed primary research literature thereforegrey resources were excluded. Retrieved records were firstscreened for their focus on abortion service delivery ac-cording to the review question by the first author and du-plicates removed. According to the inclusion/exclusioncriteria (see Table 2) studies whose focus was outside ofthe aim, along with discursive papers and those older than10 years were removed. The Preferred Reporting Items forSystematic Reviews and Meta-Analyses (PRISMA) guide-lines were employed to report the review process [37](see Fig. 1). The sources and numbers of papers re-trieved and screened according to their relevance areoutlined at Table 3. Most papers were then excluded(999) at closer examination as they were not concernedwith specific service delivery aspects the paper by Loeberis one example [38].Forty-one papers were appraised using the Critical Ap-

praisal Skills Programme tool for qualitative research[39] and Pluye et al.’s [40] scoring system was used toassess the non-experimental and mixed method studies.Fourteen items were discarded due to methodologicalconcerns. The lead author first appraised the papersusing the checklists of both tools which were independ-ently verified by the DB and ES.Data were extracted from the twenty-nine papers and

first described according to characteristics of the research(e.g., primary author, year of publication, study setting); re-search participants (age, gender, and socio-demographicdata); study aim; study design, and findings (see Table 3).The conceptual framework outlined at Table 1 was thenapplied to identify the dimensions of access and demandor supply perspective. A content analysis of the extractedtext relating to each dimensions of access was performed

by the first author and then discussed with all authors.The questions aligned with each dimension of access aswere used to interrogate the findings of the paper. Wethen identified evidence of processes and outcomes thatcontributed to the ability of the service to increase ac-cess to abortion, as well as the constraints, to provideinsight into how access to services could be improvedin Australia.

ResultsTwenty-nine papers were included in this review (seeTable 3). Fourteen papers were from the United Kingdom(UK) [41–54], seven from the United States (US) [55–61],two from Russia [62, 63], two from Australia [22, 23],three from New Zealand (NZ) [64–66] and one Canadianpaper [67]. Of these papers all were quantitative except forthree qualitative studies [22, 57, 61].We categorized the papers according to the aspect of

the abortion service under study, outcome measures, di-mensions of access covered (see Table 4) and their focuson supply, demand or both (see Table 5). Of these, sixpapers focus specifically on service delivery related to as-pects of surgical termination of pregnancy (STOP) whilenine papers were concerned with medical termination(MTOP). Other papers describe both types of abortionwith service related outcomes according to the compo-nents of care [48, 63], approach to service integration [45],referral, booking and counselling [43, 44, 49, 56, 67]and the type of facility where the services are provided[23, 46, 60, 61, 64–66]. Of the access dimensions covered,least covered were adequacy and affordability with supplyfocused papers gaining more attention than those solelyconcerned with demand side issues. The results of the ana-lysis of the findings section of the 29 papers as per thequestions generated from the dimensions in Table 1 are de-scribed below. We have specifically reported factors thathave been identified to enhance access service delivery andthose that have been found to constrain access to services.

Table 2 The inclusion/exclusion criteria applied to the screening of papers for the review

Included Excluded

Health service research examining how women access health providersand early abortion services, how much care costs, and what happens towomen as a result of this care

Clinical studies examining safety and effectiveness of medications, devices,diagnostic products and treatment regimens intended for early abortion

Research examining first trimester abortion service delivery processes,activities, strategies or components with the goal of improvingprovision, quality, utilization, coverage, efficiency, and equity

Research examining input aspects or resources of abortion care such ashuman resources, insurance schemes, drug supply or procurement,national policy or governance

Studies that include women’s and provider’s experiences of an actualearly abortion service or specific aspects of the delivery of the service orapproaches involved

Studies exploring women’s preferences, reasons, opinions for or aboutservices if they needed them. Papers concerning health professional’sgeneral experiences of provision or interest in provision

Primary research paper Discursive or descriptive outlines of projects, conference abstracts

High income country Upper middle, middle, lower middle and low income country setting

English Non English

>2005 <2005


AvailabilityThe availability of both MTOP and STOP services atfacilities was found in one study to increase access.Tupper et al. describe the development of a new MTOPservice in the UK to address a gap in the public sectorprovision of abortion; and to increase the timeliness andchoice of type of first trimester abortion for women in anarea where only STOP had previously been availableand MTOP via an out of area private provider [53].This retrospective audit of the first 12 months of theservice indicate that it went some way towards address-ing the need for an increase in the availably of MTOPand meeting the Department of Health targets on TOPto reduce waiting times and increase the number ofwomen provided with an abortion under 10 weeks’ gesta-tion. The findings show that all available appointmentswere filled in the first week that the service was openedhowever some patients had to be referred in the first8 months due to a lack of staffing capacity. The servicewas therefore extended to accommodate the larger thananticipated demand resulting in lower numbers of onwardreferrals. Another UK study evaluated a newly established,public and NGO sector MTOP service to increasewomen’s choice in an area where STOP was only available.However the impact of the new service was not reportedother than the numbers of successful early MTOP pro-cedures [46].

Three papers in the review outline the NGO, PlannedParenthood’s efforts to increase the availability of MTOPin the one State in the US by providing medical abortionvia telemedicine at clinics without an on-site physician[57–59]. Women noted the service enabled them toundergo the procedure sooner without waiting for anappointment which ensured the availability of MTOP asper the gestational age limit. Staff noted that the servicewas able to achieve a greater reach and offer morechoice for abortion, as well as access to timely same daytreatment. Staff stated that they found the process ofintroducing the service useful in building their skills andability to provide new services [57]. There was an in-crease in the proportion of medical abortions in theclinics from 46 to 54 %. Clinic patients had increasedodds of obtaining both MTOP before 13 weeks’ gestationafter the introduction of telemedicine [58, 59].Another paper examined the use of a telephone book-

ing service to increase the availability abortion via man-ual vacuum aspiration (MVA) under local anaesthesia ina local English hospital [52]. The study established thatdemand from referrers for the telephone booking clinicwas greater than could be accommodated by the service[52]. However, substituting two doctor assessment clinicsof 10 patients for two clinics of six patients, supported by2.5 nurse telephone clinics, was able to increase theservice capacity by 25 %.

Fig. 1 The Literature review selection process. Preferred Reporting diagram for Systematic Reviews and Meta-analyses (PRISMA) showing selectionof publications for review


Table

3Summaryof

allp

apersinclud

edin

thereview

Reference

Con

text

Metho

dSample/participants

Aim

Find

ings

(Astle,C

ameron

&John

ston

e2012)[54]

Med

icalabortio

n:NationalH

ealth

Serviceho

spitalScotland

UK

Quantitativede

scrip

tive:

Aretrospe

ctiveauditof

facilitydata

1128

wom

enun

dergoing

med

icalabortio

n(upto

64days’g

estatio

n)over

9-mon

thpe

riod

Toestablishho

wearly

med

ical

dischargeim

pactsup

onan

abortio

nservicein

term

sof

unsche

duled

re-attendanceratesandcontraception

provision

atdischarge.

590(52%)choseEM

D.The

rewas

nosign

ificant

differencein

unsche

duled

re-atten

danceratesbe

tweenEM

D(n=23,4

%)a

nddaycase

grou

ps(n=20,4

%).Therewas

nosign

ificant

differencein

theprop

ortio

nof

wom

enin

each

grou

pwho

leftho

spitalw

ithan

effectivemetho

dof

contraception

(n=362,61

%andn=355,60

%for

EMDanddaycase

grou

ps,respe

ctively).

(Blum

etal.

2012)[55]

Medicalabortion:Stanford

University

Hospital'sOB/GYN

clinic,PaloAlto,

CA;Plann

edParentho

odMarMon

te,

Sacram

ento,2

clinicsof

theFamily

Planning

AssociatesMedicalGroup

,Ch

icago,USA

Quantitativede

scrip

tive:

prospe

ctiveclinicalstud

yandsurvey

429wom

enused

apreg

nancy

testto

determ

inebaselinehC

Gon

thedayof

mifepristone

administrationandfollow-up

hCG1weeklater.189wom

encompleted

asurvey.

Toassesstheeffectivenessof

asemi-

quantitativeho

mepregnancytestas

apo

ssiblereplacem

entfor

in-person

follow-upafterm

edicalabortion.

Thetestiden

tifiedtheon

eon

going

preg

nancyin

theclinicalstud

ycoho

rt.

Sensitivity

andspecificity

were

calculated

at100.0%

and97.0%.The

majority

ofparticipantsin

both

the

clinicalstud

yandtheuser

compreh

ension

survey

foun

dthetest

tobe

“veryeasy”or

“easy”

touse.

(Cam

eron

etal.

