AR Responds: The Scottish Government Consultation on Future Arrangements for Early Medical Abortion at Home
Abortion Rights is the only national UK pro-choice campaign. We formed in 2003 as a merger of the National Abortion Campaign (NAC) and the Abortion Law Reform Association (ALRA). We oppose any attack on the 1967 Abortion Act.
We believe the law should be brought into line with public opinion, so that women can make their own reproductive decisions. Central to our campaign is recognising the needs of all women in society. Abortion Rights has defended the disabled community, BME women, the migrant community and those from the LGBT community as well as young and old.
Abortion Rights seeks to empower women and actively campaigns to defend and extend the right to free, safe, legal and accessible abortion (including in Northern Ireland); to ensure equal access to information and terminations across the UK rather than a “postcode lottery”; and to challenge the social stigma that continues to negatively impact women’s reproductive choices.
Abortion Rights is membership-based organisation, with over 1000 members who pay a small annual membership fee. Our membership has a strong Trades Union make up from well-established links built up over years.
We have approximately 80 branches and regions, of varying levels, currently affiliated to Abortion Rights. For example, the Trades Union Congress (TUC), the Scottish TUC, UNITE, RMT, UNSION, CWU, NEA, GMB, FBU and UCU.
Abortion Rights’ Chair and Officers have day-to-day responsibilities for decision making between quarterly Executive Committee (EC) meetings.
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Question 1
a) Positive impact
b) Positive impact
c) Positive impact
The current arrangements put in place due to Covid-19 have had a positive impact on women accessing abortion services in relation to all of the above considerations.
The provision of abortion pills for home administration is a long overdue and progressive step forward. One which is in line with modern medicine and clinically safe. International scientific evidence1 clearly demonstrates the safety and clinical appropriateness of home administration. Medical abortion is recommended by the World Health Organisation, with
both abortion pills included within their list of essential medicines, which compromises lifesaving medicines that should be available in every country.
In terms of access, it is undoubtedly the case that permitting home administration for both pills increases women’s access to abortion healthcare. Home administration removes real and significant barriers which women have prevented women accessing services in a timely and appropriate manner in the past.
Abortion Rights considers that the following barriers will be lessened by home administration:
The requirement to travel for services.
Home administration of abortion pills, after a consultation by telephone or video call, means that women no longer have to travel to access abortion services. To date, women have been required to attend multiple appointments to access services initially, including appointments with a GP or local sexual and reproductive health service. After clearing that hurdle women
1Int J Gynaecol Obstet. 2016 Sep; 134(3):268-71. doi: 10.1016/j.ijgo.2016.02.018. Epub 2016 May 26. Prospective study of home use of mifepristone and misoprostol for medical abortion up to 10weeks of pregnancy in Kazakhstan. Platais I, Tsereteli T, Grebennikova G, Lotarevich T, Winikoff B, and
Acta Obstet Gynecol Scand. 2014 Jul;93(7):647-53. doi: 10.1111/aogs.12398. Epub 2014 May 23. Medical abortion with mifepristone and home administration of misoprostol up to 63 days’ gestation. Løkeland M, Iversen OE, Engeland A, Økland I, Bjørge L. Free full text:
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are then required to attend usually at a hospital or sexual and reproductive health clinic in order to be given mifepristone. After taking this medication women can return home. A change in the legislation in 2017 means that women can also be prescribed the second abortion pill, to take at home, during this appointment.
However, whether the second pill is prescribed for home use or not varies by Health Board. This means that the provision and level of service received by women essentially comes down to their postcode2. If the second abortion pill is not provided for home administration women are required to attend back at the original hospital or clinic, 24-48 hours later, to be prescribed misoprostol.
Home administration ends the unnecessary need for women to travel for these multiple appointments. It places women at the centre of their healthcare and provides a system which reflects the reality of women’s lives. Further, providing medication that can be taken at home ensures that women seeking abortion services do not risk an abortion commencing on public transport, a barbaric situation, which has no place in modern Scotland. In a 2017 study a women gave her experience, “when I was on the bus I could feel that I was bleeding a lot […] I was really tired. I was just kind of, y’know: ‘I’ve spent 45 minutes on a bus for a two-minute appointment..?’3.
