Choices about abortion method: assessing the quality of patient information leaflets in England and Wales
* Dr H. Bekker, Unit of Psychiatry and Behavioural Sciences, University of Leeds, 15 Hyde Terrace, Leeds, LS2 9LT, UK.
Objective To assess the quality of patient leaflets regarding the choice between medical and surgical abortions.
Design Cross sectional survey.
Setting NHS and private providers of abortion services in England and Wales.
Sample Leaflets from three private providers, all teaching hospitals (n= 14) and a representative sample of NHS district hospitals (n= 27), accessed by approximately 100,000 women per year.
Methods On telephoning the above abortion services, the leaflets provided to women choosing to have medical or surgical abortions were requested. Content analysis of leaflets included: application of a coding frame assessing adequacy of information about options, risks and procedures; the Flesch Readability Ease scale.
Main outcome measures Provision of leaflet, adequacy of information and ease of readability.
Results Seventy-three percent (44/60) of contacted providers offered women a leaflet. Of these 44 leaflets, one mentioned medical and 15 surgical abortion methods only. Adequacy of information provision was low, with on average 10/23 points covered about the surgical method, 12/21 points about the medical method and 7/11 points about aftercare. Readability scores were poor with 24/44 (55%) rated as ‘difficult’ or ‘fairly difficult’. Among NHS providers, scores were slightly higher in the teaching than in the district hospitals.
Conclusions On average, leaflets provided half the information possible about the risks and procedures of medical and surgical methods. In addition, readability was rated as difficult in over half the leaflets. It seems unlikely that these leaflets enable women to make informed choices between abortion methods and, therefore, do not meet the requirements of current guidelines.
Women with unwanted pregnancies of less than nine weeks of gestation have a choice between medical and surgical methods of abortion1. The medical method involves the use of prostaglandins with or without antiprogesterone to induce miscarriage. The surgical method involves vacuum aspiration under anaesthetic. Both procedures have associated risks (see Table 1). In most cases, the choice of method depends on women's preferences rather than on any medical requirement1,2.
Table 1. Summary of key information about medical and surgical abortion methods.
|•Aim: tablets cause miscarriage.||•Aim: operation removes pregnancy by suction.|
|•Number of visits: 2||•Number of visits: 1|
|•Length visit 1: lasts half an hour||•Length visit 1: 6 hours|
|Length visit 2: lasts 6 hours|| |
|•Procedure visit 1: 1 tablet taken by mouth||•Procedure visit 1: 4 tablets in vagina + general anaesthetic + suction operation|
|Procedure visit 2: 4 tablets put in the vagina|| |
|•Success rate: 96%||•Success rate: 99%|
|•Infection rate: 0.5%||•Infection rate: 5%|
|•Other risks: pain and heavy bleed similar to those of a heavy period||•Other risks: general anaesthetic; damage to cervix and womb|
To enable women to make an informed choice between abortion methods, health professionals need to provide complete, accurate and relevant information describing the benefits, risks and procedures of both alternatives3–5. Further, current guidelines state, ‘Verbal advice must be supported by accurate, impartial printed information which the women considering abortion can understand and may take away and read before the procedure’1.
Current research has focussed on the acceptability of different abortion methods to women6–10. Although women state both methods of termination are acceptable6, some findings suggest that not all women played a part in the decision making about treatment option and/or felt they had a choice on the abortion method7. Few, if any, studies have documented the information women receive prior to their decision making about abortion method3,11. In consequence, it is unclear whether or not women receive sufficient information that enables them to take part in the decision process and make informed choices about their treatment options.
The aim of this study is to evaluate the quality of patient leaflets, regarding the choice between medical and surgical abortions, provided by abortion services within England and Wales.
A cross sectional survey of patient leaflets about abortion methods.
Private and NHS organisations in England and Wales were contacted. Specifically, the three largest private abortion organisations, identified from a Department of Health approved list of independent sector services12; all teaching hospitals, 17 hospitals are explicitly linked with medical schools13; a representative sample of NHS district hospitals, three district hospital in each of the nine health regions were selected. Only those teaching hospitals that offered an abortion service and a supporting leaflet were eligible for inclusion in this study (n= 14). Sample selection for the district hospitals was as follows: hospitals within each health region were listed alphabetically14; the first, middle and last hospitals were contacted; if the selected hospital did not offer an abortion service and/or provide an information leaflet, this was noted and the hospital listed immediately below, immediately above for the last on the list, was contacted.