2010)[41]

Medicalabortion:ho

spitalEdinb

urgh

,Scotland

,UK

Quantitativede

scrip

tive:

prospe

ctiveclinicalstud

yandsurvey

145wom

enchoseto

goho

me

toabort,69

%wom

encompleted

questio

nnaires

Toassesseffectivenessandsatisfaction

ofwom

enwith

early

medicaldischarge

afterabo

rtion

Thecommon

estreason

sgivenfor

choo

sing

togo

homewere:to

get

homesoon

er(53%)andto

bein

the

privacyof

one’sow

nho

me(47%),

81%

ofthewom

enstated

that

bleeding

was

either

“asexpe

cted

”(55%)o

r“not

asbadas

expe

cted

”(26%),and58

%of

thewom

enstated

that

thepain

was

“asexpe

cted

”(40%)

or“not

asbadas

expected”(18%),84

%of

thewom

ensaidthatthey

would

recommendthismetho

dto

afriend.

(Cam

eron

etal.

2012)[42]

Med

icalabortio

n:Ro

yalInfirm

ary

ofEdinbu

rgh,Scotland

,UK

Quantitativede

scrip

tive:

prospe

ctiveclinicalstud

yandsurvey

476op

tedforteleph

one

follow-up

Toevaluate

teleph

onefollow-upin

term

sof

describ

ingthenu

mbe

rsof

wom

enchoo

sing

tobe

followed

upin

thisway,follow-uprates,efficacy

ofLSUPtestforde

tectingon

going

preg

nanciesandwom

en’s

satisfaction

476ou

tof

619wom

en(77%).op

ted

forteleph

onefollow-up,

4wom

en(1%)attendedtheclinicbeforeteleph

one

follow-upbecauseof

painor

bleeding

.Atotalof410

(87%)o

fthe

remaining

472

wom

enweresuccessfullycontactedby

teleph

one.Sixtywom

en(15%)screened

‘positive’,three

ofwho

mhadon

going

pregnancies,andon

ewom

anfalsely

screened

‘negative’.The

sensitivityof

the

teleph

onefollow-upwas

75%

[95%

confiden

ceinterval(CI)30.1–95.4],and

specificity

was

86%

(95%

CI8

2.2–89).

Thene

gativepred

ictivevaluewas

99.7%(95%CI

98.4–99.9),and

positive

predictiv

evaluewas

5%

(95%

CI

1.7–13.7).Allwom

ensurveyed

(n=75)

wou

ldrecommendteleph

onefollow-up

toafriend.


Table

3Summaryof

allp

apersinclud

edin

thereview

(Con

tinued)

(David

etal.

2007)[62]

Perm

,BereznikiandVelikyNovgo

rod

20health

caresites

(five

maternity

hospitals,six

wom

en’sconsultation

centreslinkedto

thoseho

spitals,

threefamily

planning

clinicsandsix

children’spo

lyclinicsRussia

Quantitativede

scrip

tive:

impact,p

re-andpo

st-

interven

tionsurveys

489abortio

nclientsin

2000,

559in

2002

and527in

2003

surveyed

inthreefacilities

Toevaluate

apo

stabortio

ncare

prog

ram

toincrease

uptake

offamily

planning

Theprojectinterventio

nsappearto

have

extend

edthecoverage

ofcontraceptive

coun

selling

tonearlyallabo

rtionclients.

Providerstraining

resultedinincreased,

andpo

ssiblymoreeffective,discussio

nsabou

tcontraceptionwith

abortionclients.

Morethan

80%of

post-abo

rtionclients

expressedno

ton

lyan

intentionto

use

medicalcontraceptionbu

thad

identified

theirm

etho

dof

choice.Finding

ssugg

est

thatcertainwom

enconceive

againsoon

afteranabortionprocedureandaremore

likelyto

abortag

ainrather

than

tryto

preventthe

unwantedpregnancy.Ab

ortion

iswidelyavailableandeasilyaccessible,

reducing

theneed

forw

omen

topractice

consistentand

effectivecontraception,but

mostw

omen

saythatthey

wouldprefer

topreventu

nwantedpregnanciesthrough

theuseof

mod

erncontraceptionho

wever

theseareeither

tooexpe

nsiveor

repo

rted

lyfaildu

eto

poor

quality.

(Dod

ge,H

aide

r&Hacker2012)

[56]

Medicalandsurgicalabortion:USA

Quantitativede

scrip

tive:

simulated

patient

calls

toservices

inthe5mostand

6leastabortionrestrictive

states

usingasurvey

142teleph

onecalls

were

madeto

48no

n-provider

facilities;46

facilitieswere

contacted3tim

esand2

werecontactedtw

ice

Todeterm

inethequ

ality

andqu

antity

ofreferralsforabo

rtion

services

from

reprod

uctivehealth

carefacilitiesthat

dono

tprovide

abortionservices.

45.8%of

callresultedinadirectreferral,

19.0%resultedinan

indirectreferral,8.5%

resultedinan

inapprop

riate

referraland

26.8%resultedinno

referral.Facilitiesin

leastrestrictivestates

weresig

nificantly

morelikelyto

provideunprom

pted

direct

referrals(p=0.006)andsig

nificantly

less

likelyto

provideno

referral(p<0.001)than

facilitiesinmostrestrictivestates,tho

ugh

thesedifferences

disapp

earedafter

prom

ptingthestaffm

embertoprovidea

referral.

(Doran

&Hornibroo

k2014)[22]

Surgicalabortio

n:New

South

Wales,A

ustralia

Qualitativede

scrip

tive

13ruralw

omen

who

had

anearly

surgicalabortio

n5mon

thsto

15years’prior

Toidentifyfactorsthatwom

enexperienceinrelationto

theirability

toaccessan

abortionserviceand

follow-upcare

Themainbarrierruralw

omen

experienced

was

travellin

grelativelylong

distancesto

accessan

abortionclinicbecauseof

lack

ofservices

intheirlocalarea.W

omen

with

limitedfinancialresourcesneeded

tobo

rrowmon

eyforthe

procedureand

associated

costsof

traveland

accommod

ation.Wom

en’sHealth

Centres

providearang

eof

supp

ortand

referral

inform

ation.Lack

ofintegrated

carewas

repo

rted.

(Esenet

al.2006)

[43]

Med

icalandsurgicalabortio

n:TO

PclinicSouthTyne

side

Foun

datio

nTrust,EnglandUK

Quantitativede

scrip

tive:

prospe

ctivesurvey

and

exam

inationof

case

notes

340wom

enrequ

estin

gterm

inationof

preg

nancy

seen

attheclinicin

2003

Toevaluate

theterm

inationof

pregnancyserviceinSouth

Tynesid

einclud

ingou

rcom

pliance

with

RoyalCollege

ofObstetricians

Thenu

mbero

freferralsrepresented

one-fifth

ofallbirths

inou

runitdu

ring

thestud

yperiod.Teenagerswerethe

largestsinglegrou

pof

wom

enrequ

esting

term

inationof

pregnancyandthemajority


Table

3Summaryof

allp

apersinclud

edin

thereview

(Con

tinued)

andGynaecologiststerm

inationof

pregnancygu

idelines

werenu

lliparou

s.Therewere85

wom

enwho

wereseekingarepeatterm

inationof

pregnancy.TheRC

OGminimum

referral

standard

was

met

in80

%of

cases.A

good

numbero

fwom

enwereun

sureof

theirm

enstrualdatesandon

ly5%had

used

emergencycontraception.Atotalof

96%wereeitherno

tusin

gcontraception,

usingco

ndom

sor

taking

oral

contraceptiv

esirreg

ularly.A

totalo

f50

%of

thewom

enattend

edho

spita

lwitho

utaCertificateAbeing

completedbythereferring

practition

er.Surgical

term

inationwas

preferred

over

med

ical

term

inationin

thecoho

rtof

wom

enwho

couldexercise

achoice.

(Finnie,Foy&

Mathe

r2006)

[44]

Med


n:SouthDurham

intheNorth

Eastof

England,

UK

Quantitativede

scrip

tive:

survey

andreview

edthe

case

notesof

wom

en

Wom

enattend

ingtwo

fertilitycontrolclinicsgeneral

practitionerswho

referred

wom

ento

theseclinics

Toiden

tifyservice-relatedde

lays

andbarriersfacedby

wom

enseekingabortio

ncare

Of210wom

ensurveyed

,132

(63%)

respon

ded.

Of1

07referred

byGPs,16

(15%)h

adto

makeasecond

appo

intm

ent

with

anotherG

Pwilling

toreferthem

and

34(32%)w

aitedtwoor

moredays

toreceiveada

tefortheirho

spital

appo

intm

ent.Th

enatio

nalstand

ard

waitin

gtim

eof

3weeks

from

first

appo

intm

entwith

thereferringdo

ctor

totheprocedurewas

achieved

for5

6/127

wom

en(44%;95%CI,35–53).Wom

enratedglob

alsatisfaction,provision

ofinform

ationandstaffinteractionmore

high

lyinsecond

arythan

primarycare.O

f170GPs

surveyed,140

(82%)respo

nded;

33(24%)con

sidered

them

selves

‘broadly

anti-abortio

n’.

