Consultation Response: Early Medical Abortion at Home
FiLiA’s response to the Department of Health and Social Care Consultation: Home use of both pills for early medical abortion up to 10 weeks gestation.
In response to the COVID-19 pandemic, the UK government approved a temporary measure for women and girls to have a remote (online or telephone) consultation with a clinician and then take the two medicines for an early medical abortion at home (up to 10 weeks gestation). Previously, a woman had to travel to an abortion service to be seen in-person and take the first pill. This consultation sought to gather views on whether the government should continue this innovative delivery of abortion services after the pandemic is finished. We examined the evidence and said yes: this is safe, preferred by many women and increases access to necessary healthcare for women and girls.
Early medical abortion (EMA) can be accessed during the first 10 weeks of pregnancy. EMAs involve taking two different pills to terminate a pregnancy. Before the COVID-19 pandemic, women needed to travel to a clinic to be assessed in-person and take the first pill. However, a temporary measure was approved by the UK Government in spring 2020 to allow women to access abortion remotely: having an online or telephone consultation with a trained clinician and taking both pills for EMA at home. This was to help keep women safe during the pandemic. This consultation invited views on what the effect of this measure has been and whether to continue after the threat of the virus has abated.
We understand from reports from women, large-scale studies, as well as abortion and healthcare providers that this has been a positive measure. Our consultation responses called upon Government to make this way of accessing abortion a permanently available option for women and girls.
Question: Do you consider that the temporary measure has had an impact on the provision of abortion services for women and girls accessing these services with particular regard to safety?
We answered: Yes, it has had a positive impact
We consider the temporary measure to have had a positive impact on the safety of women accessing an abortion. Available data strongly indicate the temporary measure has been safe and effective from a medical perspective.
A study recently published by Aiken at al. used an England and Wales national sample that compared 22,158 traditional early medical abortions to 29,984 abortions undertaken using telemedicine-hybrid model (of which 18,435 had no ultrasound test). They noted no reports of serious infection leading to hospital admission, major surgery or death. Incidence of ectopic pregnancy was the same in both groups. Of the 29,984 cases in the telemedicine-hybrid cohort, there were 11 (0.04%) reports of abortions where the gestational age was higher than 10 weeks yet these were all completed at home with no further medical problems. The authors write: “We found no evidence that significant adverse events were higher in the telemedicine-hybrid cohort.” These data, therefore, indicate no differences in abortion success rates or significant differences in safety risks (such as the prevalence of serious medical complications) between the ‘traditional model’ of early medical abortion, and a model that allows for telemedicine with both pills taken at home. The new measure has been associated with an overall reduction in the average gestational age in EMA, and it is well-established that earlier abortions present fewer health risks.
Similarly, Reynolds-Wright et al. reported on a telemedicine and at-home abortion service in NHS Lothian, which included 642 women under 10 weeks gestation and no women beyond the gestational limit of 12 weeks in Scotland. The authors concluded: “This model of telemedicine medical abortion without routine ultrasound is safe, and has high efficacy and high acceptability among women. This study provides support for continuation of this model of care in this setting beyond the current pandemic.”
While not as easily defined nor measurable an outcome, expected associated improvements to the emotional and physical safety of women and girls related to having greater choice, accessibility and flexibility in accessing abortion, seem considerable and ought also be factored into the question of general improvements to women’s safety. Women seeking abortions may be survivors of sexual violence, trauma or in potentially vulnerable or abusive situations. The option to access treatment more flexibly, without needing to travel to a clinic, are likely to keep such women safer. We note worries that some women might not feel able to speak safely at home, alongside the possibility of being coerced into an abortion should the whole process be performed without face-to-face contact. In our view, such concerns serve not to undermine the data supporting the safety and acceptability of making permanent the option of an abortion via telemedicine, but rather highlight the parallel importance of continuing to maintain reliable, accessible in-person clinical services providing abortion for any women who need/prefer them. Additionally, a large survey by Erlank et al (full-text in pre-print) reported no concerns regarding privacy or coercion raised by the women followed-up after their telemedical consultation and at-home abortion; rather, the authors noted many patients preferred phone consultation, perceiving this as less stressful, with reduced worry around being judged.
We also note concerns from some regarding the possible effects of at-home abortion and disposal of products of conception, which we find somewhat irrelevant to the question being considered in this consultation. Since 2018, women have been legally allowed to take the second pill for abortion at home. Therefore whether to make permanent the temporary measure seems unlikely to make a difference here. Additionally, while emotionally, experientially and medically very different scenarios, it may also worth bearing in mind that 1 in 8 pregnancies sadly end in a miscarriage, and women are commonly expected to manage these outside a clinical setting. That a question of pregnancy tissue should be used as a rhetorical point against the proposed at-home model of both pills for abortion seems insensitive and disrespectful to women when considering this broader context.
