Table 3 Summary of all papers included in the review

(Astle, Cameron & Johnstone 2012) [54]

Medical abortion: National Health Service hospital Scotland UK

Quantitative descriptive: A retrospective audit of facility data

1128 women undergoing medical abortion (up to 64 days’ gestation) over 9-month period

To establish how early medical discharge impacts upon an abortion service in terms of unscheduled re-attendance rates and contraception provision at discharge.

590 (52 %) chose EMD. There was no significant difference in unscheduled re-attendance rates between EMD (n = 23, 4 %) and day case groups (n = 20, 4 %). There was no significant difference in the proportion of women in each group who left hospital with an effective method of contraception (n = 362, 61 % and n = 355, 60 % for EMD and day case groups, respectively).

(Blum et al. 2012) [55]

Medical abortion: Stanford University Hospital's OB/GYN clinic, Palo Alto, CA; Planned Parenthood Mar Monte, Sacramento, 2 clinics of the Family Planning Associates Medical Group, Chicago, USA

Quantitative descriptive: prospective clinical study and survey

429 women used a pregnancy test to determine baseline hCG on the day of mifepristone administration and follow-up hCG 1 week later. 189 women completed a survey.

To assess the effectiveness of a semi-quantitative home pregnancy test as a possible replacement for in-person follow-up after medical abortion.

The test identified the one ongoing pregnancy in the clinical study cohort. Sensitivity and specificity were calculated at 100.0 % and 97.0 %. The majority of participants in both the clinical study and the user comprehension survey found the test to be “very easy” or “easy” to use.

(Cameron et al. 2010) [41]

Medical abortion: hospital Edinburgh, Scotland, UK

Quantitative descriptive: prospective clinical study and survey

145 women chose to go home to abort, 69 % women completed questionnaires

To assess effectiveness and satisfaction of women with early medical discharge after abortion

The commonest reasons given for choosing to go home were: to get home sooner (53 %) and to be in the privacy of one’s own home (47 %), 81 % of the women stated that bleeding was either “as expected” (55 %) or “not as bad as expected” (26 %), and 58 % of the women stated that the pain was “as expected” (40 %) or “not as bad as expected” (18 %), 84 % of the women said that they would recommend this method to a friend.

(Cameron et al. 2012) [42]

Medical abortion: Royal Infirmary of Edinburgh, Scotland, UK

Quantitative descriptive: prospective clinical study and survey

476 opted for telephone follow-up

To evaluate telephone follow-up in terms of describing the numbers of women choosing to be followed up in this way, follow-up rates, efficacy of LSUP test for detecting ongoing pregnancies and women’s satisfaction

476 out of 619 women (77 %). opted for telephone follow-up, 4 women (1 %) attended the clinic before telephone follow-up because of pain or bleeding. A total of 410 (87 %) of the remaining 472 women were successfully contacted by telephone. Sixty women (15 %) screened ‘positive’, three of whom had ongoing pregnancies, and one woman falsely screened ‘negative’. The sensitivity of the telephone follow-up was 75 % [95 % confidence interval (CI) 30.1–95.4], and specificity was 86 % (95 % CI 82.2–89). The negative predictive value was 99.7 % (95 % CI 98.4–99.9), and positive predictive value was 5 % (95 % CI 1.7–13.7). All women surveyed (n = 75) would recommend telephone follow-up to a friend.

(David et al. 2007) [62]

Perm, Berezniki and Veliky Novgorod 20 health care sites (five maternity hospitals, six women’s consultation centres linked to those hospitals, three family planning clinics and six children’s polyclinics Russia

Quantitative descriptive: impact, pre- and post-intervention surveys

489 abortion clients in 2000, 559 in 2002 and 527 in 2003 surveyed in three facilities

To evaluate a post abortion care program to increase uptake of family planning

The project interventions appear to have extended the coverage of contraceptive counselling to nearly all abortion clients. Providers training resulted in increased, and possibly more effective, discussions about contraception with abortion clients. More than 80 % of post-abortion clients expressed not only an intention to use medical contraception but had identified their method of choice. Findings suggest that certain women conceive again soon after an abortion procedure and are more likely to abort again rather than try to prevent the unwanted pregnancy. Abortion is widely available and easily accessible, reducing the need for women to practice consistent and effective contraception, but most women say that they would prefer to prevent unwanted pregnancies through the use of modern contraception however these are either too expensive or reportedly fail due to poor quality.