(Graham,

Jayade

va&

Guthrie2010)

[45]

Med


n:Hulland

EastRiding

hospitals

inYo

rkshire,Eng

land

UK

Quantitativede

scrip

tive:

Aretrospe

ctiveauditof

facilitydata

8,476med

icalor

surgical

indu

cedabortio

nsun

dertaken

at14

weeks’

gestationor

unde

r

Toassess

theeffectiven

essof

anintegrated

care

pathway

for

deliveryof

eviden

ce-based

practicein

abortio

ncare.

100wom

enwerere-adm

itted

into

the

gynaecolog

icalwards

ofho

spitals.

Readmissionrate

was

1.2%.The

ICP

show

edthat97

%of

wom

enhad

chlamydiascreeningpriortotheabortio

n;allw

omen

hadacontraceptivediscussio

nand43

%leftusingalong

-acting

reversiblemetho

dof

contraception

(LARC

).How

ever,dataou

tsidethecare

pathway

was

notdo

cumented,andhence

thestandard

ofcare

givenon

readmission

was

difficultto

locate

andvariableinqu

ality.

(Grin

dlay,Lane&

Grossman

2013)

[57]

Med

icalabortio

n:Planne

dParentho

odclinicsUSA

Qualitativein-dep

thinterviewsthem

atically

analysed

25wom

enreceivingmedical

abortionservices

(20telemedicine

patientsand5in-personpatients)

and15

clinicstaff.

Toevaluatepatients’andproviders’

experiences

with

telemedicine

provision

ofmedicalabortion.

Patientsandproviderscitedadvantages

oftelemed

icine,includ

ingde

creased

travelforpatientsandph

ysicians

and

greateravailabilityof

locatio

nsand


Table

3Summaryof

allp

apersinclud

edin

thereview

(Con

tinued)

appo

intm

enttim

escomparedwith

in-personprovision.Overall,patients

werepo

sitiveor

indifferent

abou

thaving

theconversatio

nwith

thedo

ctor

take

placeviatelemed

icine,with

most

repo

rtingitfeltprivate/secure

andin

somecaseseven

morecomfortab

lethan

anin-personvisit.How

ever,o

ther

wom

enpreferredbe

ingin

thesame

room

with

theph

ysician,

highlighting

theim

portance

ofinform

ingwom

enab

outtheirop

tions

sothey

canchoo

setheirpreferredservicemod

ality.

(Grossman

etal.

2011)[58]

Med

icalabortio

n:Planne

dParentho

odaffiliate

inIowa

USA

Quantitativede

scrip

tive:

prospectiveclinicalcoho

rtstud

yandself-administered

survey

Of578en

rolledparticipants,

follow-updata

wereob

tained

for223telemed

icinepatients

and226face-to-face

patients.

Toestim

atetheeffectiven

essand

acceptability

oftelemed

icine

provisionof

early

med

icalabortio

ncomparedwith

provisionwith

aface-to-face

physicianvisit

99%

oftelemed

icinepatientshada

successful

abortio

nwas

for(95%

confiden

ceinterval[CI]96–100

%)a

nd97

%forface-to-face

patients(95%

CI

94–99%).91

%of

allp

articipantswere

verysatisfiedwith

theirabo

rtion

,althou

ghinmultivariableanalysis,telemedicine

patientshadhigh

erod

dsof

saying

they

wou

ldrecommendtheserviceto

afriend

comparedwith

face-to

-face

patients(odd

sratio,1.72;95

%CI1.26–2.34).25%of

telemedicinepatientssaidthey

wou

ldhave

preferredbeinginthesameroom

with

thedo

ctor.You

ngerage,

(Grossman

etal.

2013)[59]

Med

icalabortio

n:Planne

dParentho

odaffiliate

inIowa

USA

Quantitativede

scrip

tive:

Review

ofIowavital

statistic

data

andbilling

data

from

theclinic

system

17956abortio

nen

coun

ters

2yearspriorto

andafterthe

introd

uctio

nof

telemed

icine

inJune

2008

Toassesstheeffectof

atelemedicine

mod

elprovidingmedicalabortion

onservicedeliveryinaclinicsystem

Theabortio

nrate

decreasedin

Iowa

aftertelemed

icineintrod

uctio

n,andthe

prop

ortio

nof

abortio

nsin

theclinics

that

weremed

icalincreasedfro

m46

%to

54%.A

fter

telemed

icinewas

introd

uced

,and

with

adjustmen

tfor

othe

rfactors,clinicpatientshad

increasedod

dsof

obtainingbo

thmed

icalabortio

nandabortio

nbe

fore

13weeks’g

estatio

n.Alth

ough

distance

travelledto

theclinicde

creasedon

lyslightly,w

omen

livingfarthe

rthan

50milesfro

mthene

arestclinicofferin

gsurgicalabortio

nweremorelikelyto

obtain

anabortio

naftertelemed

icine

introd

uctio

n.

(Gup

ta&

Kapw

epwe

2007)[46]

Med

icalabortio

n:Waltham

Forestin

England,

UK.

Quantitativede

scrip

tive:

Aretrospe

ctiveauditof

facilitydata

1,257abortio

nswere

unde

rtaken

inWaltham

Forestin

2004/5

Toevaluate

ane

wlyestablishe

dservicewith

anNGO

A92

%completed

abortio

nou

tcom

ewas

achieved

.58/63

completed

EMA;

5/63

failedEM

A.


Table

3Summaryof

allp

apersinclud

edin

thereview

(Con

tinued)

(Ham

odaet

al.

2005)[47]

Surgicalabortion:Ab

erdeen

RoyalInfirm

ary,National

Health

Servicesetting

.Scotland

UK

Quantitativede

scrip

tive:

prospe

ctiveclinicalstud

yandsurvey

56wom

enTo

assessthefeasibility,acceptability

andefficacyof

MVA

underlocal

anaesthesia

forterminationof

pregnancyup

to63

days’

gestation

Themean(SD)ge

stationwas

50(9.4)

days.A

totalo

f55/56(98%)wom

enhadasuccessful

proced

ureanddidno

trequ

ireanyfurthe

rsurgicalor

med

ical

treatm

ent.Fifty-five(98%)w

omen

were

satisfiedwith

theproced

ure,48

(86%)

said

they

wou

ldrecommen

ditto

afrien

dand45

(80%)saidthey

wou

ldhave

thesamemetho

dagainin

the

future.A

nxiety

levels,asreflected

bythe

visualanalog

uescales,sho

wed

asig

nificant

fallin

anxietyscores

followingthe

proced

ure(p<0.01).

(Jon

es&Jerm

an2013)[60]

Med

icalandsurgical

abortio

n:AllUSstates

Quantitativede

scrip

tive:

natio

nalsam

pleof

8,338

abortio

npatients

Toassess

how

farabortio

npatientstravelledto

aprovider

in2008

andwhich

grou

pswere

morelikelyto

travelfarthe

r

In2008,w

omen

travelledameandistance

of30

milesforabortio

ncare

services,w

ithamed

ianof

15miles.Sixty-sevenpe

rcen

tof

patientstravelledless

than

25miles,

andsixpe

rcen

ttravelledmorethan

100miles.Con

trollingforothe

rfactors,

wom

enwho

lived

inastatewith

a24-h

waitin

gpe

riod,

wom

enob

tainingsecond

trim

esterabortio

ns,tho

sewho

crossed

statelines,and

,inparticular,ruralwom

enweremorelikelyto

travelgreaterdistances

relativeto

theircoun

terparts.W

omen

ofcolour

wereless

likelyto

travellong

distancescomparedto

non-Hispanicwhite

wom

en.

(Kim

port,C

ockrill

&Weitz2012)

[61]

Medicalandsurgicalabortion:

threeabortionclinicslocated

intheMidwestand

southUSA

Qualitative:them

atic

analysis

41wom

enwho

received

anabortio

nTo

understand

impactsof

abortion

clinicstructures

andprocesses

Theprocessesandstructures

oftheabortio

nclinicnecessitatedby

therealities

ofantiabo

rtionho

stilitieslead

somewom

ento

reactn

egativelyto

theclinicexperience

inwaysconsistentwith

thesocialmythof

theabortio

nclinic.Staffinteractions

can

mitigate

oralleviatetheseexperiences.

