Remote abortion care should always be offered to ensure the health of women, irrespective of whether there is a pandemic, argue Elizabeth Chloe Romanis and Jordan Parsons
On 30 March 2020, the Department of Health and Social Care liberalised abortion regulations, allowing women in England to be consulted about abortion care remotely and to take both abortion medications, mifepristone and misoprostol, at home. This same change had already been made the previous week, but was then revoked within a couple of hours. The Scottish and Welsh governments both followed suit on 31 March 2020 and have also authorised the remote prescription of abortion pills and for both pills to be taken at home. Before these interventions, women were required to attend clinics in order to access treatment that could have safely been provided remotely—a stance that was paradoxical during the pandemic.
This change to the law is welcome as it finally ensures that for the duration of the pandemic, women will have safe access to essential healthcare. However, there remain three key issues that are important to highlight. First, these orders only apply in Great Britain, leaving those seeking abortion care in Northern Ireland vulnerable. Second, the change in law is only temporary and there are good reasons to believe that the change should be permanent. Finally, the political nature of the Department of Health and Social Care’s U-turn.
What about Northern Ireland?
Remote abortion may now be (temporarily) lawful in Great Britain; however, it remains unlawful in Northern Ireland. A new framework for abortion provision came into force in Northern Ireland on 31 March 2020 following the decriminalisation of abortion in July 2019. This framework allows for abortion “on demand” until 11 weeks and six days gestation, and when it is prescribed and administered by a medical practitioner “in General Practitioners premises, clinics provided by a Health and Social Care (HSC) trust, and HSC hospitals… and women’s homes where the second stage of early medical terminations may be carried out.” This expressly precludes women from taking the first abortion pill at home.
Unlike their counterparts across the rest of the UK, women in Northern Ireland will have to leave their homes to have an abortion, risking serious injury to their health and that of their family in order to access that care. They are also likely to experience a significant delay in accessing care as there are even fewer resources available for abortion care during this time. Action needs to be taken here to ensure that there is equity in access to basic care for these women left behind. There is no reason why Northern Ireland cannot follow England, Scotland, and Wales in implementing telemedical abortion provision, and the failure to do so is causing, and will continue to cause, undue harm to thousands of women throughout the pandemic.
Telemedical abortion should not be a temporary measure
The new law in England is to be in force for two years (until 30 March 2022) or until the temporary provisions of the Coronavirus Act 2020 expire. The approval orders in Wales and Scotland are yet to appear online, but it is expected that they are also temporary as government press releases make specific reference to covid-19.
Abortion is essential healthcare necessary to protect the physical and mental health of women; its provision is far less risky to health than the consequences of unwanted pregnancy. There is always a need to facilitate convenient abortion care in order to ensure the health of women—irrespective of whether a pandemic is preventing women from leaving their homes. Even before covid-19, there were other real geographical, social, and practical barriers that were limiting women’s access to abortion care and these will still exist after the pandemic.
For those living in rural parts of the UK—particularly in Scotland—the nearest clinic can be far away. With recent clinic closures (that happened before and were unrelated to the pandemic), this geographical inequality has worsened. Clinic attendance is sometimes an inescapably financial problem. Not only might it require time off work, but many of those seeking abortions have caring responsibilities, either for existing children or other family members. When the nearest clinic is hours away, these responsibilities may prevent a person seeking an abortion early on in their pregnancy, thus increasing the risk of complications when they eventually do.
This disaster is going to allow healthcare providers to set up the infrastructure to provide safe and effective healthcare for women at home. It would be a setback if, after covid-19, women are forced once again to return to a state of affairs in which accessing abortion care is, for many, more difficult than it should be.
Telemedical abortion services were provided before the pandemic in other countries, including parts of the United States and Australia. We also have a substantial body of evidence demonstrating that services trialling telemedical abortion are safe, effective, and efficient. Furthermore, service users also report that telemedical provision is acceptable. Follow-up services can also be made available in the rare circumstances where a woman believes that she needs further (medical) assistance.
A political manoeuvre
While we should champion the change in the law here as crucial to ensure that women can continue to access basic and essential care, the delay in government action on this matter, and the U-turning by the government on conditions in England, should be scrutinised.
We estimated (based on 2018 Department of Health and Social Care statistics) that there are more than 14 000 women in England and Wales who are already pregnant and who will need early medical abortion care over the next 12 weeks. For these women waiting for treatment, the last week caused considerable distress, including unnecessarily exposing some of them to increased risk when they had to access this care. This was both negligent and unwarranted, as the risks associated with abortion treatment increase with duration of pregnancy.
Furthermore, because of the changing regulations there has been, and may remain among some women, considerable confusion about what treatment is available. Some news outlets mistakenly published before 31 March that remote abortion care was already lawful in Wales and Scotland when it was not, which would have also perpetuated confusion.
The significant difference between the Department of Health and Social Care’s first approval order related to England and the second a week later, is the express provision of how the order is “undone.” The first was clear that the order was temporary but did not specify for how long the order was operational. Returning to the previous rules around remote abortion that have been in place since 2018 (the second pill can be taken at home, but the woman must attend a clinic to be prescribed abortion pills and she must be supervised taking the first pill) would have meant issuing another approval order.
However, in the second and current approval order, provision is made for the automatic revocation of relaxed remote abortion rules. This means that the old regressive law, which unnecessarily interferes with women’s reproductive health and choices, can come back into effect without the government needing to issue an explanation.
This was a deliberately political manoeuvre. It does not require the secretary of state to actively revoke the new rules, which could potentially spark greater pushback than the expiration of a time limited change. It is a great shame that measures with the potential to improve women’s reproductive health will, for the sake of political expediency, cease to operate at the end of this pandemic.
Elizabeth Chloe Romanis is a Wellcome PhD candidate in bioethics and medical jurisprudence at the University of Manchester working on reproductive health, law, and ethics. Twitter @ECRomanis
Competing interests: None declared.
Jordan Parsons is a Wellcome PhD candidate in bioethics at the University of Bristol working on best interests decision making in renal care. Twitter @Jordan_Parsons_
Competing interests: None declared.