The cost of travel.
An ongoing barrier to accessing abortion services in the system outlined above is that women require to have the financial means to attend all the required appointments. This requirement hits women in rural, remote and islands communities hardest and is an ongoing barrier to the access to services. Removing this need to travel and the associated cost again increases women’s’ access to services.
2 National Statistics, Termination of Pregnancy statistics, year ending December 2019, Public Health Scotland.
3 Purcell, C. , Cameron, S., Lawton, J., Glasier, A. and Harden, J. (2017) Self-management of first trimester medical termination of pregnancy: a qualitative study of women’s experiences. BJOG: An International Journal of Obstetrics and Gynaecology, 124(13), pp. 2001-2008. (doi: 10.1111/1471- 0528.14690) (PMID:28421651) (PMCID:PMC5724679) http://eprints.gla.ac.uk/140042/
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The cost of childcare.
Home administration also removes the requirement for women to source and pay for any additionally required childcare in order to attend appointments. Again, this additional cost on top of the travel costs is a barrier to access which is removed by home administration.
Time off work.
Abortion Rights believes that home administration of abortion medication puts women at the centre of their care. As the travel requirement is removed, it means that women are less likely to require time off work to attend appointments. In additional, with home administration, women can decide when to take the pills in order to have control over their own treatment and symptoms. This is in line with increasing trend towards patient autonomy within medical services.
Domestic violence.
Women in abusive and/or controlling relationships find it difficult to attend the multiple appointments required of them to access abortion services. In addition to all of the above factors, women in violent relationships may require to account for time and/or their whereabouts meaning multiple appointments out of the normal are difficult.
Home administration of medication removes the need for all of the in-person appointments and therefore increases access for women suffering domestic violence. A 2018 study, which looked at barriers to abortion access noted the following regarding domestic violence:
“Just over 1 in 6 reasons (18%) involved a situation where women did not feel able to seek abortion services at a clinic or hospital because of the fear or threat of partner violence or a situation involving a controlling family. These circumstances ranged from fear of strong disapproval on religious grounds— leading to shunning or, in extreme circumstances, fear of honor killing—to inability to leave the house without permission from a partner and fear of physical violence from a partner disapproving of abortion… Susan, who is 30 years old and lives in England, described her situation living with domestic violence and unable to seek care at a clinic or hospital for fear of partner intervention or retaliation: ‘I’m in a controlling relationship, he watches my every move, I’m so scared he will find out, I believe he’s trying
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to trap me and will hurt me. I can’t breathe. If he finds out, he wouldn’t let me go ahead, then I will be trapped forever. I cannot live my life like this.”4
Doctors for Choice have stated that by revoking these temporary regulatory changes women in violent relationships will be at risk of escalating abuse.
In terms of the effect on waiting times, data produced by the Royal College of Obstetricians and Gynaecologists which collates data from independent sector providers, who provide about 75% of abortions in the UK, show that the average waiting time for an abortion has halved during the time of data collection, reducing to 4.5 days.
In 2019, the National Institute of Clinical Health and Care Excellence (NICE) carried out an evidence review looking into what factors help or hinder the accessibility and sustainability of a safe abortion service which sets out many of these factors, amongst others. 5
4 Aiken, A. R. A., Guthrie, K. A., Schellekens, M., Trussell, J., Gomperts, R. (2018). Barriers to accessing abortion services and perspectives on using mifepristone and misoprostol at home in Great Britain. Contraception, 97, 177-183
5 https://www.nice.org.uk/guidance/ng140/evidence/a-accessibility-and-sustainability-of-abortion-services pdf-6905052973
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Question 2.
Positive impact.
In the current climate, Abortion Rights believes that the current arrangements greatly reduces the risk of women contracting covid-19 by requiring them to attend multiple appointments and the potential necessary use public transport as set out above. In turn, it is submitted that this reduces the risk posed to healthcare workers of contracting covid-19 as it reduces the number of patients attending hospitals.