(Lipp2009)[48]

Med

icalandsurgical

abortio

n:NationalH

ealth

ServiceTrustsin

Wales,U

K

Quantitativede

scrip

tive:

survey

AllNationalH

ealth

Service

Trusts

Toestablishcurren

tprovisionin

term

inationof

preg

nancy

Inthenine

Trustspe

rform

ingabortio

ns,

med

icalabortio

nsaccoun

tedfor57

%andsurgicalabortio

nsfor43

%.D

octors

intraining

wereinvolved

insixTrusts.A

llbu

ton

eTrustcompliedwith

referraltim

es.

Five

Trustsprovided

ade

dicatedclinic.

Writteninform

ationprovided

priorto

abortio

nvariedin

accessibility

andqu

ality.

Cho

iceof

abortio

nwith

inge

stationband

swas

limitedin

someTrustswith

someon

lyprovidingmed

icalterm

ination.Essential

abortio

naftercarewas

perfo

rmed

byTrusts,

whe

reas

follow-upandcoun

selling

were

less

compreh

ensive.


Table

3Summaryof

allp

apersinclud

edin

thereview

(Con

tinued)

(Mason

2005)

[49]

Med

icalandsurgical

abortio

n:tw

oPrim

ary

CareTruststo

aNational

Health

Service-fund

edabortio

nclinicin

theNorth

Westof

England

Quantitativede

scrip

tive:

survey

allclinicattend

eesfro

mwithin

thestud

yarea

duringa

6-mon

thperiod

Toinvestigatethereferralprocess

90%

ofthewom

enwerereferred

directly

from

thefirsthe

alth

profession

althey

consultedto

theabortionclinic.Fivepercent

ofthewom

enwereeither

referre

dto

anotherh

ealth

professio

nalorn

otreferre

danyw

here.Twelve

percentof

thewom

enhadto

waitlong

erthan

the3weeks

recommendedby

theRo

yalC

ollege

ofObstetricians

andGynaecologistsgu

ideline.

Inaminority

ofcasesthiswaitextend

edup

to7weeks.H

owever,m

ostwom

enwere

satisfiedwith

theleng

thof

wait,thehealth

professio

naltheyconsultedwith

and,in

particular,the

care

they

received

atthe

abortionclinicitself.

(McKay

&Ru

therford

2013)

[50]

Medicalabortion:Peterborou

ghCityHospital,UK,

Quantitativede

scrip

tive:

survey

at24

hand

2weeks

followingthe

proced

ure

127wom

enTo

assess

wom

en’s

satisfaction

with

theho

memed

icalabortio

nservice.

At24

h,over

95%of

wom

enwho

respon

ded,agreed

orstrong

lyagreed

thatthey

feltprepared

forthe

painand

bleeding

thatthey

experienced

atho

me.

At2weeks,97.3%of

respon

dentsfelt

thatthey

hadhadenou

ghinform

ation

andknew

whatto

expect,and

were

thereforesatisfiedwith

theprocedure.

Only15

%of

wom

enwerelostto

clinical

follow-upat2weeks.The

majority

ofwom

enaresatisfiedwith

theho

memedical

abortionservice.Thesehigh

satisfaction

ratesaremaintainedat2weeks.Telepho

nefollow-up2weeksafterthe

abortionwas

safeandeffective.

(Nickson

,Smith

&Shelley2006)

[23]

Med

icalandsurgical

abortio

nVictoria,A

ustralia

Quantitativede

scrip

tive:

multi-centre,cross-

sectionalo

bservatio

nal

stud

yusingasurvey

Allwom

enaccessingprivate

services

over

ape

riodof

12weeks.

Toinvestigatetheextent

andcost

oftravelun

dertaken

bywom

enaccessingTO

Pservices.

1,244Australianresid

entrespo

ndentswho

resid

edinVictoria,9.3%travelledmore

than

100km

toaccessservices.Teenagers

were2.5tim

esmorelikelythan

other

respon

dentsto

travelfurtherthan

100

kilometres(km)(18.2%comparedwith

7.8%,O

R=2.5,95

%CI1.5–4.2,p<0.001).

Wom

enoriginated

from

allA

ustralianStates

andTerritoriesexcept

SouthAu

stralia

and

13.7%werefro

mStatisticalDivision

sother

than

Melbo

urne.M

orethan

one-third

ofrespon

dents(41.3%)cho

setheirclinic

becausethey

werereferredby

ado

ctor

orgeneralpractition

er.

(Norman,H

estrin

&Dueck

2014)

[67]


British

ColumbiaWom

en’s

Hospitaland

Health

Centre,

Canada

Quantitativede

scrip

tive:

Aretrospe

ctiveauditof

calls

1998–2008teleph

onecalls

Toreview

thetoll-fre

epreg

nancy

optio

nsserviceprovisionmod

elforcoun

selling

andreferral

Over2000wom

enannu

allyaccessservice

viathePO

Sline,networks

ofcareproviders

areestablish

edandlinkedto

centralsup

port,

andcentralprogram

plannersreceivetim

ely

inform

ationon

newservicegaps

andaccess

barriers.


Table

3Summaryof

allp

apersinclud

edin

thereview

(Con

tinued)

(Oliveras,Larsen

&David

2005)

[63]


Hospitalsinthreecitiesin

Perm

,Berezniki,Veliky

Novgo

rodRussia

Quantitativede

scrip

tive

second

aryanalysisof

data

collected

inasurvey

489abortio

nclients

Toexploreclient

satisfaction

with

abortio

ncare

Client

characteristics,ingeneral,didno

taffect

overallsatisfactionthou

ghtherewere

significantd

ifferencesinoverallsatisfactionfor

unmarriedversus

marriedwom

en(OR=0·29,

CI=0·13,0·63).Similarly,m

ostcharacteristics

oftheabortionvisit

wereno

trelated

toclient

satisfaction,although

wom

enwho

were

awakeforthe

procedurewerelesslikelyto

besatisfied(OR=0·37,CI=0·16,0·89).

Inform

ationprovided

toabortionclientsabout

self-carewas

themostimpo

rtant

predictoro

foverallsatisfactionforabo

rtion

clients

(OR=3·55,CI=1·64,7·69)

(Pillaiet

al.2015)

[51]

Surgicalabortio

n:NHS

SexualHealth

Service,UK

Quantitativede

scrip

tive:

Aretrospe

ctiveauditof

facilitydata

1681

wom

enTo

assess

theapplicability,

acceptabilityandcostimplications

ofintro

ducing

MVA

with

local

anaesthesia

forfullyconscious

first-trimesterterminationof

pregnancy

MVA

was

chosen

by305/1681

potentially

eligiblewom

en.Fortypercenth

adthe

procedureon

thedaythey

attend

edfor

assessment.79

%gave

apainscoreof

3or

lessou

tof10.Co

mplications

occurre

din

sixcases(2%);theseinclud

edcervical

rigidity,a

false

passage,retained

prod

ucts

ofconceptio

n,bleeding

(morethan

200ml)

andon

eallergicreaction.Eigh

typercentof

wom

enchoseto

commence

along

-acting

reversiblecontraception(LARC

)metho

dat

thetim

eof

MVA

.Operatingtheatre

utilisatio

nwas

redu

cedby

oneterm

ination

listperw

eekandcostsaving

sof

arou

nd£60000perann

umwererealise

d.

(Sharm

a&

Guthrie2006)

[52]

Surgicalabortio

n:Wom

enandCh

ildren’sHospital,Hull

RoyalInfirm

ary,Hull,UK

Quantitativede

scrip

tive:

Aprospe

ctiveauditof

facilitydata

andstaff

survey

12wom

en<10

weeks’

gestationat

thetim

eof

term

ination,February–

March

2004,23staff

Toevaluate

nurseledteleph

one

bookingserviceandlocal

anaesthetic

outpatient

surgical

term

inationof

pregnancy

Dem

andfro

mreferre

rsforthe

teleph

one

bookingclinicwas

greaterthancouldbe

accommod

ated

bytheservice.Teleph

one

consultatio

nwas

popu

larw

ithpatientsas

itwas

carriedou

tattheircon

venience

intheirh

omes,and

with

staffasitredu

ced

clinicassessmenttim

e.Somestaffm

embers

feltthatconsultin

gover

theteleph

one

affected

theirassessm

entof

thepatient’s

emotionalstatus.Outpatient

LA-STO

Pseem

edwellacceptedby

both

staffand

patientsas

itofferedpatientsaconvenient

andsafemetho

dof

early

abortion.A

preliminarycostingindicatedanetsaving

plus

increasedservicecapacity.

