Women's health plan 2021 to 2024: final report

Contraception, Abortion, Sexual Health and Pre Pregnancy

Priority: Improve access to Abortion Services

Aims:

1. All women will be able to access timely abortion care without judgment.

2. All women will have choice about how and where they access abortion care.

Short Term Actions

Action: Make telephone or video consultation universally available as an option for abortion services.

• A Chief Medical Officer letter was issued to NHS Boards in December 2021 which required Boards to make telephone or video consultation universally available.
• NHS Boards have confirmed that telephone consultations are now routinely offered.

Action: For post abortion contraception, provide all women with 6 or 12 months progestogen only pill with their abortion medications. Fast track to long acting reversible contraception if desired.

• A Chief Medical Officer letter was issued to NHS Boards in December 2021 asking them to offer the progestogen-only pill to patients during their abortion consultation.
• Clinicians have provided feedback that this is now routinely offered where this is suitable for the patient.

Action: Review data collected on abortions to ensure it is relevant, whilst protecting anonymity.

• Public Health Scotland (PHS) amended the existing abortion database to provide an updated digital platform, which enables NHS Boards to directly input data about abortions.

Directions were issued by the Scottish Government on 27 April 2022, signed by the then Minister for Public Health, Women’s Health and Sport. These directions contained information on the updated data that NHS Boards are required to provide to Public Health Scotland about each abortion and the timescales for its provision.

Medium Term Actions

Action: NHS, Local Authorities, Justice agencies and Scottish Government to work together to find ways of preventing women feeling harassed when accessing abortion care due to protests or vigils.

• The Abortion Services (Safe Access Zones) (Scotland) Act 2024 was passed in Parliament on 12th June 2024 by 118 votes to 1. The Act was brought forward by Ms Gillian Mackay MSP as a Member’s Bill which was fully supported by the Scottish Government. The Act received Royal Ascent on 22nd July 2024, and has been in force since 24th September 2024.

Action: Increase options for women around where they can take abortion medication (mifepristone).

• An evaluation of Early Medical Abortion at Home (EMAH) was published in March 2023. The evaluation concluded that the evidence demonstrates the high effectiveness of EMAH care within Scotland, and we know that increasing the options for women around where they can take abortion medication improves the accessibility of services.

Work has been taken forward on the recommendations that were set out in the evaluation to continue improvement of services. The Scottish Government has worked with Scottish Abortion Care Providers (SACP) network to share updated clinical guidance that places a stronger emphasis on patient choice across all aspects of the abortion process, for example ensuring that women are offered and able to attend an in-person appointment or ultrasound scan where they would wish to, even in cases where there is no clinical need.

New patient information guidance on the NHS Inform website that takes into account a range of feedback received during the evaluation has also been published.

The Scottish Government has also published an approval to allow women to take mifepristone at home up to 24 weeks gestation following an in-person appointment when they will take misoprostol and pass the pregnancy in a hospital or clinic.

Action: Provide mid-trimester abortion care locally or regionally for all indications.

In June 2022, the Scottish Government wrote to all Health Boards to request that all mainland Boards provide abortions to at least 20 weeks gestation with the aim of providing services at later gestations where possible, in line with the Healthcare Improvement Scotland Sexual Health Standards 2022. All mainland Boards subsequently confirmed that they were providing services to at least 19+6 weeks gestation.

The Scottish Government has committed to ensuring abortion provision within Scotland to the legal limit of 24 weeks, for all patients. National Services Scotland (NSS) has done significant work to consider the available delivery options for a later stage abortion service in Scotland.

Following that, the Scottish Government has set up a short-life working group with staff from NHS Boards to consider the range of options proposed by NSS and recommend the most appropriate delivery option for a service.

Long Term Actions

Action: Build on the (abortion) recommendations above by reviewing the provision of abortion services in Scotland to ensure services for all those deciding to terminate their pregnancy are fully accessible and person-centred.

The Scottish Government is working with NHS Boards to ensure that patient choice remains at the forefront of abortion care, including increasing access to early surgical abortions, which has been discussed with NHS Board Chief Executives.

The Programme for Government commits the undertaking of a review of the law on abortion, with the aim to ensure provision of abortion services is treated first and foremost as a healthcare matter. The review will aim to identify potential proposals for reform, within specified term limits, before the end of this parliament.

Expert Group on the review of abortion law

The Abortion Act 1967 is the most prominent piece of legislation relating to abortion within Scotland. Since that Act came into force, the abortion care landscape has changed considerably. In 1967 medical abortion did not exist; all abortions were done in hospital using surgical techniques. In Scotland, in 2023, 98.1% of abortions were done using medical methods, and more than 55% were early medical abortions where both medications were taken at home.

To ensure that any legal framework best reflects current practice, and the needs of patients and staff, the Scottish Government committed to taking forward a review of the law on abortion. This will consider the current law, whether any changes might be needed, and what those changes could look like. A public consultation is expected to be held in 2025 to ensure a range of views can be considered before any proposals are published.