A coding frame (Appendix 1) was developed with reference to the literature on informed choice and guidelines on information provision about abortion methods1–4,6,7,15. In addition, during development, the coding frame was piloted on the first five leaflets received by the first author (SSMW). The classification of leaflet content was discussed with the second author (HLB), any disagreements between classification categories were discussed and the coding frame was modified accordingly. The final coding frame classified the leaflet information into four categories of information adequacy: reference to patient choice between treatment alternatives; information about the benefits, risks and procedures of both medical and surgical methods; aftercare; service issues. In total, four subcategories were associated with explicit reference to patient choice (each sub category reported), service issues (each subcategory reported), surgical method (total score of 23 points reported), medical methods (total score of 21 points) and aftercare (total score of 11 points reported). The Flesch Readability Ease formula16 was applied to leaflets. Interpretation of these scores was aided with reference to daily newspapers, thus reflecting the level of difficulty of the associated text17.
All organisations were contacted by telephone and, for those providing leaflets about abortion methods, this information was requested. The coding frame and readability formula were applied systematically to each leaflet. The data were stored and managed using the Statistical Package for the Social Sciences (SPSS).
Univariate analyses were used to summarise the findings. As only three private organisations, and therefore three leaflets, provided services to women in England and Wales, their scores were not included in multivariate comparisons across service providers.
In total, 83% (60/72) of the hospitals contacted offered an abortion service; 73% (44/60) provided patients with written information. Of these 44 service providers with written information, all private clinics (n= 3), 93% (13/14) teaching hospitals and 52% (14/27) district hospitals offered both medical and surgical abortion methods. The rest offered just the surgical option.
Sixty-four percent (28/44) of service providers supplied written information about both abortion methods. Only 30% (13/44) explicitly stated that women could still choose not to terminate. Also, 36% (16/44) did not state gestation limit for the method of abortion on offer. No observable differences by service provider were noted (Table 2).
Table 2. Number of leaflets mentioning abortion options.
|Choice between abortion and no abortion||0||9||4|
|Both medical and surgical||3||12||13|
Of the 43 leaflets that discussed surgical abortion, 60% (26/43) scored less than half the total score (≤11/23) for information about this method; 34% (10/29) of the leaflets discussing the medical abortion scored less than half (≤10/21) the total score for information about this method; 23% (10/44) of the leaflets discussing aftercare scored less than half (≤5/11) the total score for information about postprocedure management. In addition, 68% (30/44) of the leaflets did not mention issues of patient confidentiality, 5% (2/44) did not attribute the affiliation of the leaflet and 36% (16/44) did not state a date of production. The quality of information content about surgical and medical methods was less in district than in teaching hospitals (surgical method: F= 4.005, df= 1, P= 0.05; medical method: F= 5.293, df= 1, P= 0.03) (Table 3).
Table 3. Information content of leaflets—score given for accurately mentioned items.
|Description of surgical method and risks out of 23 points||10||7.5–12|| 9.7||7.8–12||13||10–15||11||9.3–12|
|Description of medical method and risks out of 21 points||14|| 12–15||11||8.4–13||13||12–15||12|| 11–13|
|Description of aftercare out of 11 points|| 7.0||2.7–11|| 7.3||6.2–8.4|| 8.6||7.5–9.6|| 7.7||6.9–8.4|
Twenty leaflets (45%) were at a standard ease of readability or lower (Table 4). The mean readability score for all leaflets was 60 (95% CI = 58–62): teaching hospital's rate was 62 (95% CI = 58–65); district hospital's rate was 60 (95% CI = 57–61) and private clinic's rate was 59 (95% CI = 58–59). Readability scores did not differ significantly between service providers (F= 1.570, df= 1, P= 0.22).