(Silva&McN

eill

2008)[64]

Med


n:throug

hout

New

Zealand

Quantitativede

scrip

tive:

analysisof

Cen

susdata

andStatisticsNZdata,

calculationof

distances

from

site

ofreferral

Nationw

ideTO

Pservice

inform

ationfro

m2006

Toassessgeog

raph

icaccessibility

tofirsttrimesterterminationof

pregnancy

Wom

enwho

liveinregion

sthatdo

noto

ffer

localTOPservices

musttravelonaverage

221km

toaccessTO

Pservices.Thisequates

toan

averagereturn-tripdistance

of442km

.Threeof

thefiveregion

sthatdo

noth

ave

localTOPservices

availablehave

ahigh

erthan

averageprop

ortionof

Maoripo

pulation


Table

3Summaryof

allp

apersinclud

edin

thereview

(Con

tinued)

(Silva,McN

eill&

Ashton2011)

[65]

Med


n:Nineof

atotalo

f13

firsttrim

ester

clinicsthroug

hout

New

Zealand

Quantitativede

scrip

tive:

Aprospe

ctiveauditof

facilitydata

andsurvey

ofwom

en

2,950patientsattend

ing

nine

abortio

nclinics

betw

eenFebruary

and

May

2000

Toiden

tifythefactorsaffecting

thetim

elinessof

services

infirst

trim

esterabortio

nservice

Wom

enwho

wentto

privateclinichad

asig

nificantly

shorterd

elay

comparedto

publicclinics.Co

ntrolling

forclinictype,

wom

enwho

wenttoclinicsthatoffered

medicalabortio

nsor

clinicsthatoffered

singledayservices

experienced

lessdelay.

Also

,wom

enwho

hadmorethan

one

visit

with

theirreferringdo

ctor

experienced

agreaterd

elay

than

thosewho

hadasin

gle

visit.The

earlier

inpregnancywom

ensoug

htservices

thelong

erthedelay.

Wom

en’sdecisio

n-makingdidno

thave

asig

nificanteffecton

delay.

(Sno

ok&Silva

2013)[66]

Med


n:commun

ity-based

services

ina

high

-dep

rivationdistricthe

alth

boardNew

Zealand

Quantitativede

scrip

tive:

Aprospe

ctiveauditof

facilitydata

180wom

enwho

had

anabortio

nin

2010

Tode

scrib

etheservices

develope

dandassess

safety

andtim

elinessforthefirstyear

ofservice.

Eigh

ty-twopercentof

locally

provided

abortions

in2010

weremedicalabortio

ns,

completed

onaveragelessthan

2days

after

referralto

theservice.One

percento

fpatientsexperienced

haem

orrhagingpo

stabortion,and4%hadretained

prod

ucts.

Theseratesarewith

inaccepted

standards

foranabortionservice.

(Tup

per&

And

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Other studies in the review identified the impact ofthe health workforce on the availability of abortion ser-vices. A shortage of doctors, particularly female doctorswho were willing to perform abortions was noted bystaff of women’s health centres in rural Australia. Inaddition, staff cited a shortage of rural general practi-tioners as impacting upon the availability of referral pointsand follow up care [22]. A study of GPs (No = 126) in thenorth east of England UK found that approximately one-third surveyed did not provide on-site pregnancy testing(52; 37 %) and believed they had insufficient informationabout abortion services (43; 32 %) [44]. It is suggested thatthese factors affected service availability.One study from NZ showed that a newly established

community-based abortion clinic in one district healthboard (DHB) developed to provide local service provisionand prevent out-of-region referrals was able to contribute

to addressing the need for increased availability. Of the180 women from the DHB who had an abortion in2010, 81 % (n = 145) had an abortion locally, while theremaining 19 % went outside the region for the service[66]. However, service availability did not appear to beequitable as three of the five regions that did not haveabortion services were found to have a higher thanaverage proportion of a largely disadvantaged IndigenousMaori population.

AccessibilityTwo studies in the review investigated the use of technol-ogy to address accessibility issues, in particular to elimin-ate travelling time and overcome geographical barriers toabortion services. Qualitative interviews with women whoselected a MTOP telemedicine clinic stated that they didso due to logistical concerns as they were unable to access

Table 4 Access Dimensions Covered across papers in the review

Availability Accessibility Affordability Adequacy Acceptability Quality

(Astle, Cameron & Johnstone 2012) [54] √

(Blum et al. 2012) [55] √

(Cameron et al. 2010) [41] √ √

(Cameron et al. 2012) [42] √

(David et al. 2007) [62] √ √

(Dodge, Haider & Hacker 2012) [56] √

(Doran & Hornibrook 2014) [22] √ √ √ √

(Esen et al. 2006) [43] √ √

(Finnie, Foy & Mather 2006) [44] √ √ √

(Graham, Jayadeva & Guthrie 2010) [45] √

(Grindlay, Lane & Grossman 2013) [57] √ √ √ √ √

(Grossman et al. 2011) [58] √ √

(Grossman et al. 2013) [59] √ √

(Gupta & Kapwepwe 2007) [46] √ √

(Hamoda et al. 2005) [47] √ √

(Jones & Jerman 2013) [60] √

(Kimport, Cockrill & Weitz 2012) [61] √ √ √

(Lipp 2009) [48] √ √

(Mason 2005) [49] √

(McKay & Rutherford 2013) [50] √

(Nickson, Smith & Shelley 2006) [23] √ √ √

(Norman, Hestrin & Dueck 2014) [67] √ √ √

(Oliveras, Larsen & David 2005) [63] √ √

(Pillai et al. 2015) [51] √ √

(Sharma & Guthrie 2006) [52] √ √ √

(Silva & McNeill 2008) [64] √

(Silva, McNeill & Ashton 2011) [65] √

(Snook & Silva 2013) [66] √ √ √

(Tupper & Andrews 2007) [53] √ √ √


Table 5 Approach to abortion service, outcomes, access dimension and perspective

Aspect of abortion service under study Outcome measures Supply and/or demandperspective

Outpatient/home based/early medicaldischarge (MTOP)

(Astle, Cameron & Johnstone2012) [54]

Unscheduled re-attendance rates, contraceptionprovision at discharge rate

Supply

(Cameron et al. 2010) [41] Women’s satisfaction Demand

(McKay & Rutherford2013) [50]

Women’s satisfaction Demand

(Tupper & Andrews 2007) [53] Referral rates, completion rates Supply

(Blum et al. 2012) [55] Home-based follow up using semiquantitative pregnancy test

Sensitivity and specificity of a pregnancy testand women’s usability

Supply–demand

(Cameron et al. 2012) [42] Home-based follow up using nurse-ledtelephone calls

follow-up rates, efficacy for detecting ongoingpregnancies and women’s satisfaction

Supply–demand

In patient/clinic based telemedicine(MTOP)

(Grindlay, Lane & Grossman2013) [57]

Women and staff experience and satisfaction Demand

(Grossman et al. 2011) [58] Completion rates, women’s satisfaction,preferences and recommendations

Demand

(Grossman et al. 2013) [59] Abortion rates, distance women travelled Supply–demand

Outpatient STOP

(Doran & Hornibrook2014) [22]

Outpatient STOP Experience of access to facility Demand

(Hamoda et al. 2005) [47] MVA under local anaesthesia Completion rates, satisfaction, anxiety levels Supply–demand

(Pillai et al. 2015) [51] MVA under local anaesthesia Completion rates, Pain, complications,contraception uptake, cost

Supply–demand

(Sharma & Guthrie 2006) [52] MVA under local anaesthesia andtelephone booking service

Number abortion completions, of telephoneconsultations, referrals, and staff satisfaction

Supply

Abortion care components

(Lipp 2009) [48] STOP and MTOP services Service provision types Supply

(Oliveras, Larsen & David2005) [63]

MVA STOP, MSTOP, dilation and curettage,post-abortion family planning counselling

Women’s satisfaction Demand

(David et al. 2007) [62] Post abortion care program Contraception counselling delivered Supply

Care delivery program type

(Graham, Jayadeva & Guthrie2010) [45]

Integrated care pathway, MTOP and STOP Re-admission rate, contraception advicereceived and uptake

Supply

Referral, booking and counselling

(Dodge, Haider & Hacker2012) [56]

Referral advice Referral rates Supply

(Esen et al. 2006) [43] Referral process Waiting times Supply

(Finnie, Foy & Mather2006) [44]

Referral process Waiting times within the pathway to inducedabortion, women’s rating of care, GPs’ attitudesand self-reported practice

Supply–demand

(Mason 2005) [49] Public service referral process Length of wait, number of professionals involved,women’s satisfaction

Supply–demand

(Norman, Hestrin & Dueck2014) [67]

Toll free options service provision Use rate Supply

Facility type

(Gupta & Kapwepwe2007) [46]