(Dodge, Haider & Hacker 2012) [56]

Medical and surgical abortion: USA

Quantitative descriptive: simulated patient calls to services in the 5 most and 6 least abortion restrictive states using a survey

142 telephone calls were made to 48 non-provider facilities; 46 facilities were contacted 3 times and 2 were contacted twice

To determine the quality and quantity of referrals for abortion services from reproductive health care facilities that do not provide abortion services.

45.8 % of call resulted in a direct referral, 19.0 % resulted in an indirect referral, 8.5 % resulted in an inappropriate referral and 26.8 % resulted in no referral. Facilities in least restrictive states were significantly more likely to provide unprompted direct referrals (p = 0.006) and significantly less likely to provide no referral (p < 0.001) than facilities in most restrictive states, though these differences disappeared after prompting the staff member to provide a referral.

(Doran & Hornibrook 2014) [22]

Surgical abortion: New South Wales, Australia

Qualitative descriptive

13 rural women who had an early surgical abortion 5 months to 15 years’ prior

To identify factors that women experience in relation to their ability to access an abortion service and follow-up care

The main barrier rural women experienced was travelling relatively long distances to access an abortion clinic because of lack of services in their local area. Women with limited financial resources needed to borrow money for the procedure and associated costs of travel and accommodation. Women’s Health Centres provide a range of support and referral information. Lack of integrated care was reported.

(Esen et al. 2006) [43]

Medical and surgical abortion: TOP clinic South Tyneside Foundation Trust, England UK

Quantitative descriptive: prospective survey and examination of case notes

340 women requesting termination of pregnancy seen at the clinic in 2003

To evaluate the termination of pregnancy service in South Tyneside including our compliance with Royal College of Obstetricians and Gynaecologists termination of pregnancy guidelines

The number of referrals represented one-fifth of all births in our unit during the study period. Teenagers were the largest single group of women requesting termination of pregnancy and the majority were nulliparous. There were 85 women who were seeking a repeat termination of pregnancy. The RCOG minimum referral standard was met in 80 % of cases. A good number of women were unsure of their menstrual dates and only 5 % had used emergency contraception. A total of 96 % were either not using contraception, using condoms or taking oral contraceptives irregularly. A total of 50 % of the women attended hospital without a Certificate A being completed by the referring practitioner. Surgical termination was preferred over medical termination in the cohort of women who could exercise a choice.

(Finnie, Foy & Mather 2006) [44]

Medical and surgical abortion: South Durham in the North East of England, UK

Quantitative descriptive: survey and reviewed the case notes of women

Women attending two fertility control clinics general practitioners who referred women to these clinics

To identify service-related delays and barriers faced by women seeking abortion care

Of 210 women surveyed, 132 (63 %) responded. Of 107 referred by GPs, 16 (15 %) had to make a second appointment with another GP willing to refer them and 34 (32 %) waited two or more days to receive a date for their hospital appointment. The national standard waiting time of 3 weeks from first appointment with the referring doctor to the procedure was achieved for 56/127 women (44 %; 95 % CI, 35–53). Women rated global satisfaction, provision of information and staff interaction more highly in secondary than primary care. Of 170 GPs surveyed, 140 (82 %) responded; 33 (24 %) considered themselves ‘broadly anti-abortion’.

(Graham, Jayadeva & Guthrie 2010) [45]

Medical and surgical abortion: Hull and East Riding hospitals in Yorkshire, England UK

Quantitative descriptive: A retrospective audit of facility data

8,476 medical or surgical induced abortions undertaken at 14 weeks’ gestation or under

To assess the effectiveness of an integrated care pathway for delivery of evidence-based practice in abortion care.

100 women were re-admitted into the gynaecological wards of hospitals. Readmission rate was 1.2 %. The ICP showed that 97 % of women had chlamydia screening prior to the abortion; all women had a contraceptive discussion and 43 % left using a long-acting reversible method of contraception (LARC). However, data outside the care pathway was not documented, and hence the standard of care given on readmission was difficult to locate and variable in quality.