Setting aside consideration of the pandemic, Abortion Rights believe that the current arrangements mean that women are seen and treated quickly, minimising the potential for complications. The reduction in barriers, set out above, mean that women are able to access services earlier in their pregnancy. The longer a woman carriers an unwanted pregnancy the greater the risk to her and her health.
As Doctors for Choice have stated that the current system, “allows Doctors [sic] to provide better quality care to women and pregnant people who need an abortion”
The current arrangements mean that consultations are quicker and more efficient, freeing up clinicians to concentrate on cases which are more complicated. Further, the introduction of self-referral for telemedicine reduces pressure on GP and local sexual and reproductive health services.
A study into abortion provision in England and Wales concluded that the recent changes “further builds a strong case for changing policies to match the evidence base”. The authors also suggested that, “further research is conducted to inform and enable task-shifting of first trimester surgical abortions to nurses and midwives in UK primary care. EMA services to GP clinics would increase the number of trained health professionals that perform simple abortion procedures, freeing up specialists for more urgent, complicated cases, such as those seeking abortion in later in pregnancy”6.
6 Systematic review of early abortion services in low- and middle-income country primary care: potential for reverse innovation and application in the UK context Jacy Zhou, Rebecca Blaylock & Matthew Harris: Globalization and Health volume 16, Article number: 91 (2020) https://link.springer.com/article/10.1186/s12992-020-00613-z
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Question 3.
There are fewer risks with the current arrangements because there is no need for attendance at multiple appointments which, as set out above, places significant barriers in relation to accessing abortion services.
The Royal College of Obstetricians and Gynaecologists have stated that, “over the last decade the percentage of early medical abortions has almost doubled, from 37% in 2008 to 71% in 2018. This has significantly reduced the need for hospital admission and the risk of women suffering complications associated with surgical procedures. This simple adjustment to service delivery also means that precious NHS resources are saved by reducing the number of visits that a woman has to make to a clinic to obtain her medication”7.
Doctors for Choice have confirmed that concerns over safeguarding have proved to be unfounded.
A relevant risk in these measures – as with abortion services in Scotland in general – is the difference in service provision by different Health Boards throughout Scotland. It is Abortion Rights’ belief that all women in Scotland should have equal access to abortion regardless of their class, postcode or wealth.
The termination of pregnancy statistics produced by Public Health Scotland, to December 2019 demonstrate that around only half of medical terminations in 2019 involved self administration of misoprostol in the home setting. This proportion varied significantly by NHS Board of treatment – ranging from 10% in NHS Highland to 75% in NHS Lothian.
It is submitted that this is a serious risk to access for women seeking abortion services. These changes were brought in in 2017 and over two years later only 10% of women in NHS Highland are able to take misoprostol in the home setting.
7 RCOG Better for women – improving the health and wellbeing of girls and women – December 2019 https://www.rcog.org.uk/globalassets/documents/news/campaigns-and opinions/better-for-women/better-for-women-full-report.pdf
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Abortion Rights considers that these inequalities in access to services will remain unless the Scottish Government, actively and from the centre, works with Health Boards to ensure that services across Scotland meet the changes which this consultation proposes.
Those opposed to the current arrangements appear to focus on the lack of in-person consultation. Abortion Rights considers that it is important to note that there is no requirement for either of the two doctors certifying the ground for termination to have seen or examined the woman seeking treatment. Further, there is no legal requirement for women to undergo a scan before having an abortion in order to determine gestational dates.
Routine pre-abortion ultrasound scanning is unnecessary. Most women can determine the stage of their pregnancy by the date of their last period. The current arrangements trust women to provide information to their healthcare professionals, in the same way information is exchanged between patient and clinician in any other procedure.
Those providing abortion healthcare require, under the Abortion Act 1967, to demonstrate that they have acted in good faith. Such clinicians work in a heavily regulated environment from which the public and the public interest can take confidence.