NGO Completion rates Supply

(Jones & Jerman 2013) [60] Public and private clinics Distance travelled Supply


a clinic close by even if they preferred to do so [57].Women also stated that this saved them time, the stress ofdriving to a facility and the need to take time off work.The researchers found that women living more than 80km from the closest facility that offered STOP were morelikely to obtain an abortion after the introduction of tele-medicine [58, 59].Accessibility in the studies reviewed is manly discussed

in relation to constraints. The time and travel distancerequired to access abortion services is examined in anumber of studies included in the review with accessibil-ity for rural women and adolescents more disadvantagedaccording to three papers. The statistical model in Joneset al. US study showed that having an early abortion wasnot associated with increased travel but that womenwho lived in rural areas and those who lived in a statewith a 24-h waiting period were more likely to experi-ence increased travel [60]. In Australia, Nickson foundthat there were limited rural services and adolescentswere 2.5 times more likely than other women to travelmore than 100 km (18.2 % compared with 7.8 %, OR = 2.5,95 % CI 1.5–4.2, p < 0.001) [23]. Interstate travel in orderto access an abortion was noted in two Australian studies[22, 23] with public transport largely unavailable [22].A qualitative study of women’s experiences of three

abortion clinics in the US noted that women sometimesmade a decision to travel a greater distance to specificclinics to avoid protesters and the associated stress [61].Avoiding protesters was also noted by women as onereason for selecting a particular clinic in an Australianhowever, most women selected the clinic on where theyobtained their abortion on proximity to their place ofresidence [23].Several studies were included in the review revealed is-

sues regarding referral and the accessibility of services.Dodge et al. [56] studied referral to abortion services inAmerica from staff at facilities that did not provide abor-tion showing that less than half of the women receiveddirect referrals. Women who did not prompt the stafffor a referral during a call to facilities in States with lessrestrictive abortion laws were significantly more likely to

be provided with direct referrals (p = 0.006) than womenwho called facilities in more restrictive states. Accessibilitywas also hampered according to women in an Australianstudy by slow referrals from health providers [22]. In theUK it was found that referral for abortion was mostly fromgeneral practitioner doctors (GP) [44]. However, a reviewof clinic records in one area in the UK shows that abouthalf of the patients were referred without a Certificate “A”being completed by the referring GP, the reasons for thisin some cases was due to issues doctors had with abortionand their conscientious objection to TOP. It was sug-gested that this may impact upon the speed at whichwomen are able to obtain and abortion [43]. Women inNZ who had more than one visit from their referring doc-tor also experienced a longer delay to receive an abortionthan those who had a single visit [65].Timeliness of referral was also examined in studies in

relation to established recommendations from the UKRoyal College of Obstetricians and Gynaecologists (RCOG).Finnie et al. found that referral targets were largely achievedwith 52% of women seen within 48 h of making an appoint-ment [44]. In addition, the majority (97 %) of women hadabortion procedures within 14 days of clinic appointments[44]. Mason’s study found that twelve percent of thewomen had to wait longer than the 3 weeks, exceeding theRCOG’s recommendations regarding referral [49]. Thesurvey of GPs found they referred girls under 16 yearswho requested an abortion with a parent or guardian[44]. Fewer (72; 52 %) reported that would refer un-accompanied girls under 16.Services factors were found to affect the speed at which

women were able to gain an abortion in NZ however therationale for this is not clear. Silva et al. found that womenwho obtained their abortion from a private clinic had asignificantly shorter delay compared to those whoattended public clinics. A shorter delay was also experi-enced by women who received care from facilities thatprovided MTOP or single day services and for thosewomen with a lower gestational age [65]. Another NZstudy also found that women choosing MTOP had ashorter wait than those obtaining a STOP [66].

Table 5 Approach to abortion service, outcomes, access dimension and perspective (Continued)

(Kimport, Cockrill & Weitz2012) [61]

Public and private clinics Experience of facility structure and process Demand

(Nickson, Smith & Shelley2006) [23]

Private services Distance travelled, money and time expendedundertaking travel, and reasons women choseparticular clinics

Supply–demand

(Silva & McNeill 2008) [64] Public and private clinics Number of services, return trip drivingdistance

Supply

(Silva, McNeill & Ashton2011) [65]

Public and private clinics offeringMTOP vs single day services

Timeliness Supply

(Snook & Silva 2013) [66] Community based services Safety and timeliness Supply


AffordabilitySome of the studies included in this review examinedcosts from the perspective of the health system, healthprofessionals and the individual women. In one Englishprimary health care trust Tupper et al. found that a newMTOP service contributed towards cost savings in theUK National Health Service (NHS) budget [53]. The au-thors compare the cost of their services with those of the‘Payment by Results’ national tariff of fixed prices that re-flect national average prices for hospital procedures. Costsper case in the new service are outlined as £157 GBP atset up which was estimated to be £85 GBP within 5 yearsof operation. This compares favourably to the £498 ‘Pay-ment by Results’ per case on for surgical termination and£423 for medical termination.A study undertaken in a different English primary

health care trust a year earlier noted that the cost of aMTOP or a STOP (day case) ranged from £462 to £578per patient [52]. Sharma et al. study of a pilot local an-aesthetic outpatient STOP service found that the costcould be reduced to £366 per patient. However, if thisinvolved outpatient consultation the cost was £217 perpatient which could be further reduced to £177 if thenurse telephone clinic was used. The nurse telephoneclinic reduced the time needed by the doctor to assesseach patient, which increased the number of patientsthat could be seen per clinic. Recent research in the UKalso examining a local anaesthetic outpatient STOP ser-vice found that a cost savings was made of approximately£60000 per year and that the operating theatre use was re-duced by one termination list per week [51].Interviews with American women accessing a MTOP

telemedicine clinic [57] explained that they selected theas it saved them money that they would have had tospend on travel. For some women obtaining a STOP inAustralia was very expensive, particularly rural womenwho in one study said they had borrowed money to covernot only the abortion fee but pay for travel, accommoda-tion and additional childcare costs [22].

AdequacyThe adequacy of abortion services in terms of theorganization of clinics and their hours, of operation,cleanliness and administration processes was the subjectof interest in three studies in the review. Interviews withUS staff and women revealed that the telemedicineMTOP service offered services more frequently and witha wider range of times available to women than clinicbased services. Prior to the telemedicine service staffnoted that women could only see doctors on a particularday of the week or month that they visited the clinic,whereas telemedicine enabled women to schedule theirconsultation any day of the week if needed [57]. Abortionclients from a USAID funded Women and Infant Health

Project who were surveyed in three cities in Russia ratedlevel of comfort and hygiene. Ratings of comfort had thegreatest variation with 41 % of clients rating comfort asgood, 47 % as fair and 11 % as poor. Less than two percent of women rated their satisfaction with hygiene aspoor while 69 % reported satisfaction with hygiene asgood, [63]. Interviews with women obtaining abortionsfrom three clinics in the US described women’s experi-ences of antiabortion protesters outside and the clinics’ se-curity measures in response [61]. The findings show thatboth experiences served to increase women’s feelings ofstigmatisation. Women described being “buzzed in” pass-ing through metal detectors and paying in cash that madethe process seem impersonal and illicit.

AcceptabilityFour of the six papers in this review, that describe theacceptability of services that enable women to terminatetheir pregnancy at home rather than return to the hospitalor clinic after a MTOP, report on women’s acceptability ofthis practice. A survey of 100 women in the UK found thatwomen chose to go home as soon as possible after the pro-cedure (53 %) and to be in the privacy of their own home(47 %). The majority of women did not regard the amountof pain or bleeding to be a considerable issue [41]. Thesefindings concur with another survey of 127 women who re-ported that they were adequately prepared for the amountof bleeding and pain they experienced at home [50].Women in both surveys were satisfied with the procedurewith most women in Cameron et al. research (84 %) statingthey would recommend home medical abortion [41].Blum et al. research in the US examined women’s ac-

ceptability of a test to detect continuing pregnancy athome after their MTOP. The majority of women sur-veyed found the test easy to use with two thirds (58.1 %,n = 190) correctly identifying the need to return to theclinic based on the home test reading measures of serumhuman chorionic gonadotropin being the same or higherthan their baseline level [55].When offered, Cameroon et al. [42] found telephone

follow up and self-performed pregnancy testing aftertheir MTOP was more popular with women in the UKup to 9 weeks gestation than return visits to the hospital(476 out of 619 women or 77 %). Women stated thatthis was more convenient, less stressful and reduced theneed for travel. The majority found the follow up callsfrom nurses re-assuring and would likely recommendthis approach to others. Most women also expressed theirpreference for a low-sensitivity urine pregnancy test at2 weeks after their MTOP (97 %). However, if given achoice the majority indicated a preference for self-assessment without a follow-up phone call (52 %) while43 % stated that they would have been ‘unlikely’ tochoose self-assessment.


