Evidence base to inform health service configuration for abortion provision: the SACHA (Shaping Abortion for Change) multi-component study

Background: Significant changes to the nature and context of abortion provision are taking place in the United Kingdom. Empirical evidence is needed to guide efforts to respond to these changes. Objective(s): To provide an evidence base to inform optimal configuration of health services and systems in response to current and future changes in abortion provision in the UK. Design and methods: Observational study comprising five integrated components: (1) a realist review to generate evidence to guide optimal abortion provision and a scoping review of interventions aimed at preparing non-specialist health professionals to provide abortion care and support; (2) country-based case studies identifying transferable lessons for policy and practice in the UK; (3) a Knowledge, Attitude, Behaviour and Practice survey among healthcare practitioners; (4) qualitative research with women with recent experience of abortion to explore their experiences of care and support; (5) consultations with key stakeholders on the implications for policy, practice and research of findings from the research. Data collection period April 2020-January 2023. Setting and participants: Primary setting: Britain. Data-gathering sites: Canada, Sweden, Australia. Forty-eight recent abortion patients recruited via independent providers and National Health Service hospitals in England, Wales and Scotland; 771 health professionals (doctors, nurses, midwives; pharmacists); 31 stakeholders with expertise in abortion in Canada, Sweden and Australia; 15 key stakeholders with expertise in abortion research, policy and practice in Britain. Main outcome measures: Abortion-related knowledge, attitude and practice among health professionals, including inclination to provide abortion, and competence and capacity to do so. Selected trends in abortion rates and their correlates, and the views of health professionals with expertise in abortion, in Sweden, Canada and Australia. Accounts of experience and preferences among women with recent experience of abortion. Results: Patients and health professionals were found to be broadly in favour of relaxation of current laws on abortion in Britain: specifically, to dispense with the requirement for two doctors to sign authorising an abortion; to permit healthcare professionals other than clinicians to prescribe abortion medication and perform vacuum aspiration; and to allow abortion to be provided in additional suitable resourced and equipped facilities, notably community sexual and reproductive health services. Training was considered necessary to equip health professionals for an extended role in abortion provision as were permissions to licence premises other than those currently approved. Patients' assessment of abortion services in Britain was positive. Suggestions for further improvement included increasing the timeliness of care, resolving disparities between expectations and reality, providing emotional and psychological support, and offering choice to patients. Evidence from other countries cautioned against assumptions of direct transferability of models of care. Considerations of competence, capacity and resources are important to policy and practice decisions. Limitations: The study may suffer the inherent weaknesses of observational studies in terms of the potential for bias. It was carried out during the exceptional period of the COVID-19 pandemic with implications for the ease with which it could be conducted and for the generalisability of the findings. In the component exploring patients' perspectives, we did not capture patients who disclosed experiencing an abusive relationship, and the number of women aged under 20 was small. Our inability to capture the views of patients in Northern Ireland, despite strenuous efforts to do so, was a source of regret. Conclusions: The needs of abortion patients are well met by abortion services in Britain. Options in terms of how abortion is carried out, by whom and where, need to be made available to take account of different circumstances. Future work: Continued investigation into the views and experience of patients, healthcare professionals and stakeholders, in Britain and in other countries, is needed to ensure that the regulation and provision of abortion care and support keep pace with therapeutic and technological trends. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129529) and is published in full in Health and Social Care Delivery Research; Vol. 14, No. 11. See the NIHR Funding and Awards website for further award information.