Abortion Rights believes that these decisions are clinical decisions and therefore should be determined between the woman and her treating clinician, using their clinical judgment, there is no requirement for any overly prescriptive legal requirement which removes medical autonomy and judgment, and is not present in any other medical procedure.
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Question 4.
Yes.
Abortion Rights believes that continuing the current arrangements for early medical abortion at home improves the service for all women, by making it more accessible.
As set out above, travel is a particular barrier to women accessing services. It is submitted that this burden is increased exponentially for disabled women who have specific access and travel needs. This can result in disabled women relying on the help of others and the confidentiality of their healthcare needs can therefore be compromised. The current arrangement removes this barrier and means abortion services for disabled women are more accessible and more confidential.
Further, the current system, as referenced above increases access for women living in an abusive relationship.
Due to the patriarchal society in which we live, abortion is too often still stigmatised and used to reinforce gender stereotypes of women and sexual relationships. In particular, a barrier to accessing abortion services can be due to religious and cultural matters. Again, the current systems helps to break down some of these barriers meaning that services can be accessed from home and are therefore more straightforward and private. It is submitted that the same point applies to women of limited immigration status who may otherwise be reluctant to seek services.
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Question 5.
Yes
Abortion Rights are firmly of the view that the current arrangements reduce socio-economic inequalities which currently exist in the provision of abortion services.
As set out above travel, cost of travel, cost of childcare and time off work all mean that women in lower socio-economic groups have to overcome many barriers to access abortion services. Too often in Scotland, abortion services are not only determined by your postcode but also by your class and your ability to pay.
This is particularly the case in the current economic climate where jobs are insecure and the use of temporary and zero hours contracts are on the increase. Women working in these types of roles cannot afford to turn down work in order to attend multiple appointments to access abortion services. Not only will turning down work result in a reduction in their income, it also has the potential to reduce their earning potential significantly. In the current economy it is more of an employers’ market that ever before. Zero hours contracts and temporary contracts allow employers to hire and fire employees with impunity.
If a woman, working on a zero hours contract, requires multiple days off to attend appointments, and then further time off to undergo the abortion procedure, she may well find that she is not subsequently offered any shifts, or that there is a significant reduction in her shifts.
The current system would prevent all of this, as it cuts out the need for multiple appointments and allows women to take the medications at a time which is suitable for them in line with their lives and commitments.
We are in agreement with Doctors for Choice in their statement that “attempts to revoke temporary regulatory changes would therefore disproportionately affect women of lower socio-economic status”.
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Question 6.
Yes
Abortion Rights believes that the current arrangements allow for much wider access to abortion services for women living in rural or island communities. Please see above comments regarding the reduction in the need to travel.
As well as comments outlined above we also consider that the current arrangements ensure that women living in rural areas do not struggle to access services due to the conscientious objections of local GPs.
Abortion Rights notes with concern that women can be refused services by a medical practitioner who conscientiously objects and not be provided with any further referral information. Living in a rural area means that often there is only one GP practice and no sexual health clinic nearby.
This leaves women with significant hurdles to get across in order to access abortion services. It is submitted that the current arrangements negate this issue as it is presumed that clinicians providing the telephone and telemedicine consultations do not conscientiously object. This means that women are not pushed from pillar to post while trying to access their legal right to a healthcare procedure.
However, abortion services will remain restricted if Health Boards fail to implement these changes. Please see comments above regarding the postcode lottery in terms of home use of misoprostol two years on from implementation.
For these current arrangements to be a success and widen access for all women the Scottish Government will require to work with Health Boards to ensure that all women in Scotland can benefit from the changes proposed. In Abortion Rights’ view there is little point in changing the procedures if, in reality, women are unable to make use of the services because of local difficulties and/or bureaucracies.
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Question 7.
(a) Abortion Rights believes that the current arrangements (put in place due to COVID-19) should continue – in other words allowing women to proceed without an in person appointment and take mifepristone at home, where this is clinically appropriate.
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