Elizabeth Chloe Romanis, Jordan Parsons, and Nathan Hodson
In an unprecedented move, yesterday the Department of Health and Social Care liberalised restrictions on abortion care in England only to revoke that decision hours later. This returned the legal position for abortion provision back to that stated in the approval order of the Secretary of State for Health, Matt Hancock, in 2018. The 2018 approval order is very clear that remote prescription and provision of abortion medication is unlawful. Women must still attend an abortion clinic in order to access treatment, which is especially concerning given the current COVID-19 emergency.
For the first time in over 50 years, women living in England, Scotland and Wales must risk their lives to terminate a pregnancy. This regressive step demands urgent action.
Changes on 23rd March 2020
The approval order released yesterday (23rd March) stated that it was now temporarily lawful for a woman to take both abortion medications at home provided they consult with a licensed clinic via electronic means (video link or telephone) and with a registered medical practitioner by the same means who prescribes abortion medications. Following the prescription (and delivery of the medication to the woman’s home) she is then able to take both tablets to procure a miscarriage, 24-48 hours apart, at home. The order was clear that it applied only to England, for constitutional reasons, and was temporary in response to COVID-19 but with no fixed end date.
The reason for the decision to revert this order is, at present, unclear since the Department of Health and Social Care have yet to issue a statement and the Government website simply reads that the approval order was ‘published in error.’
This is unsatisfactory, especially given the number of women whose health is impacted by this decision and its reversal. We estimated earlier that around 14,000 already pregnant women will need access to abortion care within the next 10 weeks, and this is before accounting for any new conceptions that occur during this period of social distancing and potential lockdown. Some experts have proposed that ‘isolation sex’ will lead to a ‘coronavirus baby boom’ over the next year as a result of more people staying home, and some media outlets are estimating that need access to care at some point in the duration of the current emergency. Some media outlets are estimating that approximately 44,000 women will need access to care at some point in the duration of the current emergency, despite the very real health risks to the women and their families – as well as clinic staff – and the social barriers that might prevent their access during school closures and difficulty travelling. This presents a significant health risk. The Department of Health must provide an explanation and reinstate yesterday’s temporary order.
The position abortion providers have been placed in is unfair. Yesterday there was reasonably an expectation that service provision could be adapted, and today it is clear that such adaptations would not be legally permissible. Some providers are seeking urgent clarification from the Department of Health.
For the time being, the requirements of the Abortion Act 1967 mean that the 2018 approval order by Matt Hancock applies again in England (and the position has been unaffected in Scotland and Wales). This means that both abortion medications – mifepristone and misoprostol – must be prescribed in a licensed clinic and a woman receiving treatment must take the former in the clinic. They can take misoprostol home to self-administer 24-48 hours later.
Why we need remote access
Abortion care by telemedicine (remotely) is very safe and effective, as demonstrated by substantial evidence. Making this safe and easier method of provision available will ensure that women can access treatment, staying safe and keeping others safe, during the COVID-19 pandemic.
In an earlier blog post for the BMJ Sexual and Reproductive Health we raised our concerns about limited access to abortion during this crisis. Accessing a clinic in present conditions is far more difficult for women who are dependent on public transport to get to a clinic and for women who are self-isolating, caring for dependents at home, or worried that travelling will endanger themselves or their families. For the number of women who need treatment, a significant number will have their health impacted by the current legal restrictions on care. This is because they either will have to delay accessing treatment – and the evidence overwhelmingly suggests that risk in medical abortion increases with the duration of pregnancy – or they will have to expose themselves to others in travelling to or being in clinics and risk exposure to COVID-19. This is an unacceptable situation.
Abortion is a form of reproductive healthcare that is essential for women’s physical and mental health and effectively preventing safe access during this crisis is actively harmful to thousands of women across the UK.
It is also safer for abortion providers themselves to be able to work more remotely. Given the extraordinary steps announced by the Prime Minister to prevent unnecessary contact last night, it is inappropriate that abortions are still being provided in person, given evidence from other countries shows that telemedical abortion provision is safe and effective. Yet the law essentially forces abortion providers to put the health of themselves and their families at risk in order to help women.
Further access issues
The British Pregnancy Advisory Service have also raised other concerns about the operation of the Abortion Act 1967 during this time, including the need for two doctors to agree that a woman’s abortion is lawful under one of the grounds provided under the Abortion Act. (See their letter-writing campaign on this issue). During this emergency this requirement for two signatures is far harder to obtain, especially if clinics are able – as a result of the legal restrictions – to engage in remote working.
The very fact that these restrictions are having such an impact in an unforeseen way further adds to the persuasiveness of BPAS’s campaign to decriminalise abortion across the UK.
We remain grateful to the continuous efforts of the Department of Health and Social Care as they work tirelessly to protect us during this pandemic. However, we are perplexed by the decision to revoke this order. The Department had the bandwidth to issue the simple authorisation, and indeed to remove it again. To reinstate the authorisation would be easy and would have a huge impact on many women trying to do the right thing during this lock down.