By Dr Siobhan Kirk
Northern Ireland (NI) had one of the most restrictive and punitive abortion laws in Europe until 2019. An advantage of the non-functioning Northern Ireland Assembly in 2019 was that the law was changed to allow abortion under the UK Parliament’s Northern Ireland Act 2019. However, the Health Minister and the Department of Health NI have failed to commission or fund services and there remains significant political resistance. Many women are still having to travel to England for abortion services in the ongoing pandemic.
The Abortion Regulations (NI) 2020 came into effect on 31st March 2020, just after the UK lockdown. This new legislation provides the framework for allowing lawful access to abortion, with lack of any conditionality up to 12-weeks gestation. One signature (doctor, nurse or midwife) is required for certification before 12-weeks gestation, and two signatures are required above this gestation.
For years, women have been accessing abortion care in England, funded since 2017 by the UK Department of Health and Social Care and provided by three main private abortion providers. Following the new legislation, the intention of the NI Government was for women to continue to travel as, despite the Abortion Regulations, no local services existed and there had been no effort to fund or commission abortion. However, once lockdown started, travel was difficult and two women tragically attempted to take their own life after arranging abortion in England and then having their flights cancelled. To continue to export all abortion care was not a safe or reasonable option.
The Multidisciplinary Northern Ireland Abortion and Contraception Task Group (NIACT), created to inform the commissioning and implementation of abortion in NI, held its first meeting on 30th March 2020 to quickly implement a temporary emergency early medical abortion (EMA) service in NI during the COVID-19 pandemic. This would allow safe local access, ideally within existing sexual & reproductive health services but in some Trusts utilising gynaecology and genitourinary medicine staff. This was possible due to the downturn in other services due to the pandemic. On 9th April formal direction came from the Chief Medical Officer allowing Trusts to provide abortions. Protocols, IT consultation templates, and patient information leaflets were designed in line with NICE guidelines. Official notification and certification forms were provided by the Department of Health.
EMA clinics were rapidly commenced in three of the five trusts in Northern Ireland and within eight weeks there was a regional service. Informing Choices NI (ICNI), a sexual health charity, agreed to provide a central access point facilitating self-referral. The article published in the BMJ SRH reports on the first three months of this experience.
Unlike in the rest of the UK and Ireland, at home mifepristone is not permitted under the NI Regulations. After a telephone consultation, a clinic visit is arranged for treatment. Time between referral and treatment is usually a few days, resulting in early gestational age at treatment, associated with fewer complications, less pain and bleeding. There is high uptake of long-acting reversible contraception, available at most clinics. Patient satisfaction has been excellent with women being very grateful to access local treatment. However, shortcomings remain as there is no service or referral pathway after 10-weeks gestation and no surgical option for women who need or would prefer it. These shortfalls are due to the ongoing lack of funding, suitable facilities, and lack of recruitment and training of willing staff and are likely to persist until the service is commissioned.
Unfortunately, despite high demand, the service in all trusts is fragile as clinicians have resumed normal clinical commitments. From October 2020, the Northern Trust ceased to offer EMA. Women from this area now have to travel to England or access pills online. Furthermore, trusts are struggling to continue to provide EMA and three trusts have only one doctor with limited or no nursing and clerical support. Changes are urgently needed.
Allowing at home mifepristone would improve the ongoing feasibility of EMA. Additionally, the ICNI central access point is unsustainable without funding and is in need of this. Furthermore, lack of official signposting to the central access point has meant many women inadvertently contacting anti-choice organisations claiming to offer services to women requesting abortion. This has caused delays and misinformation on gestational age, resulting in some women being unsuitable for treatment in NI, and has also caused significant distress.
Further amplifying problems, the NI Regulations do not allow for exclusion zones and as lockdown restrictions ease, there are increasing protests from anti-choice organisations. Additionally, no risk assessments have been made for the women travelling unnecessarily to high COVID areas of England, often the most vulnerable with mental health issues, serious medical conditions and language barriers. The Health Minister and DoH are failing in their duty of care to these women.
The Department of Health NI show no sign of commissioning the comprehensive regional abortion service that is urgently needed, with no discussions having taken place since May 2020. The Royal College of Obstetricians & Gynaecologists and the Faculty of Sexual & Reproductive Healthcare have written to the Health Minister and Secretary of State for NI regarding these issues but have received no response to date. Our colleagues and politicians from the rest of the UK who attended the All Party Parliamentary Group on Sexual Health “A way forward: Commissioning abortion services in Northern Ireland” virtual meeting on 14th December 2020 were shocked at the challenges to women accessing abortion services and the pressure on the staff providing care. Although health is a devolved matter, action could be taken by the Secretary of State and Westminster.
We have come a long way, but safe local abortion care is still unavailable to many of the women who need it. Work needs doing to highlight the urgent need, to improve public awareness of accessibility, and to support the dedicated health care professionals who want to optimise comprehensive local abortion care.
Dr Siobhan Kirk is an Associate Specialist in Gynaecology and Specialty Improvement Lead for Sexual & Reproductive Health in Belfast HSC Trust. She is a Fellow of both the Royal College of Obstetricians & Gynaecologists and the Faculty of Sexual & Reproductive Healthcare and is a British Menopause Society accredited menopause specialist. As the SRH representative for Doctors for Choice NI and a member of the Northern Ireland Abortion and Contraception Task Group, she has been closely involved with the implementation and management of the emergency early medical abortion service in NI during the COVID-19 pandemic.