Introduction of NHS Early Medical Abortion Service in Northern Ireland
In response to the Covid-19 pandemic and the lack of commissioned abortion services in Northern Ireland, the NHS introduced the first Early Medical Abortion (EMA) Service. The service was established rapidly by the NI Abortion and Contraception Taskgroup, providing women with access to safe abortion care up to 9 weeks and 6 days of gestation. Legal requirements and a referral pathway through Informing Choices NI were put in place to ensure quality and confidential care for women in need.
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The Introduction of the first NHS Early Medical Abortion Service in Northern Ireland-an emergency response to the Covid-19 pandemic Dr Siobhan Kirk, Dr Leanne Morgan Belfast HSC T rust
Background In October 2019 abortion was decriminalised in NI but no service commissioned The Abortion (Northern Ireland) Regulations 2020 came into effect 31/03/20 UK lockdown measures 23/03/20 in response to Covid-19 pandemic Travel restrictions difficult to access abortion care in England (two women attempted suicide when flights were cancelled) End of March/early April at home use of mifepristone approved in England,Scotland,Wales and Ireland-NOT in NI regulations
NI Abortion and Contraception Taskgroup (NIACT) Multidisciplinary-input into the commissioning, development and implementation of an abortion service in NI First meeting 30/03/20- priority to set up temporary emergency early medical abortion service throughout NI ideally within existing SRH services Within days an EMA service was established in two of five Trusts
Legal Requirements in NI-EMA Estimated gestation up to 9 weeks and 6 days Mifepristone must be taken on NHS premises Certification form completed-one signature/kept in clinic 3 years Notification form must be completed and sent to CMO within 14 days
Development of the EMA Service Willing staff identified and online training resources utilised Clinic documentation/protocols/policies/patient information produced in line with RCOG/NICE guidelines Template for telephone consultation/treatment /follow up forms for online LilieIT system designed Pharmacy links established and medication ordered
Referral Pathway Informing Choices NI agreed to be Central Access Point Women self refer to Informing Choices NI Non-directive pregnancy choices and post pregnancy counselling Initial assessment and safeguarding Daily referral via secure email to each clinic Clinic contacts patient for telephone consultation Clinic locations-Belfast, Ballymena, Londonderry, Dundonald and Portadown
EMA Consultation &Treatment Initial telephone consultation then appointment to attend clinic Scan if clinically indicated First tablet Mifepristone must be taken in clinic Subdermal contraceptive implant insertion/ IM contraceptive injection/contraceptive pill supplied/option to return for coil Take home pack with misoprostol,analgesia,patient information leaflet and low sensitivity pregnancy test
First 3 months-NI First EMA treatment on 9thApril 2020, within 8 weeks there was a regional service 572 women referred for treatment,524 consultations,447 treated 1/3 treatments were very early medical abortion (VEMA) Contraception offered at all clinics, high LARC uptake Excellent patient feedback and no reported serious complications
EMA data by Trust (09/04/20-09/07/20) 300 250 200 150 100 50 0 Belfast HSCT Northern HSCT Western HSCT South Eastern HSCT Southern HSCT Referrals Total treatments VEMA
Belfast clinic in focus :April-July 2020 Trust with the highest number of referrals -48%(252) Average time from referral to consultation 1.58 days Average time from consultation to treatment 0.81 days Average age 28.9 years 40.6% had USS 50.9% opted for LARC
Gestation at EMA 60 *All less than 10 weeks 52 51 50 40 40 30.2% were less than six weeks (VEMA) 31 30 18 17 20 *7 found to be greater than 10 weeks on USS and referred to other services within and outside NI 10 0 4 5 6 7 8 9
Contraception following EMA 60 57 LARC uptake: 108 (50.9%) 51 50 47 189 (89.2%) opted for a reliable method 40 29 30 20 10 8 4 1 0 Implant Coil Depo-provera Progestogen only pill Combined pill Evra patch Condoms
The staff made it so much easier. I felt very comfortable and safe. Service was great. I did not expect such a wonderful service. Would recommend. What you are doing in lockdown is perfect. Discreet, essential service. Needs to continue. Really thankful really impressed with service. Thank you Service User Feedback Great to have in NI. Should be available in NI in longterm. Great, well supported, friendly, non- judgemental. Was worried I was going to be seen going into clinic. Am glad it is a mixed service!
We have come a long way but Abortion remains a highly emotive issue with considerable political resistance The Department of Health NI have said it is a matter for the NI Executive and they are under no legal obligation to commission services The temporary service in the Northern Trust has ceased from 2nd October 2020 due to restoration of contraceptive services and continued local access in NI is unlikely Many women still need to travel to England The Regulations do not allow for at home mifepristone
The future-where do we go from here? Urgent need for a comprehensive, funded and commissioned service The future of the temporary EMA service is uncertain No surgical option or treatment over 10 weeks gestation We need the continued support of FSRH,RCOG and BSACP colleagues Improved access to LARC/immediate postnatal contraception