Question: Do you consider that the temporary measure has had an impact on the provision of abortion services for women and girls accessing these services with particular regard to accessibility?
We answered: Yes, it has had a positive impact
We consider the temporary measure to be overwhelmingly positive in increasing access to abortion. This can be understood from feminist first-principles, listening to women’s voices and understanding the diversity of women’s lives. Women face different existing barriers to access to abortion, including: perceived stigma, geography, economic situation, social/family obligations such as caring responsibilities, risks of violence and mental health challenges.
Feedback from women who accessed abortion services under the temporary measure (i.e. telemedicine and at-home abortion) indicates a positive impact. Erlank et al surveyed 1,243 women (13.7% of all telemedicine EMAs in their study period). They reported 83% of women preferred telemedicine, and 66% would choose this method again in the absence of threat from coronavirus. The study reported high satisfaction rates, with women respondents highlighting favourably the method’s convenience, ease of being allowed to manage the process at home and privacy.
Similarly, Meurice et al (pre-print) surveyed 1,144 women who had undergone a telemedicine EMA. They reported similarly high satisfaction rates (78.3% were ‘very satisfied’) and wrote: “if needed in future, most (77.8%) would prefer home use of mifepristone and misoprostol and pills by post (68.9%).”
Question: Do you consider that the temporary measure has had an impact on the provision of abortion services for women and girls accessing these services with particular regard to privacy and confidentiality of access?
We answered: Yes, it has had a positive impact
Prior to the pandemic, a serious feminist concern has been the escalation of protests around abortion clinics. Such anti-abortion protests can intimidate and harass women seeking healthcare, exposing their identities, and make access to abortion feel neither private nor confidential. Political discussions have been had around the necessity to create so-called ‘buffer zones’ to prevent protests in close vicinity of abortion clinics, so as to allow women to access treatment without such harassment. We support measures to introduce buffer zones at a national level. In the meantime, telemedicine and at-home abortion might offer an alternative for women who may otherwise quite reasonably fear attending an in-person appointment due to local protests. We note that at the time of writing, protests by a US-based anti-abortion group called “40 Days for Life” have been organised against 14 UK abortion clinics.
Question: Do you consider that the temporary measure has had an impact on the provision of abortion services for those providing services? This might include greater workforce flexibility, efficiency of service delivery, value for money etc.
We answered: Yes, it has had a positive impact
We note the overwhelmingly positive statements from abortion providers and clinicians who support the temporary measure being made permanent. They have found telemedicine highly effective in terms of delivering a safe, quality service, based on indicators including low rates of complications and high satisfaction levels from women accessing abortion. In our assessment, service providers appear unanimous in stating that the temporary measure has allowed them to deliver needed care more efficiently, flexibly and in a manner that is more compassionate to women.
Question: Have other NHS services been affected by the temporary measure?
We answered: I don’t know
The exceptional circumstances of the COVID-19 pandemic have caused changes to service provision across the board in the NHS, alongside various significant socio-economic factors, including lockdown restrictions. What can be reasonably deduced is that the temporary measure is highly likely to have been positive for the NHS. Women continue to need access to abortion, alongside pregnancy and maternity services, regardless of any pandemic. Benefits to the NHS from the temporary measure to allow at-home early medical abortion may include: reduction in the number of women presenting for an abortion in later gestational stages of an unwanted pregnancy, mitigation of possible negative medical consequences if women had felt left with little alternative but to seek help for an abortion from unsafe sources, and easing of potential negative mental health effects on women who wished to have an abortion but felt unable to access one amidst the uncertainty of the pandemic. Additionally, the introduction of a socially distanced method for abortion likely reduced the risk of women and service providers either contracting or spreading coronavirus.
Question: What information do you consider should be given to women around the risks of accessing pills under the temporary measure if their pregnancy may potentially be over 10 weeks gestation?
We answered: We consider this question to be outside the remit of a Governmental decision. What information to be given to women ought instead be for clinicians, abortion experts and health bodies to decide through the usual methodology of developing robust guidelines for medical practice, building from systematic reviews of evidence, expertise and updates as new scientific data become available. The National Institute for Health and Care Excellence and Royal College of Obstetricians and Gynaecologists, alongside abortion providers such as the British Pregnancy Advisory Service, for example, would seem best placed to decide this, likely in collaboration.
Question: Outside of the pandemic do you consider there are benefits or disadvantages in relation to safeguarding and women’s safety in requiring them to make at least one visit to a service to be assessed by a clinician?
