Early medical abortion at home: consultation

2. Background

The Abortion Act 1967 requirements

6. The Abortion Act 1967 ('the Act') sets out the legal requirements which should be met before an abortion can be carried out lawfully in Scotland. This Act still applies across Great Britain, although policy on abortion is now a devolved matter and so the Scottish Parliament could potentially pass legislation on abortion in future.

7. The Act requires two registered medical practitioners (doctors) to certify that they are of the opinion that at least one of the grounds under the Act for an abortion have been met^[2]. Except in an emergency (situations where an abortion is immediately necessary to save the life or prevent grave permanent injury to the physical or mental health of the pregnant woman), an abortion can only be carried out in an NHS hospital (which can include some sexual health clinics that can be viewed as hospitals) or in a place approved by Scottish Ministers.

8. Section 1(3A) of the Act clarifies that Ministers can approve a 'class of places' where medical abortions can take place. This therefore allows women's homes to be approved as places where abortion treatment can be administered. Two approvals have been made so far in Scotland using this power.

Early Medical Abortion at Home – developments over time

9. In Scotland, the majority (over 80%) of women opting for an abortion (also known as a termination of pregnancy) have an early medical abortion. An early medical abortion is an abortion in the first twelve weeks of pregnancy, where the woman takes two sets of pills to end the pregnancy. The first pill, mifepristone, blocks the main hormone, progesterone, that makes the lining of the uterus (womb) suitable for the fertilised egg. The second medication, misoprostol, causes the lining of the womb to break down and the woman to pass the pregnancy.

10. Until late 2017, women were required to attend a hospital clinic to take both mifepristone and then, 24 to 48 hours later, misoprostol. In most cases, women still self-administered both pills. In some cases, for women having an early medical abortion, they would leave the clinic straight after taking misoprostol so they could pass their pregnancy at home. However, this limited women's control over the timing of passing their pregnancy.

11. Since the end of October 2017, many women in Scotland have been able to take misoprostol at home^[3]. In addition, many other women who have sadly suffered a miscarriage have been taking misoprostol at home for some time for pregnancies under 13 weeks gestation. However, until the end of March 2020, women seeking an abortion were all required to take mifepristone in a hospital clinic, such as an NHS Board's sexual health service. The evidence shows that taking misoprostol and passing a pregnancy at home is safe for early medical abortions^[4].

Current COVID-19 arrangements

12. Since 31 March 2020, in light of COVID-19 and the importance of minimising risks of spreading the virus, abortion care providers in Scotland have been able to allow women having an early medical abortion to take both sets of pills at home, where this is considered appropriate for them and the woman wishes to do so. The Scottish Abortion Care Providers (SACP) have produced guidelines for staff to help them decide where this is appropriate or where they need to see a woman in person, for example so they can have an ultrasound scan. Copies of the COVID-19 approval and the SACP guidelines are provided in Annexes A and B. In addition to the SACP guidelines, the Royal College of Obstetricians and Gynaecologists (RCOG) has also produced UK-wide guidance on how to provide abortion services during COVID-19.

13. This means women can have an appointment with a doctor or nurse remotely via telephone or video call to discuss their options and the process, and their own circumstances, such as when their last menstrual period was and whether they have any medical conditions which need to be taken into consideration. If the woman wishes to have their abortion at home and the doctor or nurse is satisfied that they meet the criteria for this, they can be prescribed mifepristone and misoprostol to be taken at home. During their appointment and in the medication pack, women receive clear instructions on how and when to take their medication and the circumstances when they should get in touch for help and who to contact – for example if they experience any complications or if they think they may still be pregnant. Women can either have their medication pack delivered to them (normally either by NHS Board staff or a courier) or in some areas they need to come and collect their pack from a clinic reception.

14. Women are able to take mifepristone and misoprostol at home for early medical abortion in a number of other countries, either during the COVID-19 pandemic or longer term.

15. While some women are still being seen in person for at least one appointment, this means many women are now able to stay at home to minimise any physical contact with others. Feedback from NHS Boards suggests that, where they have carried out surveys, the great majority of women prefer to be able to have their abortion in the comfort and privacy of their own home. Some NHS Boards have also found it has helped to reduce the waiting times for women to have their appointment and, if they wish to proceed, their abortion. This may both help improve service delivery, but also mean more women are now able to have their abortion at an earlier gestation; this is beneficial as the earlier the gestation the less bleeding and pain and the lower the risks of any significant complications from the procedure. We would particularly welcome information from both individuals and NHS Boards who have sought feedback from women about their experiences of early medical abortion care.