As the first phase of this review, Professor Anna Glasier OBE is chairing an expert group as part of her role as Scotland’s Women’s Health Champion. The group consists of a range of legal, academic, clinical and women’s rights experts and will discuss all aspects of the law on abortion including, but not limited to the Abortion Act 1967.

Priority: Improve access to contraception services, including rapid and easily accessible postnatal contraception

Aims:

1. All women will be able to access a full range of contraception easily, quickly and confidentially.

2. All women will be able to access sexual health services easily, quickly and confidentially

3. All women who choose to become pregnant will have easy access to the information and advice they need to best prepare themselves for pregnancy.

Short Term Actions

Action: Promote use of video or telephone, in addition to face-to-face, consultation for women, including those in prisons, to provide greater privacy, dignity, choice and flexibility.

The Scottish Prison Service have recently introduced hard-wired, in-cell telephony system, which has been introduced across the whole of the prison estate. This will support longer term ambitions for a range of digital services.

The Scottish Government, in partnership with Social Work Scotland and COSLA, are working in collaboration with the Scottish Prison Service to explore the potential benefits of using Near Me within prison social work. Starting in May 2024 the programme has been undertaking some initial testing with HMP Stirling and social work departments in different parts of Scotland. The programme will be widened out based on learning and outcomes from the discovery work in HMP Stirling.

Healthcare for Women living in prisons

Women living in prison are much more likely to experience both physical and psychological problems which can be worsened by using substances as well as mental and physical adversities in both childhood and adulthood.

The Scottish Prison Service (SPS) published its Strategy for Women in Custody in 2022. It is founded on the principle that all aspects of the care of women in custody should be designed for women and take account of their likely experience of trauma and adversity. In 2022, the SPS opened two Community Custody Units (CCUs) in Dundee and Glasgow. The Bella Centre in Dundee, and Lilias Centre in Glasgow, help women develop key life-skills and greater independence in order to give them the best possible chance of a successful return to the community after leaving custody. HMP Stirling, the new national facility for women with more complex needs and risks, was opened in 2023. HMP Stirling has been re-designed with the aim of creating gender-specific and trauma-informed settings with support to help women prepare for release.

Given the specific health needs of women living in custody, the Scottish Government has committed additional investment to enable NHS Boards to deliver trauma informed healthcare so that women will have access to holistic, recovery and outcome focussed healthcare to reduce inequalities and improve the life chances of women living in prison.

Action: Provide accessible information and advice on pre-pregnancy care.

Providing support to plan a pregnancy can help raise awareness of the importance of optimising health before pregnancy. Known as pre-pregnancy, or preconception health, new information on this important topic has been published on the NHS Inform Women’s Health Platform, included on the Ready Steady Baby! website and on the Parent Club website.

This content also links through to a personalised tool developed by the charity Tommy’s designed to help women to access information tailored to their needs and enable better access to any additional information or support needs they may have.

Information and support for women who do not wish to get pregnant is also available on the Women’s Health Platform via information on sexual health, contraception and abortion.

Medium Term Actions

Action: Develop a Framework for pre-pregnancy care, to raise awareness and understanding of the importance of optimising health before pregnancy, including healthy diet, keeping active, stopping smoking and the risk of drinking alcohol during pregnancy or when planning for pregnancy.

A broad stakeholder Preconception Health and Care collaborative has been established to develop a Framework to support activity on preconception and inter-conception care.

There are four broad areas that this work will bring together to shape next steps including Research, Policy, Communications and Practice.

The first step will be to open up conversations on preconception and increasing knowledge and awareness of its importance. The actions that are in progress to support delivery on these four broad areas are:

• Set out the range of actions that contribution to health and wellbeing before a pregnancy;
• Gathering the voices of the general public on their understanding of preconception health and care;
• Small scale pilot testing of international approaches to open up conversations on preconception planning, including through routine healthcare contacts;
• Identification of existing data that would inform a national picture on preconception care measures that could be monitored over time;
• Establishment of a Scottish arm of the UK Preconception Care network on research to inform policy and practice.

This work will continue beyond this phase of the Women’s Health Plan.

Action: Provide training for non-NHS staff to support conversations with women about health and healthcare services.

The importance of creating supportive and informal spaces where women can access information on women’s health has been raised on many occasions. These spaces can help women to feel empowered and also encourage a more positive culture around women’s health that counters pervasive stigma and myths.

To enable this, the ALLIANCE produced a Conversation Café toolkit as part of their women’s health programme, recognising the value that peer support networks can bring to self-management, and helping non-NHS staff to talk about women’s health and support other women in their communities.

• Following initial testing the Conversation Café toolkit has officially published on The Alliance website.

“Great resources! Opportunity to connect and grow together” – Toolkit user (X post)

The Conversation Café toolkit was produced to support groups to host their own Conversation Cafés to discuss aspects of women’s health experiences. It is a guide for delivery, which can be used flexibly to help non-NHS staff to set up, host and evaluate their independent Café.

Since its publication the toolkit has been requested and used by a number of organisations, libraries and community groups to explore the topic of women’s health with their lived experience participants.

Action: Provide creative, holistic and outreach models of care for sexual health and contraception services.

