The President of the Royal College of Obstetricians and Gynaecologists (RCOG), Professor Lesley Regan, has joined in calls for women to be able to take abortion pills ‘in the comfort of their own homes’, rather than an abortion clinic or hospital under medical supervision. Scotland has already revealed plans to change the law and Regan has pledged to campaign for the right for women to do so in England and Wales. She has been busy doing so across the media this week in The Times, Woman’s Hour, The Guardian, Daily Mail etc.
Both Regan and Anne Furedi, CEO of British Pregnancy Advisory Service (BPAS), one of Britain’s leading abortion providers, claim that this is ‘safe and sensible’ and that ‘it is unacceptable for any woman to be made to risk miscarrying on her way home from a clinic’. It is also ‘potentially time-consuming and cumbersome in that each visit may involve rearranging work and childcare commitments’. Despite presenting no hard evidence for these claims, they remain unchallenged in the media.
Medical abortions accounted for 62 per cent of total abortions in England and Wales in 2016 – a big increase from the 30 per cent of medical abortions carried out in 2006. In Scotland, medical abortions account for 81 per cent of the total.
Medical abortions are most commonly used for early abortions, up to nine weeks, but can also be used after 13 weeks of pregnancy. A woman is given an oral dose of Mifegyne (mifepristone, also known as RU486) at a clinic/hospital to kill the foetus. Following a short wait to ensure that the drug has absorbed properly, women leave the hospital or clinic. The second stage of the abortion involves attendance at the hospital or clinic, up to 48 hours later, when misoprostol is administered, either orally or vaginally. This causes uterine cramping to expel the dead foetus.
Section 1 (3) of the Abortion Act 1967 says treatment for early medical abortion may take place only in a NHS hospital or approved independent sector place. According to NHS guidance, the courts have decided that this means that both mifepristone and misoprostol must be taken in the hospital or approved independent sector place. Women leave the premises after the first dose and may be given the choice either to stay on the premises or to go home, after taking misoprostol, for the expulsion of the foetus. A follow-up visit is advised 7-14 days later to ensure that the abortion is complete and there are no complications.
Those campaigning for a change want the woman to take the second set of pills at home. They say it will be easier for women to take it on a Friday, to have the final part of the abortion at the weekend, and it would give more comfort and privacy.
Regan admitted on Woman’s Hour that there is no hard evidence or data showing that women are having problems with the current arrangements, relying instead on anecdotal evidence. Presumably the driver is her desire to make the whole process of abortion even easier and less regulated.
In all the coverage, no mention has been made of the medical evidence on taking abortion drugs. Yet there are many reasons why taking them is far from ‘safe’ and ‘easy’ and why changing practice will be to the detriment of women’s physical and emotional health.
1. Although campaigners say that the patient’s home should be the location where misoprostol is taken, once she leaves the clinic there is nothing to stop the abortion pill being taken at other locations such as schools, colleges etc. It is not clear how the NHS could ensure the pills are taken at home – they lose all control over that once the woman leaves the clinic. In reality, the pills can be taken anywhere.
2. It removes all medical information, supervision and support for a medical procedure. While this is of concern for all women it is particularly so with teenage girls or vulnerable women. There is no control over when, where or even who is taking the pills. Taking such strong drugs is a serious matter. In trials, almost all women using mifepristone for medical abortions experienced abdominal pain or uterine cramping, and a significant number experienced nausea, vomiting, and diarrhoea. But the complications can be worse than this, as I will show.
3. Contrary to claims by the Scottish Government, and indeed most people’s assumption, medical abortions are not safer than surgical. A study of 42,600 first trimester abortions in Finland (where there is good registry data, unlike the UK) found that six weeks post abortion the incidence of complications after medical abortion was four times higher than surgical – 20 per cent compared with 5.6 per cent.
4. For later medical abortions, after 13 weeks gestation, the proportion of incomplete medical abortions that needed subsequent surgical intervention varies widely between studies, ranging from 2.5 per cent in one to 53 per cent in a UK multicentre study.
5. Even for early medical abortions, up to 9 weeks gestation, the RCOG reports (p41) a Finnish study that found 6 per cent of women needed subsequent surgical intervention compared with less than 1 per cent of those having surgical abortions. Part of the reason for this is that high doses of the abortion drugs can lead to unacceptably high levels of side effects, but with lower doses some failures will occur and then abortion by another method is needed.
6. Women may be unaware that their abortion is incomplete and therefore seek medical help only when infection develops. Taking the pill outside medical supervision will compound this.
7. Vaginal bleeding or spotting lasts on average 9-16 days, while up to 8 per cent of patients bleed for 30 days or more. This is hardly surprising, since during medical abortion loss of the placenta and foetus continues gradually for some days/weeks afterwards, until the uterus is empty. The RCOG reports that women are more likely to seek medical help for bleeding after medical abortion than after surgical, and to report heavier bleeding than they expected, and for longer.
8. The incidence of haemorrhage is much higher in women undergoing medical abortion (although there are discrepancies in reported rates due to ill-defined criteria in reporting). The Finnish record-linkage study of 42,600 women found rates of consultation for haemorrhage were 15.6 per cent after medical compared with 2.1 per cent after surgical abortion.
9. Hospitalisation rates, while low overall, are worse for medical abortions. Government statistics for England and Wales show complications involving hospitalisation are more than twice as likely after medical abortions than after surgical ones: 206 compared with 88. However the RCOG acknowledges that a lack of standardisation in reporting in the UK hampers collection of accurate data so this number is likely to be higher. Statistics are usually drawn from clinic or hospital records that will under-represent the true rate as some women experiencing complications follow up elsewhere.
10. Abortion clinics (mainly run by BPAS and Marie Stopes International) are not routinely required to record the woman’s NHS number, thus subsequent women’s health events cannot easily be linked back to the abortion, and longitudinal research is almost impossible. This lack of data means that any adverse effects of abortion cannot be easily tracked in England and Wales. In other words, many complications are missed off records and not collected by Government statistics. So Regan and Furedi have no reliable data to verify their claims of safety. Until abortion clinics record NHS numbers routinely, they are failing to take responsibility for the long-term health of women. We do, however, have evidence from the Care Quality Commission (CQC) that there are major safety flaws and serious incidents at some Marie Stopes International clinics.
11. We know from anecdotal data that the psychological fallout from medical abortions completed at home can be severe, partly because women usually see the foetus, which they have to flush away themselves, whereas a surgical abortion keeps the foetus hidden from view of the woman. Moreover, the reminder of the abortion is always in the home, not in an anonymous clinic that they can leave behind.
One young girl describes her own experience of having a medical abortion at home:
I had to go for two appointments for the abortion, on the Thursday and the Saturday. I took the first pill and then went back on the Saturday for the second.
I think the best way of describing what happened next is to read out a bit from [her boyfriend’s] version of events:
‘The day she took the final pill and came back to my flat to wait for it to pass truly drew a new line in the sand. The hours of pain she suffered, it utterly ripped me apart to see her writhing in agony, interspersed with trips to the toilet as the process started. It culminated in one trip from which she didn’t return, all I heard was sobs, drained of energy she couldn’t even cry with the force the pain deserved. I soon discovered that it wasn’t the pain the sobs were for, it was for what she had seen in the toilet. A recognisable shape. Then flushed away.’