Data on the impact of COVID-19 arrangements in Scotland

16. While it is not possible to provide official statistics at this stage, the Scottish Government has worked with NHS Boards to monitor the progress and impacts of the new approval. NHS Boards have provided information^[5] on their early terminations (under 12 weeks) between April and June 2020. This shows that there were just over 3080 abortions at under 12 weeks gestation between April and June (including both medical and surgical abortions). Overall, 60% of women did not have an in person appointment with a doctor or nurse or ultrasound scan before their abortion, although some women who collected their medication from a clinic did take their mifepristone while they were in the clinic. Statistics have been published for January to June 2020 for England and Wales, which do show the Covid-19 arrangements have led to more women having their abortions at earlier gestations, which is likely to be due to reduced waiting times as a result of the Covid-19 arrangements^[6].

17. There are variations between NHS Boards in their use of in person appointments, although over half of mainland NHS Boards provided the full telemedicine approach in a majority of cases. Only one NHS Board did not offer telemedicine appointments at all. All others had telemedicine options available, although as noted above some Boards asked women to come to collect their package of medication as they do not have a delivery service available. NHS Boards have reported that, even where, following a telemedicine appointment they ask the woman to come to the clinic for an ultrasound scan (for example to check the gestation of the pregnancy or if there are possible concerns the woman may have signs of an ectopic pregnancy), having the initial appointment by telemedicine allows the woman's appointment in the clinic to be shorter.

18. While there are always some risks of complications associated with having any abortion, these risks are normally very low, particularly for women having an abortion at an early gestation^[7]. The Scottish Government asked NHS Boards to provide information on any significant complications^[8] women experienced and to indicate, for those women who did not have an in person appointment, if an in person appointment would possibly or probably have meant the complication would have been avoided or not.

19. Out of the 1855 abortions reported where the woman did not have an in person appointment with a doctor or nurse, there were fewer than 10 cases identified where either significant or potentially significant complications might have been avoided if the woman had been seen in person, or where there were mental health concerns for women following their abortion where an in person appointment might have made a difference. The Scottish Abortion Care Providers group is discussing the lessons that can learned to help reduce the risks of complications or other concerns in future. However, there have been no reported instances in Scotland of women mistakenly being given pills to take at home when they were over the 24 week legal abortion limit.

20. NHS Boards reported some complications which, following discussion, have been confirmed as complications which would have occurred even if the woman had been seen in person. Such complications include situations such as very heavy bleeding (haemorrhage) or incomplete abortions - they did not pass the pregnancy and needed further treatment (either a medical or surgical abortion). As noted in the NICE guidance leaflet^[9], it is not uncommon for women to need further treatment following an incomplete abortion.

Patient views

21. In addition to ensuring safety and minimising risks, it is also important to make the abortion process as accessible for women as possible. Some NHS Boards have been seeking feedback from women on their views on having their abortion fully at home, either via surveys or in some cases more in depth interviews. As noted in paragraph 15, NHS Boards have said the great majority of women surveyed have preferred not requiring an in person appointment and being able to stay at home. This is likely to be partly due to concerns about the risks of COVID-19, but in some cases there may be other reasons why travel to a clinic or hospital for an appointment may be difficult.

22. Full results of these surveys are not yet available, but by way of example, NHS Lothian has carried out surveys of a number of women who had appointments via telemedicine. Whilst results are still being analysed, of the first 322 women surveyed, 85% indicated they found the process 'very acceptable' and a further 8% found it 'somewhat acceptable'. When asked (14 days after their termination) what they felt would be their preferred method for a consultation about an abortion, 82% indicated that a telephone consultation would be their preference. 6% indicated they would prefer an in person consultation (in a clinic), 1% would prefer a video consultation and the remaining 11% were unsure.

23. While the views from these patient surveys will be fed into the results of this consultation, we are very keen to hear from other women who have accessed abortion services about their experiences of early medical abortions (either since 30 March 2020 or beforehand), including about any particular challenges they faced or concerns they had, as well as where they found the process worked well.