• A number of new models of care have been funded to improve the provision of sexual health and contraception care and advice in Scotland.

Translated Materials

The West of Scotland Sexual Health Managed Clinical Network has been awarded funding to translate and subtitle four sexual health video resources into 10 community languages, to improve accessibility to information for marginalised communities across the whole of Scotland. The project aims to ensure that people who do not speak English, or have limited English language skills, have easily accessible information to be able to make informed choices about their sexual health.

The first two resources titled “So You’ve Had a Coil Fitted?” and “The Right Contraception For You” are available now.

Choices+: Supporting young people through abortion services

New youth work support has been created to help young people and young adults aged 13-21 from the point of referral through to discharge within abortion services at the Chalmers Sexual Health Clinic in NHS Lothian. They aim to empower and inform young people about the benefits of sexual health screening, reducing risk-taking behaviours and making positive decisions about their sexual health and choice of contraception.

The project aims to increase uptake of LARC and STI testing and reduce recurrence and re-attendance to abortion services through dedicated youth work intervention and build evidence to support a model of practice which can be replicated across Scotland.

Post-Abortion Contraception

The University of Edinburgh, in partnership with NHS Lothian, have been awarded funding to co-design adaptable models for post-abortion contraception (PAC) with the aim of enhancing contraceptive services and patients’ choice of, and access to, contraception in Scotland. A Scottish Post-Abortion Contraception Framework will be developed which will consist of principles, guidance and practical resources that can be applied in a range of different contexts to improve access to PAC across Scotland.

Action: Increase availability of LARC (Long Acting Reversible Contraceptive) as one of a range of options for contraception available to women.

LARC prescription rates fell by more than 40% in 2020, due to restrictions related to the pandemic, and have now reduced further to below pre-covid levels.

The reasons for this are complex but whilst sexual health clinic appointment capacity appears to be returning to pre-pandemic levels, General Practice provision has not, which has led to challenges for women wishing to access LARC.

The Women’s Health Champion, Professor Anna Glasier, established a LARC Short Life Working Group in response to these issues.

The group discussed the many challenges and opportunities that exist in improving access and provision. The Group’s conclusions were presented to the NHS Board Chief Executives in February 2024. The Group agreed their recommendations, which included a light touch review of the NHS HIS Sexual Health Standards on LARC and abortion.

In addition, over the next two years the Sexual Health and Blood Borne Virus team within the Scottish Government will be meeting with every NHS Board in Scotland. These visits will allow for opportunities further explore the issues as well as to share good practice and explore opportunities for regional and national collaboration.

Action: Ensure that discussions on contraception take place during pregnancy. Women should be given adequate and appropriate information on their options, as well as rapid access to their preferred method where applicable.

Expanding Access to Post Partum Contraception (PPC) Project

• A new national PPC patient information leaflet has been developed and is currently being translated into additional languages with the aim for this to feature on NHS Inform.
• The new TURAS e-learning module on PPC for NHS Scotland staff is now live. Work has also commenced on a new national training package for postpartum intrauterine contraception provision.
• Work is progressing on two new PPC method-specific patient animations, which will provide information in accessible format to patients.
• The next PPC conference will be held in early 2025.
• A joint project with Public Health Scotland has commenced to collect and report national and regional interpregnancy interval data.

Long Term Actions

Action: Provide more routine sexual healthcare through i) primary care, ii) community pharmacies and iii) online where appropriate, to enable specialist sexual health services to prioritise those most at risk of sexual ill health or unintended pregnancy.

Scottish Government funding has been provided to develop innovative models of sexual healthcare.

‘Sexual Health and Abortion at the Pharmacy’ (SHARP)

Lothian and Tayside NHS Boards are undertaking an exploratory project to support expansion of the delivery of more sexual and reproductive health care through community pharmacies. Funding has been allocated under the Sexual Health and Blood Borne Virus Action Plan to facilitate a Scotland-wide survey of pharmacists on willingness, barriers and facilitators to offer more sexual and reproductive health (SRH) services. It will also allow for an online peer support pharmacist SRH network and a feasibility study of pharmacist-delivered SRH services.

The feasibility study will initially be focused on patients accessing abortion services and peri-abortion care. Three key pilot pharmacies in Lothian and Tayside will act as ‘hubs’ for patients to collect abortion care medicines and receive peri-abortion care, STI testing and post-abortion contraception. This will include all methods of contraception except intrauterine (‘coils’).

Sexual Health Website

A new sexual health website is under development, led by NHS 24 with funding from the Scottish Government. This will be delivered on NHS Inform and will serve as a single source of quality assured information, linking with the Women’s Health Platform. It will also act as a national point of access to the increasing range of services planned for virtual delivery, including postal testing, appointment booking and signposting.

Online postal self-sampling kits

After a successful pilot in NHS Lothian, funding has been awarded to Public Health Scotland to develop a national online portal for the ordering of self-sampling kits for STIs and HIV. This will allow greater access to testing especially for those in rural and island areas, those who may find additional barriers to accessing clinics and those most at risk. Whilst some areas already offer postal testing, this will ensure national coverage and a single point of access through NHS24.