We answered: Yes, disadvantages
The data collected show no medical rationale or evidence to support the idea that every woman seeking an abortion should have a compulsory visit to be assessed by a clinician in-person. The telemedicine-hybrid model has been demonstrated to be equally safe, with high satisfaction rates, thus UK service providers delivering abortion care appear to be adequately trained to assess, support and advice women remotely, with appropriate safety-netting and systems in place to identify risks and escalate concerns. Conversely, there might be greater compromises to women’s safeguarding from continuing to make a clinic visit compulsory (e.g. risk of violence, abuse or adverse mental health outcomes).
Question: To what extent do you consider making permanent home use of both pills could have a differential impact on groups of people or communities? For example, what is the impact of being able to take both pills for EMA at home on people with a disability or on people from different ethnic or religious backgrounds?
We answered:
Age – access to abortion services might vary depending-upon a woman’s age. An older woman may have greater familial or work commitments that are difficult for her to put to one side in order to attend an in-person appointment. A younger woman might be financially dependent on her parents or live at home and find it difficult to ask for support to travel to a clinic or disclose her pregnancy for fear of familial disapproval (or worse).
Gender reassignment – female individuals who identify as men may face stigma or a lack of understanding from healthcare professionals/services, or find attending a clinic designed for a function of female reproductive health upsetting/challenging.
Being pregnant or on maternity leave – the ability to access abortion is directly related to respecting the rights of pregnant women (i.e. allowing them to choose to end their pregnancy). As noted in an earlier answer, surveys of women who underwent an at-home EMA show strong satisfaction rates with majority preference for this option in the future.
Disability – Some women with disabilities might find it difficult to arrange or attend a clinic visit. For example, a woman with mobility issues may need to wait for appropriate transport, or a woman with chronic pain might find that a flare-up of her condition prevents her from attending an appointment on the day.
Race including colour, nationality, ethnic or national origin - There exist health disparities between women of different ethnicities, notably in rates of maternal mortality. The 2018 statistics suggested Black women accessing an abortion were more likely to have had a previous abortion compared to white or Asian women.
Religion or belief – Women from different religious backgrounds may face additional stigma or risks of being socially sanctioned (or worse) for an abortion.
Sex – Per definition, it is the female sex that requires access to abortions. The ability of women to obtain high-quality reproductive healthcare, given choices and autonomy is a cornerstone of feminism. Lack of adequate and equal access to safe abortion is a public health issue, especially in the light of the scale of violence against women including sexual assault, incest and rape. There seem to be no convincing medical grounds to reinstate making an in-person clinic visit compulsory for women seeking an abortion. This should be weighed against the considerable data showing positives of telemedicine and at-home EMA. Careful risk/benefit balancing might even potentially support an argument that given the absence of any health grounds for doing so, discontinuing this form of abortion provision after the pandemic might be considered discriminatory. The availability of an at-home EMA would benefit all women.
Sexual orientation – While currently an understudied area, some evidence may suggest higher rates of unwanted pregnancy and abortion for lesbian and bisexual adolescents. Lesbian and bisexual women may face stigma or a lack of understanding from healthcare professionals/services.
Question: To what extent do you consider that making permanent home use of both pills for EMA would increase or reduce the difference in access to abortion for women from more deprived backgrounds or between geographical areas with different levels of disadvantage?
We answered: Making permanent home use of both pills for EMA would allow greater access to abortion for women from more disadvantaged or geographically remote areas, thereby reducing inequalities between women of different backgrounds. Asking women to travel to a clinic requires them to have access to various means including finding funding for expenses, finding time and setting up logistics. It might be difficult for example, to organise childcare, transport or negotiate time off work with an employer. Being able to undergo the process at home with clinical support from trained professionals via telemedicine allows women greater access, reduced costs and flexibility. We, therefore, see making permanent home use of both pills for EMA as a fundamental step in equalising access to abortion between women who face different socioeconomic circumstances.
Question: Should the temporary measure enabling home use of both pills for EMA?
We answered: Become a permanent measure
Question: Have you any other comments you wish to make about whether to make home use of both pills for EMA a permanent measure?
We answered: We believe the evidence for making home use of both pills for EMA a permanent measure is strong, convincing and hugely in favour. We have found no convincing hypothetical arguments or documented clinical evidence against this contention and from a feminist perspective believe this change will have a net positive effect on the health, agency and general well-being of women and girls.
We should like to note that from the data we have seen reporting the views of women, the majority (80% in Aiken et al) expressed a preference for at-home abortion. However, some women might prefer in-person clinical care. Other women might not be eligible for home use of both pills for EMA for medical reasons. We would therefore strongly support the continuation of at-home early-medical abortion delivered via telemedicine, alongside ensuring readily accessible ‘traditional’ face-to-face services, in order to maximise the available options for all women seeking an abortion.