Form

Form HSA4: abortion notification - summary of the information collected

Updated 1 May 2024

Applies to England and Wales

In accordance with the Abortion Act 1967, registered medical practitioners must notify the Chief Medical Officer (CMO) of abortions within 14 days. The HSA4 abortion notification form is provided to collect the required information.

This page sets out the information collected on the HSA4 form.

1. Practitioner terminating the pregnancy

The full name, permanent address and General Medical Council (GMC) registration number of the registered medical practitioner terminating the pregnancy.

The practitioner also signs and dates a statement that they:

Hereby give notice that I terminated the pregnancy of the woman identified overleaf, and to the best of my knowledge the particulars on this form are correct. I further certify that I joined/did not join (delete as appropriate) in giving HSA1 having seen/not seen (delete as appropriate) and examined/not examined (delete as appropriate) her before doing so.

2. Certification

In all non-emergency cases, the full names and addresses of practitioners who joined in giving HSA1 certification that, in their opinion, which must be formed in good faith, at least one and the same grounds for abortion set out in the Abortion Act 1967 is met.

Whether the practitioners saw and/or examined the pregnant woman before giving the certificate.

3. Patient’s details

The patient’s hospital or clinic number, or NHS number. If one of these is not available, the patient’s full name is provided.

The patient’s date of birth.

For UK residents, the patient’s full postcode. If the full postcode is not available, the patient’s complete address is provided.

For non-UK residents, details of the patient’s country of residence.                       

The patient’s self-reported ethnicity, where known.  

The patient’s marital status. 

The number of previous pregnancies resulting in:

• livebirths and stillbirths over 24 weeks
• spontaneous miscarriages and ectopic pregnancies
• legal terminations

4. Treatment details

The name, address and hospital or clinic code of place of termination, including the place of treatment with antiprogesterone. This information is not required if both medicines were administered by the patient at her usual place of residence.

Whether the abortion was NHS funded or privately funded.

The date and method of feticide (if used).

Surgical terminations

The date of termination.

The dates of admission and discharge if different from date of termination.

Details of the method used. 

Medical terminations

The date of treatment with antiprogesterone or advised treatment date when medicines are prescribed to be self-administered at patient’s usual place of residence.

The date of treatment with prostaglandin or advised treatment date when medicines are prescribed to be self-administered at patient’s usual place of residence.

The date termination confirmed.

If other medical agents were used, the date of treatment and the medical agent used.

Where the medicine was administered, with tick box options for:

• all medicine administered in hospital or clinic
• one medicine administered in hospital or clinic, one medicine administered at patient’s usual place of residence
• all medicine administered at patient’s usual place of residence

The name, address and clinic code of place of treatment with prostaglandin (if different to the place of treatment with antiprogesterone).

If any medicines were administered at the patient’s usual place of residence, whether any part of the patient’s consultation and treatment for the termination of pregnancy was provided face to face (in person) by a registered medical practitioner, nurse or midwife.

If the answer to the above question is no, an optional question may be answered on whether the patient was seen in person by another healthcare professional, such as a sonographer.

If all medicine was administered at the patient’s usual place of residence, an optional question may be answered to specify which organisation provided the abortion. 

5. Gestation

The number of completed weeks’ gestation.

6. Grounds

Information on the certified grounds for terminating the pregnancy stated on the HSA1 form:

• ground A - that the continuance of the pregnancy would involve risk to the life of the pregnant woman greater than if the pregnancy were terminated
• ground B - that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman
• ground C - that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman (this includes pregnancies up to 23 weeks and 6 days)
• ground D - that the pregnancy has not exceeded its 24th week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of any existing child (or children) of the family of the pregnant woman (this includes pregnancies up to 23 weeks and 6 days)
• ground E - that there is a substantial risk that, if the child were born, it would suffer from such physical or mental abnormalities as to be seriously handicapped

Or the grounds stated on the HSA2 form where an emergency termination was performed:

• ground F - to save the life of the pregnant woman
• ground G - to prevent grave permanent injury to the physical or mental health of the pregnant woman

For terminations under grounds A or B, information is collected on the main medical conditions.

For terminations under ground C, information is collected on whether there was a risk to the woman’s mental health. If there was no risk to the woman’s mental health, information is collected on the main medical conditions.

For terminations under ground E, information is collected on the abnormality or other reason for termination and the method of diagnosis.

For terminations under grounds F or G, information is collected on the main medical conditions.

7. Selective termination

If a selective termination is performed to reduce the number of fetuses in a multiple pregnancy, information is collected on the original number of fetuses and the number of fetuses reduced to.

8. Chlamydia screening

Whether screening for chlamydia was offered.

9. Complications

Details of complications known up until the time of discharge. 

10. Death of woman

If the patient died, information on the date and cause of death.