Clare Wenham, Ernestina Coast, Katy Footman, Tiziana Leone, Rishita Nandagiri, and Joe Strong discuss the UK government’s apparent U-turn over medical abortion during the novel coronavirus outbreak. They draw on their own research and other evidence to make the case for women being able to take abortion medication at home, following a phone or video consultation.
On 23 March, the Secretary of State for Health and Social Care approved emergency measures relating to abortion regulation which would have revolutionised abortion practice in England. Women would be able to take abortion medication in their homes, without having to travel to a clinic first, with a consultation over the phone or video link. This was explained as accounting for self-isolation guidelines and the limited opportunity women would have during the COVID-19 outbreak to seek abortion, potentially leading to a number of unwanted pregnancies being forced to continue or women being forced to resort to illegal or unsafe methods to terminate them. Moreover, self-isolation may lead to an increase in sexual activity amongst some, not to mention the increased risk of sexual violence within quarantine settings. Thus, this change in regulation was heralded as a major breakthrough for emergency management of COVID-19 and meeting women’s reproductive needs. That being so, it was remarkable that within five hours of this announcement, came the following ‘This was published in error. There will be no changes to abortion regulation‘.
The British Pregnancy Advisory Service has estimated that 44,000 women in England will seek early abortion in the next 13 weeks. There is a clear need to consider the impact of COVID-19 self-isolation on all reproductive health services, and notably abortion. Not only can remote provision of healthcare ease the growing pressure on the health system, but without this option, women who find themselves with an unwanted pregnancy will be forced to choose between exposing themselves or healthcare workers to the risk of infection with COVID-19 in clinic waiting rooms, or to continue with a pregnancy they do not want. Others may choose to access abortion medications online illegally, or resort to using unsafe methods. Within this discussion, there has also been no consideration of access to contraception, and whether this might be affected through supply chain disruptions.
This is part of a broader global debate surrounding the use of medical abortion (the use of misoprostol and mifepristone to interrupt early pregnancy). Considerable research has shown that medical abortion is an effective method for termination in early pregnancy; it is cheaper than surgical abortion; and when women have a choice, they express a preference for medical abortion. There is also evidence to show that the medications can be safely provided using telemedicine, and that there are no greater safety risks to taking the medications at home. Following regulatory changes in Scotland and Wales, regulations in England changed to allow women to take the second set of pills at home, but an unnecessary clinic visit is still required to take the first pill. Two doctors’ signatures are also still required for a woman to access an abortion in the first place, despite advocacy by the Faculty of Sexual & Reproductive Health of the Royal College of Obstetricians and Gynaecologists petitioning for this to be changed during COVID-19 for only one doctor, midwife or nurse required to ensure women can access care and reduce unnecessary burden on the health system.
As with all emergencies, COVID-19 allows for a time for regulatory pause, change, and reflection. We researched the impact of Zika on women’s decisionmaking on abortion in Brazil, Colombia and El Salvador. In places where abortion is highly restricted, requests for medical abortion services through telemedicine portals saw a significant increase during the Zika public health emergency. Whilst the nature of Zika was different to coronavirus – some women may have sought abortion because of concerns about congenital zika syndrome – this COVID-19 health emergency will impact women’s decisions around pregnancy and abortion. Self-isolation puts physical barriers to accessing services, including contraception, and for some women it increases the risk of pregnancy as a result of sexual violence. What we also know is that legislation does not impact women’s decisionmaking about whether to have an abortion. All it means is that women might be forced to consider illegal or unsafe abortion methods, which directly increases social, legal, and health risks to these women. However, as we discovered when we started our research on Zika and abortion, there was no evidence in the public domain on the intersection between health emergencies and abortion.
So much concerning the COVID-19 outbreak is unknown: medical research is desperately trying to come up with answers to how the virus spreads, whether vaccine or treatment options will work, whilst epidemiologists and modellers are deciding on transmission and the utility of public health interventions. Meanwhile, hospitals across the UK are at breaking point with over-burdened health workers and facilities which are putting the NHS on the brink of collapse. With all this uncertainty, some ability to be able to limit unnecessary in-person interaction with health services, which keeps women at home and safe, using evidence-based methods of providing reproductive health care would benefit all involved. Policy-making on abortion has a history of ignoring clinical evidence which makes it so disappointing that this very forward-looking policy of telemedicine for abortion was abruptly withdrawn without explanation or justification, despite parliamentary and public pressure.
Clare Wenham is Assistant Professor of Global Health Policy at the LSE. Ernestina Coast is Professor of Health and International Development at the LSE. Katy Footman is Senior Researcher at Marie Stopes International. Tiziana Leone is Associate Professor in Health and International Development at the LSE. Rishita Nandagiri is Fellow in Health and International Development at the LSE. Joe Strong is a PhD candidate at the LSE.
This piece was first publishing on LSE Politics and Policy.
The views expressed in this post are those of the author and in no way reflect those of the International Development LSE blog or the London School of Economics and Political Science.