Women in developed countries still find it very difficult to get an abortion in early pregnancy, despite facing fewer legal constraints than in other parts of the world, concludes an analysis of the available evidence, published in the Journal of Family Planning and Reproductive Health Care.

Inadequate local service provision, negative attitudes towards abortion, and too few training opportunities for healthcare professionals all hinder access, say the researchers.

The World Health Organization (WHO) estimates that for every 100 live births in the developed world, there are around four 'unsafe' abortions carried out. Yet when performed legally and when properly regulated, abortion is one of the safest of all surgical procedures.

The researchers systematically reviewed the available evidence, published in English between 1993 and 2014, to find out what helps or hinders access to abortion services in the first 3 months of pregnancy in developed countries, from the perspective of both service providers and users.

Out of 2511 relevant articles they found, 38 dealt with early abortion and the provider and user perspective.

As far as providers are concerned the main obstacles include moral opposition to abortion; lack of suitable training; too few healthcare professionals able or willing to carry out the procedure; harassment of staff by those ideologically opposed to abortion; and insufficient resource, particularly in rural areas.

Reported rates of opposition to abortion ranged from more than one in three doctors surveyed in rural Idaho, USA to around 1 in 5 family doctors (GPs) in the UK. Among British GPs opposed to abortion, 1 in 5 did not feel they should have to declare this to a woman wanting an abortion.

As far as women are concerned the principal barriers they face include lack of local services?a particular issue for women living in rural areas on low incomes or from minority groups; healthcare professionals' negative attitudes towards abortion; and the cost of the procedure, especially in North America.

The WHO recommends a combination of two drugs for early medical, as opposed to early surgical, abortion (mifepristone and misoprostol). Medical abortion has the potential to boost access to the procedure. Yet despite the WHO listing mifepristone as an essential medicine 10 years ago, access to it continues to vary widely, the findings show. It is used widely in Sweden, for example, but is not even licensed for use in Canada.

Staff attitudes to abortion not only hinder access, but also affect women's experience of the procedure, say the researchers. In one Canadian study, more than one in 10 women said that abortion clinic staff were rude, while almost half of those surveyed in another study said they got no support from any of the clinical staff involved.

"Despite fewer legal barriers to accessing abortion services, the evidence from this review suggests that women in developed countries still face significant inequities in terms of the level of quality and access to services as recommended by the [WHO]," conclude the researchers.

On the basis of the evidence they found, they suggest that access could be improved by increasing training, particularly among mid-level practitioners; boosting the range of service options, such as telemedicine; and making services more affordable or free at the point of need.

There should also be clear guidelines on the provision of abortion to include referral protocols for staff who are opposed to abortion on cultural/ethical/religious grounds, they recommend, adding that abortion services should be part of a multidisciplinary clinic to reduce stigma and ensure better integration within mainstream care.

###