By Carrie Purcell¹, Fiona Bloomer², Lesley Hoggart³, Karen Maxwell¹, Sam Rowlands⁴

The COVID-19 pandemic, and current ‘lockdown’ situation in the UK, have seen unprecedentedly fast-paced reorganisation of healthcare services, with many exploring the potential offered by telemedicine. Until this week, abortion care seemed to be an exception to this, with women still being legally required to attend clinics in person for early medical abortion, despite this being medically unnecessary. The two-drug regimen currently used in early medical abortion uses mifepristone and misoprostol. While home use of misoprostol has been permitted in Scotland, Wales and England since 2018, women were still being asked to attend clinics to receive mifepristone, in direct conflict with government advice against all but essential travel. This requirement also put SRH professionals at unnecessary risk as they continued to carry out face-to-face consultations. It was therefore a relief when home use of mifepristone was eventually permitted in late March 2020 in England, shortly followed by Scotland and Wales, facilitating a shift to telemedicine in early abortion care. Although part of the UK, the only option available in Northern Ireland at the time of writing is telemedicine facilitated by the volunteer/activist group Alliance for Choice, in partnership with Women Help Women and Women on Web. With new regulations yet to be operationalised, women in Northern Ireland have no alternative, since travel to England – the nominal state-funded option – is not currently possible.

This exceptionalisation of abortion – that is, abortion being marked out as something different to all other forms of healthcare – is indicative of the stigma with which it continues to be marked. Abortion is bracketed, in a way upheld by the law and processes controlling its availability, as requiring special consideration. This relates very closely to the issue of abortion stigma, and our recent paper in BMJSRH examines the ways in which stigma manifest for health professionals involved in provision.

The paper presents findings from the Sexuality and Abortion Stigma Study, a Wellcome Trust-funded project which is using secondary qualitative analysis to re-examine a broad dataset on abortion in the UK spanning the last decade. Specifically, the paper looks at ways in which health professionals talked about their involvement in abortion provision. Our analysis identified four main themes:

• They encountered resistance to abortion from SRH and other O&G colleagues
• They had to contend with the – predominantly negative – prevailing broad sociocultural narratives surrounding abortion
• They could, and did, make space to enact overt positivity around their involvement in abortion provision
• They can and should frame abortion as part of normal, routine SRH care.

For many health professionals involved in abortion care, it may be that these points seem self-evident. It is also worth acknowledging that the fundamental belief in supporting women’s rights to access equitable reproductive health care which motivates many working in the field means that some do already make a specific point of framing abortion in positive ways.

However, it is also beyond doubt that negative attitudes toward abortion persist within the healthcare system and the regulations which govern it. Based on our findings, a key argument that we make is that, for abortion to be normalised – that is, treated as any other healthcare provision – change needs to be structural. While frontline providers can and do create supportive spaces for women seeking abortion, the burden to do this should not fall on individuals. As we note in framing the paper, decriminalisation is sought by the RCOG, the RCGP, and the RCM, amongst many others across the UK. (Somewhat ironically, abortion has already been decriminalised in Northern Ireland and, while regulations were issued in March 2020, provision is yet to commence due to political inaction.)

And decriminalisation will need to be coupled with structural change within the healthcare service which supports frontline health professionals in providing every facet of SRH care. This will mean supporting those working in abortion provision to be able to do their work without facing criticism or judgement, implicitly or overtly. Moreover, this needs to be the case in every jurisdiction in the UK, including Northern Ireland. Only by ensuring this is the case can abortion ever become part of normal, routine sexual and reproductive healthcare.

¹MRC/CSO Social and Public Health Sciences Unit, University of Glasgow; ²Ulster University; ³The Open University; ⁴Bournemouth University

Normalising abortion: what role can health professionals play? By Karen Maxwell, Leslie Hoggart, Fiona Bloomer , Sam Rowlands, and Carrie Purcell BMJ Sexual & Reproductive Health Published Online First: 02 April 2020. doi: 10.1136/bmjsrh-2019-200480