(Grindlay, Lane & Grossman 2013) [57]

Medical abortion: Planned Parenthood clinics USA

Qualitative in-depth interviews thematically analysed

25 women receiving medical abortion services (20 telemedicine patients and 5 in-person patients) and 15 clinic staff.

To evaluate patients’ and providers’ experiences with telemedicine provision of medical abortion.

Patients and providers cited advantages of telemedicine, including decreased travel for patients and physicians and greater availability of locations and appointment times compared with in-person provision. Overall, patients were positive or indifferent about having the conversation with the doctor take place via telemedicine, with most reporting it felt private/secure and in some cases even more comfortable than an in-person visit. However, other women preferred being in the same room with the physician, highlighting the importance of informing women about their options so they can choose their preferred service modality.

(Grossman et al. 2011) [58]

Medical abortion: Planned Parenthood affiliate in Iowa USA

Quantitative descriptive: prospective clinical cohort study and self-administered survey

Of 578 enrolled participants, follow-up data were obtained for 223 telemedicine patients and 226 face-to-face patients.

To estimate the effectiveness and acceptability of telemedicine provision of early medical abortion compared with provision with a face-to-face physician visit

99 % of telemedicine patients had a successful abortion was for (95 % confidence interval [CI] 96–100 %) and 97 % for face-to-face patients (95 % CI 94–99 %). 91 % of all participants were very satisfied with their abortion, although in multivariable analysis, telemedicine patients had higher odds of saying they would recommend the service to a friend compared with face-to-face patients (odds ratio, 1.72; 95 % CI 1.26–2.34). 25 % of telemedicine patients said they would have preferred being in the same room with the doctor. Younger age,

(Grossman et al. 2013) [59]

Medical abortion: Planned Parenthood affiliate in Iowa USA

Quantitative descriptive: Review of Iowa vital statistic data and billing data from the clinic system

17 956 abortion encounters 2 years prior to and after the introduction of telemedicine in June 2008

To assess the effect of a telemedicine model providing medical abortion on service delivery in a clinic system

The abortion rate decreased in Iowa after telemedicine introduction, and the proportion of abortions in the clinics that were medical increased from 46 % to 54 %. After telemedicine was introduced, and with adjustment for other factors, clinic patients had increased odds of obtaining both medical abortion and abortion before 13 weeks’ gestation. Although distance travelled to the clinic decreased only slightly, women living farther than 50 miles from the nearest clinic offering surgical abortion were more likely to obtain an abortion after telemedicine introduction.

(Gupta & Kapwepwe 2007) [46]

Medical abortion: Waltham Forest in England, UK.

Quantitative descriptive: A retrospective audit of facility data

1,257 abortions were undertaken in Waltham Forest in 2004/5

To evaluate a newly established service with an NGO

A 92 % completed abortion outcome was achieved. 58/63 completed EMA; 5/63 failed EMA.

(Hamoda et al. 2005) [47]

Surgical abortion: Aberdeen Royal Infirmary, National Health Service setting. Scotland UK

Quantitative descriptive: prospective clinical study and survey

56 women

To assess the feasibility, acceptability and efficacy of MVA under local anaesthesia for termination of pregnancy up to 63 days’ gestation

The mean (SD) gestation was 50 (9.4) days. A total of 55/56 (98 %) women had a successful procedure and did not require any further surgical or medical treatment. Fifty-five (98 %) women were satisfied with the procedure, 48 (86 %) said they would recommend it to a friend and 45 (80 %) said they would have the same method again in the future. Anxiety levels, as reflected by the visual analogue scales, showed a significant fall in anxiety scores following the procedure (p < 0.01).

(Jones & Jerman 2013) [60]

Medical and surgical abortion: All US states

Quantitative descriptive:

national sample of 8,338 abortion patients

To assess how far abortion patients travelled to a provider in 2008 and which groups were more likely to travel farther

In 2008, women travelled a mean distance of 30 miles for abortion care services, with a median of 15 miles. Sixty-seven percent of patients travelled less than 25 miles, and six percent travelled more than 100 miles. Controlling for other factors, women who lived in a state with a 24-h waiting period, women obtaining second trimester abortions, those who crossed state lines, and, in particular, rural women were more likely to travel greater distances relative to their counterparts. Women of colour were less likely to travel long distances compared to non-Hispanic white women.