In contrast to women in the study by Grossman et. al.[58] women in Grindlay et al. research paper [57] reportedthat they were not comfortable with the telemedicine ap-proach to MTOP. These women felt it did not enablethem to access other reproductive health services at thesame time and that they were unsure about the service asit had not been recommended and was unknown by fam-ily and friends. Despite this many women who experi-enced the telemedicine consultation stated that they weresatisfied and comfortable with a video communication asit was already part of their daily lives. Women noted thatremote service provision reduced stigma and embarrass-ment and felt less intimidated. However, others felt thatthey would have preferred having a personal interactionwith a provider and were concerned about privacy issueswith a webcam. Most staff found telemedicine acceptableto deliver to women noting issues with detecting women’sRhesus (RH) status. which led to delays in accessing theservice. National guidelines recommend the administra-tion of anti-D immunoglobulin to Rh (D) negative womenwithin 72 h of an MTOP in order to prevent maternalsensitisation and an adverse effect on a future pregnancy[68, 69]. In the Grindlay et al. study, new providers of tele-medicine based abortion services lacked the capability foron-site testing resulting in additional communication withwomen and third parties in order to establish their Rhstatus prior to the clinic visit.Three studies included in this review included an

examination of women’s acceptability of early STOP ser-vices in particular MVA under local anaesthesia. Onestudy found women experienced little pain with 79 %giving a pain score of 3 or less out of 10 [51]. Womenwere found to recover quickly from their anxiety aftertheir abortion with visual analogue scales, indicating asignificant fall in anxiety scores following the procedure(p < 0.01). [47]. Women were also satisfied with the pro-cedure in both studies. Eighty-six % of surveyed womensaid they would recommend it and 80 % said they wouldhave the same method again in the future [47]. Sharmaet al. survey [52] found that staff perceived the patientsto be satisfied, “reassured” and “relaxed” and that theprovision of a local anaesthesia gave women a choicecompared with a general anaesthesia. Telephone con-sultation was popular with patients according to staff asit was carried out at their convenience in their homes,and with staff as it reduced clinic assessment time. Staffalso noted that the telephone booking service withwomen was acceptable to patients who spent less timein the clinic but that it was more difficult to assess awomen’s emotional state.Abortion clients from a USAID funded project sur-

veyed in three cities in Russia were largely satisfied withservices received from health professionals Informationprovided to abortion clients about self-care was the most

important predictor of overall satisfaction (OR = 3.55,CI = 1.64, 7.69). How much the client paid for the abor-tion did not affect satisfaction with respect to any aspectof care [63]. Despite some women having to wait longerthan the 3 weeks recommended by the RCOG guide-lines, or in a few cases up to 7 weeks, most women saidthey were satisfied with the service they received [49].Women in a survey in the Australian State of Victoriacited the reasons for selecting a private clinic to havetheir abortion including the reputation of the clinic,quality of information received, as well as good staff andservice [23].Rural Australian women described dissatisfaction with

the attitudes of GPs who delayed referral by not providinginformation concerning options for self-referral. Thesewomen stated the need to reduce stigma and negativeattitudes to improve access to abortion [22]. Americanwomen described the impersonal attitudes of staff andthat the denial of support persons for security reasonsadded to the stigmatisation of the experience. Howeverwomen’s satisfaction was heightened by non-judgementalstaff and the presence of a patient advocate [61]. Finnie etal. surveyed women in the UK accessing MTOP andSTOP in the UK who overall rated satisfaction, provisionof information and staff interaction more highly in sec-ondary than primary care. Women noted that their GPsanti-abortion views were made known to them and al-though they were referred were provided with very littleinformation concerning their options [44].

QualityQuality standards for abortion care were noted in severalstudies in relation to professional standards, nationalstandards set by the government and local area healthstandards, as well as women’s views of the standard ofquality care.The standards of the RCOG in the UK were referred

to in comparison with the results in five studies. In thepaper by Essen and colleagues the RCOG minimum re-ferral standard of women seen by a doctor within 2weeks of referral was found to have been met in 80 % ofcases. Of the 340 women in the study 111 patients hadtheir TOP performed within 7 days of their consultationwith a doctor in the hospital which was noted as theRCOG ideal standard [43]. The national RCOG standardwaiting time of 3 weeks from first appointment with thereferring doctor to the procedure was achieved in Finnieet al. study for 56 of 127 women (44 %; 95 % Cl, 35–53)[44]. In an earlier study the numbers were less withtwelve percent of the women having to wait longer thanthe 3 weeks recommended by the RCOG guideline. In aminority of cases this wait extended up to 7 weeks [49].Lipp’s investigation into services in nine Primary HealthTrusts in Wales found that one Trust did not comply


with referral times of 3 weeks as per clinical guidelinesdue to service constraints and five of 10 Trusts provideda dedicated assessment clinic as advised for womenrequesting TOP [48]. Lipp et al. also assessed the qualityof written information provided to women prior toabortion in relation to RCOG guidelines that dictatethat verbal information should be supported by writtenimpartial, printed material [70]. Five Trusts includedwritten information that was given to women duringthe initial consultation and on discharge. The informationvaried in both content and presentation and all materialoutlined the risks of complications. Tupper et al. [53] notein their evaluation of a new service that the RCOG stan-dards and competences in providing abortion serviceswere observed but no detail of this is provided. One NZstudy compared their results of MTOP complications withthe standards set by RANZCOG. Complication rateswere very reported to be low and within the RANZCOGstandards [66].National standards were cited in a study from Scotland

in the UK. The authors audit of facility data noted thatNational Health Service (NHS) Quality ImprovementScotland standards for sexual health services, which rec-ommend that at least 60 % of women leave an abortionservice with an effective method of contraception, wasachieved [54].Graham et al. [45] investigated the use of an integrated

care pathway (ICP) in abortion care as a way of incorpor-ating local and national guidelines into everyday practiceand managing clinical risk while meeting the requirementsof clinical governance in two hospitals in the UK. The re-searchers undertook an audit of facility data and foundthat in this context clinical records are a useful tool forhigh quality record-keeping and to ensure that all womenreceive the same standard of pre-assessment care. The in-tegrated care pathway (ICP) approach to the provision ofquality of MTOP and STOP was developed for two hospi-tals in the UK and involved a checklist that included STIscreening, treatment and partner notification, prophylacticantibiotics at time of abortion, provision of contraceptioncounselling and supply. The checklist also includes re-admission investigations such as temperature taking, fullblood counts and ultra sound. The ICP evaluation showedthat 97 % of women had chlamydia screening beforethe abortion; all women had a contraceptive discussionand 43 % left using a long-acting reversible method ofcontraception [45].

DiscussionThis review has identified the dimensions of access tosurgical and medical abortion from, clinic or hospital-outpatient based abortion services, as well as new servicedelivery approaches utilising a remote telemedicine ap-proach. A range of factors, mostly from studies in the UK

and US were found to facilitate improved access to abor-tion. In particular, flexible service delivery approaches thatprovide women with cost effective options and technologybased services. These could provide possibilities for theAustralian health system. However, it is not clear howmany services in Australia provide a choice of MTOP orSTOP with the situation largely dependent upon the willof private services.Services that provided women with the choice of either

MTOP or STOP [53] and the establishment of nurse-ledtelephone consultation and outpatient services for STOP[51, 52] in this review were found to be cost effective, indemand and the uptake high. Home based MTOP withpregnancy testing and telephone follow up was also re-ported to be acceptable to women [41, 42, 50, 55]. MTOPdelivered by telemedicine was reported to have improvedthe availability and timeliness of abortion most womenfound it acceptable, reduced costs to the women andreduced the stress associated with the procedure [57–59].A private company called the Tabbot Foundation inAustralia is trialling the use of video and skype consulta-tions for MTOP that reduces the need for a health servicesvisit except for required tests, or in the case of complica-tions. All of the 303 women involved in the trial at the endof 2015, gave the service a very high rating [71]. MTOPbased telemedicine may, as in the American studies in thisreview, increase the availability of MTOP in Australia, in-cluding for women living in rural and remote settings.This could reduce costs associated with long distancetravel and enable a timelier delivery of MTOP. InAustralia, unlike in the American context, a face to faceclinic visit for telemedicine MTOP is not a requirementbut and women still need to obtain a blood test tocheck their rhesus status and an anti-D immunoglobulininjection if Rh negative [72].The review identified a number of standards, recom-

mendations and targets that provided services and pro-viders with guidance regarding the quality of abortioncare including the UK Department of Health targets [53]and RCOG recommendations regarding referral andwaiting times [43, 44, 49]. The papers in this review alsonoted provider competences outlined by RCOG [53]which include the requirement that women leave anabortion service with appropriate information and an ef-fective method of contraception [54]. These standardsmay provide RANZCOG and the Royal College of GeneralPractitioners with insights to improve practitioner compe-tence in addition to the standards associated with the rateof complications noted in one paper. Targets to reducewaiting times could also be applied nationally in Australia,as well as at State and Territory level, however this wouldbe difficult due to the variability of current serviceprovision. Targets could be applied to public provision butsuch services may not be apparent and available at all