Table 4. Readability score of leaflets. Values are given in n (%).
|41–50 (Difficult—Financial Times)||0 (0)||1 (4)||0 (0)||1 (2)|
|51–60 (Fairly difficult—Daily Telegraph)||3 (100)||14 (52)||6 (43)||23 (52)|
|61–70 (Standard—Daily Mail)||0 (0)||11 (40)||7 (50)||18 (41)|
|71–80 (Fairly easy—The Sun)||0 (0)||1 (4)||1 (7)||2 (5)|
This study documented the quality of written information provided by abortion services in England and Wales to women choosing to have medical or surgical abortions. More than a quarter (16/60) of services contacted did not support verbal advice with leaflets and, therefore, were not following current RCOG guidelines1. Of those abortion services that provided leaflets, a third (14/44) offered only the surgical option. Most leaflets contained incomplete information about the abortion choices and were difficult to understand. In addition, not only was the quality of this written information poor, quality varied across service providers with NHS teaching hospitals providing slightly better materials. However, as the patient leaflet provided by a range of service providers contained less than half the possible information about general procedures, benefits, risks and aftercare, it is unlikely that they enabled women to make informed choices about their treatment options and/or to prepare for subsequent procedures1,3,4.
In addition to this being one of the first studies to evaluate the quality of written information about abortion methods3,11, the main strengths were the representativeness of leaflet selection across service providers in England and Wales and the structured content analysis of the leaflets. This systematic analysis of the leaflets' content provides a valid and reliable appraisal of the information quality currently provided to thousands of health care users. The 44 clinics represented in this study included a range of NHS hospitals across health regions and the three largest private service providers. We estimate that the leaflets evaluated within this study were and will be accessed by approximately 100,000 women per year18.
As this study did not evaluate the content of consultation information provided to women choosing between abortion alternatives, we can only state that the leaflets did not provide complete and accessible information to women. It remains an empirical question whether or not health professionals provide sufficient information during the consultation that enables women to make informed choices. Further, although there is some evidence in other health areas that good quality written information has a role to play in women's decision making about treatment choices19 and is associated with better patient outcomes20,21, this study did not ascertain the role of written information in women's decision making about abortion method and/or impact on outcomes.
The main recommendation from this research is that abortion services provide complete, accurate, relevant and unbiased written information about abortion method choices accessible to the general population. This written information should be informed by guidelines on the aims, benefits, risks and procedures of each abortion method and assessed for readability ease. In addition, the information should be regularly updated in light of changing technologies and findings of their effectiveness. Finally, further research is still required to evaluate the effectiveness of good quality information and decision aids in facilitating women's decision making on treatment alternatives.
Appendix 1Coding frame to assess leaflet content.
Table Appendix1.. Readability score of leaflets. Values are given in n (%).
|Patient choice (each category reported)||1. Type of abortion method offered|
|2. Choice to continue, or not, with the abortion|
|3. Gestation limit for the type of abortion method on offer|
|Service issues (each category reported) 1. Confidentiality|
|2. Affiliation of organisation|
|3. Date of leaflet production|
|Surgical method (total score = 23 points)||1. Admission (number and duration: 2 points)|
|2. Prostaglandins (use, reason, side effect: 3 points)|
|3. Description of procedure (anaesthetic, dilatation of cervix, suction, duration: 4 points)|
|4. Complications: (haemorrhage, infection, retained product of conception, cervical damage, perforation of uterus, continued pregnancy, infertility—mention of each, awarded 1 point; mention of each risk with a figure quoted award 2 points—total of 14 points)|
|Medical method (total score = 21 points)||1. Admission (number, chronological order of admission, duration: 3 points)|
|2. Antiprogesterone (use, reason: 2 points)|
|3. Prostaglandin (use, reason: 2 points)|
|4. Complications: (a) Side effect of antiprogesterone and prostaglandin (nausea/ vomiting, abdominal cramp, bleeding, unknown effect on fetus: 4 points); (b) Others: (haemorrhage, infection, retained product of conception, continuing pregnancy, infertility—mention of each risk award 1 point, mention of risk with a figure quoted award 2 points—total of 10 points)|
|Aftercare (total score = 11 points)||Each of the following: pain, next menstruation, emotion, rhesus negative blood group, travel arrangement, domestic arrangement, follow up procedure, future sexual intercourse, contraception, counselling service, contact number (1 point each)|