(Kimport, Cockrill & Weitz 2012) [61]

Medical and surgical abortion: three abortion clinics located in the Midwest and south USA

Qualitative: thematic analysis

41 women who received an abortion

To understand impacts of abortion clinic structures and processes

The processes and structures of the abortion clinic necessitated by the realities of antiabortion hostilities lead some women to react negatively to the clinic experience in ways consistent with the social myth of the abortion clinic. Staff interactions can mitigate or alleviate these experiences.

(Lipp 2009) [48]

Medical and surgical abortion: National Health Service Trusts in Wales, UK

Quantitative descriptive: survey

All National Health Service Trusts

To establish current provision in termination of pregnancy

In the nine Trusts performing abortions, medical abortions accounted for 57 % and surgical abortions for 43 %. Doctors in training were involved in six Trusts. All but one Trust complied with referral times. Five Trusts provided a dedicated clinic. Written information provided prior to abortion varied in accessibility and quality. Choice of abortion within gestation bands was limited in some Trusts with some only providing medical termination. Essential abortion aftercare was performed by Trusts, whereas follow-up and counselling were less comprehensive.

(Mason 2005) [49]

Medical and surgical abortion: two Primary Care Trusts to a National Health Service-funded abortion clinic in the North West of England

Quantitative descriptive: survey

all clinic attendees from within the study area during a 6-month period

To investigate the referral process

90 % of the women were referred directly from the first health professional they consulted to the abortion clinic. Five percent of the women were either referred to another health professional or not referred anywhere. Twelve percent of the women had to wait longer than the 3 weeks recommended by the Royal College of Obstetricians and Gynaecologists guideline. In a minority of cases this wait extended up to 7 weeks. However, most women were satisfied with the length of wait, the health professional they consulted with and, in particular, the care they received at the abortion clinic itself.

(McKay & Rutherford 2013) [50]

Medical abortion: Peterborough City Hospital, UK,

Quantitative descriptive: survey at 24 h and 2 weeks following the procedure

127 women

To assess women’ s satisfaction with the home medical abortion service.

At 24 h, over 95 % of women who responded, agreed or strongly agreed that they felt prepared for the pain and bleeding that they experienced at home. At 2 weeks, 97.3 % of respondents felt that they had had enough information and knew what to expect, and were therefore satisfied with the procedure. Only 15 % of women were lost to clinical follow-up at 2 weeks. The majority of women are satisfied with the home medical abortion service. These high satisfaction rates are maintained at 2 weeks. Telephone follow-up 2 weeks after the abortion was safe and effective.

(Nickson, Smith & Shelley 2006) [23]

Medical and surgical abortion Victoria, Australia

Quantitative descriptive: multi-centre, cross-sectional observational study using a survey

All women accessing private services over a period of 12 weeks.

To investigate the extent and cost of travel undertaken by women accessing TOP services.

1,244 Australian resident respondents who resided in Victoria, 9.3 % travelled more than 100 km to access services. Teenagers were 2.5 times more likely than other respondents to travel further than 100 kilometres (km) (18.2 % compared with 7.8 %, OR = 2.5, 95 % CI 1.5–4.2, p < 0.001). Women originated from all Australian States and Territories except South Australia and 13.7 % were from Statistical Divisions other than Melbourne. More than one-third of respondents (41.3 %) chose their clinic because they were referred by a doctor or general practitioner.

(Norman, Hestrin & Dueck 2014) [67]

Medical and surgical abortion: British Columbia Women’s Hospital and Health Centre, Canada

Quantitative descriptive: A retrospective audit of calls

1998–2008 telephone calls

To review the toll-free pregnancy options service provision model for counselling and referral

Over 2000 women annually access service via the POS line, networks of care providers are established and linked to central support, and central program planners receive timely information on new service gaps and access barriers.

