COVID-19 and abortion care: why we need remote access to reproductive health services

by Elizabeth Chloe Romanis and Jordan Parsons

At the end of 2018 the Department of Health announced that in England, following measures implemented earlier in Scotland and Wales, it would become legal for pregnant women to take misoprostol, the second of the two abortion pills at home. Before this, women were required to attend an abortion clinic twice to take both abortion pills (24-48 hours apart) under supervision, often resulting in women miscarrying on their way home after the treatment is administered.

Being able to take misoprostol at home has afforded women more privacy, dignity, and freedom in how they access essential reproductive services. This change to the law, however, did not go far enough to help women in the UK.  The introduction of a health policy that would enable entirely remote access to abortion for women is necessary. The current situation we are facing amidst the COVD-19 pandemic, and the actions taken to curtail the spread of the virus, make this move more important now than ever.

The Problem

The vast majority of abortions in the UK are ‘early medical abortions’ – the treatment provided is the combination of the two abortion medications, mifepristone and misoprostol, that together safely induce miscarriage. A substantial body of evidence supports this medication’s safety and effectiveness, and shows that pregnant women find the treatment acceptable. It is also far less invasive than other forms of abortion. Early medical abortion, the World Health Organization recommends, should be carried out before nine weeks gestation. Although misoprostol is very safe earlier in pregnancy, the WHO notes that women are more likely to need further medical assistance if they receive this treatment after nine weeks. There is, therefore, a limited time window for women to access this treatment.

While there are many abortion clinics across England, Wales, and Scotland, access remains difficult for some women. Firstly, women need to live near clinics to be able to easily access them (and attend twice in a short space of time), which presents an issue for those who live in rural areas, or areas where there have been lots of clinic closures. Secondly, it is often difficult for women to get time off work, make childcare arrangements, or afford travel for two appointments.

The pandemic has exacerbated these access issues. Strained resources, social distancing, and potential lockdown will all make it much harder for women to access clinics. For those who are self-isolating, there are no provisions to enable access to abortion services; the British Pregnancy Advisory Service, which currently operates a large proportion of the UK’s (excluding Northern Ireland) reproductive healthcare clinics, has issued advice that those with a cough or temperature should isolate for seven days and rebook any appointments.

Women who are not infected may be fearful of infection and prefer to take a cautious approach given the current lack of knowledge concerning the virus (although the Royal College of Obstetricians and Gynaecologists notes that pregnant women do not so far appear to be worse affected by COVID-19). Leaving home is also likely to be far harder for those caring for dependants. These additional barriers seem likely to continue for an indefinite time period as research on the virus is conducted and the Government responds accordingly, representing a significant health risk for those who cannot access treatment at all or, as a result of delays, may have to receive a less safe or more invasive alternative.

A Potential Solution

We believe that women should be able to be consulted remotely about reproductive healthcare and potential treatment, be prescribed that treatment during that consultation, be sent the medication by post, and then women can self-administer both abortion medications at home. There was already a strong case for moving to this more accessible approach to the prescription and provision of misoprostol prior to the pandemic on the grounds of ensuring access to treatment and that women’s experiences of treatment were as comfortable as possible. Given the situation we now find ourselves in, this need is even more pressing due to additional access barriers and a potential increase in demand (due to an increase in unwanted conception during periods of restrictions on socialising outside of the home).

The telemedical abortion service model we advocate for is similar in some ways to services that are already provided in other countries, such as parts of the United States and Australia, and internationally by organisations such as Women on Web. These services have all been shown to be safe, effective, and beneficial for service users. Remote consultation by either telephone or online video conferencing would allow doctors to provide counselling prior to treatment, as is necessary per the current National Institute of Health and Care Excellence and General Medical Council guidance. Doctors would then be free to prescribe the medication and either direct timely delivery to the pregnant woman’s home or a nearby pharmacy or arrange further consultation if health concerns deem it necessary.

This is a sensible, efficient, and safe way to ensure women can still access essential care during this crisis and into the future. There are, however, legal and political barriers to the introduction of this policy which need to be addressed.

The Law

Abortion, including early medical abortion, remains highly regulated in the UK. Relevant legislation – the Abortion Act 1967 – outlines circumstances in which abortion is permissible and affords the Secretary of State for Health (and equivalents in devolved governments) the power to dictate where these lawful abortions can take place. The current permissible procedure for lawful early medical abortion at home is:

  • The pregnant woman (less than nine weeks and six days pregnant) must attend a clinic where she is prescribed both abortion medications;
  • The pregnant woman must then take the first medication, mifepristone, at the clinic; and
  • She can then take the second medication, misoprostol, home with her and self-administer 24-48 hours later.

This process (as described in Matt Hancock’s 2018 approval order of home medical abortion) expressly precludes remote prescription of abortion medications and the taking of mifepristone at home. Our proposal, though safe, sensible, and a way of ensuring women have access to an essential service, cannot lawfully be implemented unless the Secretary of State for Health, Matt Hancock, and the Ministers of the Welsh and Scottish Governments responsible for Health, Vaughan Gething and Jeane Freeman, were to change the law by issuing appropriate orders in England, Wales, and Scotland.

This policy change would be in line with movement in other countries to increase the availability of telemedical healthcare services generally and specifically reproductive health during the pandemic. Telemedical provision of abortion is necessary to ensure women have timely and equal access to healthcare. Unwanted conception will remain something women experience throughout this emergency and it is important that we ensure, through this simple step, that abortion clinics are able to support women with remote services.

 

Author’s Social Media: @ECRomanis and @Jordan_Parsons_

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