public facilities. Assessing progress on targets would re-quire comprehensive and coordinated data collection thatdoes not currently exist across Australia. The collection ofabortion data should be alongside other reproductivehealth indicators and service evaluation. One such ap-proach that might offer guidance are the input, process,outcome and impact indicators recommended by expertsat an International workshop on reproductive health indi-cators and database development [73].Difficulties accessing abortion services were noted for

particular populations in this review, in particular foradolescents and women with limited financial means[22, 23, 60, 66]. Little is known about access to abortionservices for adolescents who face issues of confidentialityand often negative attitudes of providers [74]. In WesternAustralia adolescents have been found to have the highestabortion rates [75] which is likely to reflect rates in otherStates and territories, in line with global figures [76]. Re-search is therefore needed to ensure that the needs of thehighest users of such services are best addressed.Although not mentioned by the research in this re-

view, other studies have noted higher rates of abortionsamong migrant women in HIC [77] who face barrierssuch as poor access to information about contraception,difficulty paying for services, a history of trauma andabuse, and fear of deportation [78]. Sexual and repro-ductive ill health disproportionately affects migrant andrefugee women in Australia and hence is an area of highneed requiring attention [79]. In Australia, significantbarriers have been documented regarding the access ofrefugees and migrants to primary health care [80] andrecommendations for improving access to general practicehave been put forward however, these do not include re-productive health issues such as abortion [81]. Migrantsand refugees may also have different expectations ofabortion based upon their experiences in their countriesof origin. Access for refugees in detention is even morechallenging as demonstrated by a recent case of a Somaliasylum seeker detained by the Australian Government onthe Island of Naru [75].In our review the descriptions of services were largely

public in the UK, NZ, Canada and Russia and private inUS and Australia which reflects current service-deliverymodels in these countries. The model of a public privatepartnership only appeared in one UK-based study [46].This difference dictated the papers focus on affordability.Where the cost was born by the state the discussion fo-cused on health systems savings and efficiency, whilecosts on an individual level featured in the Americanand Australian papers where women largely access ser-vices through private clinics. We found little informationconcerning ways to best support women from lowersocio economic backgrounds with payment if serviceswere unavailable in the public system. While in Australia

the universal health system Medicare reimburses costsfor STOP and MTOP services, the lack of access throughthe public system in most states and territories means thatwomen need to access private services leading to an out ofpocket gap payment, which can be prohibitive for somewomen.Apart from location of services, often concentrated in

urban areas, availability is also determined by availabilityof trained personnel. Staff shortages were noted in pa-pers in our review [22, 53] in the UK and Australia, aswell as low knowledge about abortion [44]. Gynaecologyand general practice training pathways are variable insome countries [82] and may not include abortionprovision. Therefore gynaecologists and GPs must seekadditional training to become STOP or MTOP providers,either in their own practices, or within private clinics. InAustralia, despite the availability of training for GPs toprovide MTOP in their own practices, the uptake of thistraining and translation into service delivery appears to berelatively low [83]. In the US leadership, the commitmentof medical faculties, and the support of professional bodieshave been cited as essential components of routineabortion training to increase service provision [84]. Thishighlights the leadership role of Australian medical, nurs-ing, midwifery and pharmacy faculties and associated pro-fessional associations in undertaking to increase provisionin public facilities. RANZCOG has developed a trainingprogram for its fellows and associates and produced acomprehensive resource for health professionals coveringboth STOP and MTOP procedures [85]. Task shifting withprovision of STOP and MTOP services by, for exampleregistered nurses, is also acceptable to women as noted inthis review [52] and is not associated with a higher risk ofcomplications. In Australia task shifting is in its naissancewith nurses involved in supporting abortion care forwomen, however there have been no evaluations of suchservices. This is in contrast to middle and low incomecountries where nurses and other mid-level cadres havebeen found to perform MVA as safely and effectively asdoctors in India and Nepal [86, 87].Studies in the review noted that the anti-abortion

views of doctors had slowed the referral process and thatGPs made their views known to women [22, 43, 65]. Ad-dressing conscientious objection and, more broadly,provision of sensitivity training for personnel linked toservice delivery or referral pathways is critical. Practicaltraining as well as sensitivity training is vital for all levelsof service provider including gynaecologists, GPs andother primary care providers, pharmacists and ancillarystaff. Our review did not provide insight into how suchtraining should be undertaken and its impact upon ac-cess to services. However, doctors have been found tovalue teaching about the social issues surrounding abor-tion, as well as clinical ones [82]. Suggestions have been


made by Kaposy in Canada to allow doctors conscientiousobjection while also ensuring access. This includes clearadvertisement of objection at services and regulation byprofessional associations to prevent women experiencingreferral delays, the refusal of information, or deliberatemisinformation [88].Legal restrictions in different Australian and US states

were noted to affect referral and travel in two studies inthe review [22, 56]. Variations in the legal status of abor-tion can also create confusion for providers and womenand may present unnecessary barriers to service provision.While there are no barriers to the provision of abortion inpublic hospitals in Australia when performed within thestate or territory-based legal framework, with the excep-tion of South Australia, they appear to be rarely performedin this setting [89]. The lack of abortion services may re-late to workforce issues and a lack of leadership, as well asthe values of faith based hospital services. While mostpublic hospitals will provide abortions, in certain circum-stances hospital policy may impose gestational limits andthere is generally no transparent central booking systemfor women or their GPs to access their abortion services.Kaposy highlights approaches Canada has taken to ensurepublic access that may be transferrable to Australiastates and territories. These measures include nationaldecriminalization and the designation of 33 public hospi-tals as abortion providers by the government of BritishColumbia [88].Only one study in the review specifically examined an

integrated care pathway [45]. Comprehensive abortioncare incorporates the management of complications,provision of STI testing and treatment, as well asprovision of contraception. The integration of abortionservices within family planning services and/or sexualhealth services or conversely integration of family plan-ning/sexual health services within abortion services isimportant in relation to reducing repeat abortions [90].Experiences of integrating comprehensive abortion careinto health services in HICs are difficult to locate in theliterature despite many services, such as those in Scotland,in existence [91, 92]. Studies from LMIC show that it isfeasible [93, 94] which may provide lessons for wealthiercountries.

ConclusionsClear ways forward for abortion service delivery inAustralia include the provision of choice and flexible op-tions for women, in conjunction with appropriate use oftechnology and the application of standards to ensureuniversal access and quality abortion services for allwomen. The paucity of evidence concerning access toabortion services in Australia, particularly the dimensionof availability, adequacy and quality, shows that more re-search is needed in this area. Of note is a lack of evidence

about demand for abortion services including the needs ofvulnerable groups of women whose difficulties accessingservices may misleadingly indicate a lower demand.Further research is required to examine this perspective.It is imperative that we draw on the success stories ofmodels which minimise unnecessary barriers to womenincluding the necessity to return to clinic for a post-MTOP pregnancy test. However, to implement such direc-tives leadership and advocacy is required from Australianmedical, nursing, midwifery and pharmacy faculties andtheir associated professional associations. In addition, pol-itical will is needed to decriminalise abortion across allstates and territories in Australia and ensure dedicatedpublic provision that is based on comprehensive modelstailored for all populations.

AbbreviationsGP: General practitioner; HIC: High income countries; ICP: Integrated carepathway; LMIC: Low and middle income countries; MTOP: Medical terminationof pregnancy; MVA: Manual vacuum aspiration; NZ: New Zealand;RANZCOG: Royal Australian and New Zealand College of Obstetricians andGynaecologists; RCOG: Royal College of obstetricians and gynaecologists;STI: Sexually transmitted disease; STOP: Surgical termination of pregnancy;UK: United Kingdom; US: United States; USAID: United States of America AidAgency; WHO: World Health Organization

AcknowledgementsNone.

FundingThis study was unfunded.

Availability of data and materialsAll data is available in the public domain.

Authors’ contributionsAD designed the research, led the literature search and analysis and wrotethe manuscript. DB contributed to the framework, analysis and discussion.ES and JE contributed to the writing of the background, discussion andedited the paper. All authors read and approved the final manuscript.

Competing interestsThe authors declare that they have no competing interests.

Consent for publicationNot applicable.

Ethics approval and consentNot applicable, all data is in the public domain.

Author details1Faculty of Health, University of Technology, Sydney (UTS), P.O. Box 123,Ultimo, NSW 2007, Sydney, NSW, Australia. 2Discipline, Gynaecology andNeonatology, University of Sydney, Family Planning New South Wales,28-336 Liverpool Road, Ashfield, NSW 2131, Australia. 3Family Planning NewSouth Wales, 28-336 Liverpool Road, Ashfield, NSW 2131, Australia. 4PublicHealth, Faculty of Health, University of Technology, Sydney (UTS), JonesStreet, Sydney, NSW, Australia.

Received: 8 June 2016 Accepted: 12 October 2016

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