(Oliveras, Larsen & David 2005) [63]

Medical and surgical abortion: Hospitals in three cities in Perm, Berezniki, Veliky Novgorod Russia

Quantitative descriptive secondary analysis of data collected in a survey

489 abortion clients

To explore client satisfaction with abortion care

Client characteristics, in general, did not affect overall satisfaction though there were significant differences in overall satisfaction for unmarried versus married women (OR = 0 · 29, CI = 0 · 13, 0 · 63). Similarly, most characteristics of the abortion visit were not related to client satisfaction, although women who were awake for the procedure were less likely to be satisfied (OR = 0 · 37, CI = 0 · 16, 0 · 89). Information provided to abortion clients about self-care was the most important predictor of overall satisfaction for abortion clients (OR = 3 · 55, CI = 1 · 64, 7 · 69)

(Pillai et al. 2015) [51]

Surgical abortion: NHS Sexual Health Service, UK

Quantitative descriptive: A retrospective audit of facility data

1681 women

To assess the applicability, acceptability and cost implications of introducing MVA with local anaesthesia for fully conscious first-trimester termination of pregnancy

MVA was chosen by 305/1681 potentially eligible women. Forty percent had the procedure on the day they attended for assessment. 79 % gave a pain score of 3 or less out of 10. Complications occurred in six cases (2 %); these included cervical rigidity, a false passage, retained products of conception, bleeding (more than 200 ml) and one allergic reaction. Eighty percent of women chose to commence a long-acting reversible contraception (LARC) method at the time of MVA. Operating theatre utilisation was reduced by one termination list per week and cost savings of around £60 000 per annum were realised.

(Sharma & Guthrie 2006) [52]

Surgical abortion: Women and Children’s Hospital, Hull Royal Infirmary, Hull, UK

Quantitative descriptive: A prospective audit of facility data and staff survey

12 women <10 weeks’ gestation at the time of termination, February–March 2004, 23 staff

To evaluate nurse led telephone booking service and local anaesthetic outpatient surgical termination of pregnancy

Demand from referrers for the telephone booking clinic was greater than could be accommodated by the service. Telephone consultation was popular with patients as it was carried out at their convenience in their homes, and with staff as it reduced clinic assessment time. Some staff members felt that consulting over the telephone affected their assessment of the patient’s emotional status. Outpatient LA-STOP seemed well accepted by both staff and patients as it offered patients a convenient and safe method of early abortion. A preliminary costing indicated a net saving plus increased service capacity.

(Silva & McNeill 2008) [64]

Medical and surgical abortion: throughout New Zealand

Quantitative descriptive: analysis of Census data and Statistics NZ data, calculation of distances from site of referral

Nationwide TOP service information from 2006

To assess geographic accessibility to first trimester termination of pregnancy

Women who live in regions that do not offer local TOP services must travel on average 221 km to access TOP services. This equates to an average return-trip distance of 442 km. Three of the five regions that do not have local TOP services available have a higher than average proportion of Maori population

(Silva, McNeill & Ashton 2011) [65]

Medical and surgical abortion: Nine of a total of 13 first trimester clinics throughout New Zealand

Quantitative descriptive: A prospective audit of facility data and survey of women

2,950 patients attending nine abortion clinics between February and May 2000

To identify the factors affecting the timeliness of services in first trimester abortion service

Women who went to private clinic had a significantly shorter delay compared to public clinics. Controlling for clinic type, women who went to clinics that offered medical abortions or clinics that offered single day services experienced less delay. Also, women who had more than one visit with their referring doctor experienced a greater delay than those who had a single visit. The earlier in pregnancy women sought services the longer the delay. Women’s decision-making did not have a significant effect on delay.

(Snook & Silva 2013) [66]

Medical and surgical abortion: community-based services in a high-deprivation district health board New Zealand

Quantitative descriptive: A prospective audit of facility data

180 women who had an abortion in 2010

To describe the services developed and assess safety and timeliness for the first year of service.

Eighty-two percent of locally provided abortions in 2010 were medical abortions, completed on average less than 2 days after referral to the service. One percent of patients experienced haemorrhaging post abortion, and 4 % had retained products. These rates are within accepted standards for an abortion service.

(Tupper & Andrews 2007) [53]

Medical abortion: Morecambe Bay Primary Care Trust UK

Quantitative descriptive: A prospective audit of facility data

171 women referred

To report on setting up and running a new outpatient service for early medical termination under 7 weeks’ gestation.

Of 171 patients referred in the first year, 148 were offered an appointment and 100 women completed outpatient treatment for medical termination under 7 weeks’ gestation