Early medical abortion at home - future arrangements: consultation analysis

Impact Assessments

As a result of the Public Sector Equality Duty (Scottish Specific Duties), the Fairer Scotland Duty, and the Islands (Scotland) Act 2018, the Scottish Government must consider the potential impacts of any new or significant policy change on specific population groups. As such, the consultation document asked a series of questions to elicit respondents views on the potential impacts for each group of continuing the current arrangements for EMAH. These groups included:

• Equality groups, including people with the protected characteristics of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation;
• People in different socio-economic circumstances; and
• Equality for women living in rural or island locations.

Impact on Equality Groups

Q4. Do you have any views on the potential impacts of continuing the current arrangements for early medical abortion at home (put in place due to COVID-19) on equalities groups (the protected characteristics of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation)? - Impact on equalities groups

Impact on Equality Groups

	All Respondents		Excluding Right to Life Campaign
	Number	Percent	Number	Percent
Yes	4611	83%	1831	66%
No	365	7%	365	13%
I Don't Know	400	7%	400	15%
Not Answered	161	3%	161	6%
Total	5537	100%	2757	100%

The majority of respondents indicated that they had views on the potential impact on equality groups of continuing the current arrangements (83% of all respondents or 66% of those excluding the Right to Life standard campaign responses). In addition, 4,658 qualitative comments were provided. Of those who provided comments, 484 (10%) felt the impacts were positive compared to 3,998 (86%) who felt they were negative. The remainder of the comments either outlined mixed impacts, did not clearly outline whether the impacts were considered to be positive or negative, or were not relevant to the question as they typically either outlined their preferred approach or advocated for an end to all abortions.

Pregnancy and Maternity

Many respondents felt that continuing EMAH would have a negative impact on pregnant women's physical and mental health. As discussed throughout the previous chapter, this included concerns that the following risks may apply:

• Risks around complications from the procedure which could impact their physical health, require further medical or surgical intervention, or result in their death;
• Risks to their mental health related to their decision or 'trauma' of the procedure;
• That little/no information would be provided on alternatives, and/or no moral or psychological support would be provided across the course of the procedure;
• Risks that the gestational period may be further along than expected, recommended, or legal for the procedure;
• That women may be being coerced or forced into the abortion, and/or that EMAH made it too easy for abuse to go unnoticed; and
• That women may face emotional or physical abuse if their partner or family found out about the abortion, which was felt to be more likely if the entire process happened at home.

It was suggested that this could create inequality in healthcare because some respondents believed that women were not being given the protection, medical attention or emotional support they required, and that they were not being adequately cared for.

However, others argued that fears over safeguarding had been shown to be unfounded. Rather, they argued that women had been more able to alert practitioners to abuse/coercion via the telemedicine model, and had been more able to access the procedure without their abuser finding out as they had not needed to visit a clinic.

In addition, several proposed that EMAH empowered pregnant women by offering a choice of access methods, providing women with greater autonomy, and making access to the service more confidential/private. These amendments were considered to support women to make their own decisions and be less impacted by external factors or other people's opinions/advice. It was also felt to have improved their safety as they were able to access the procedure more quickly, thus reducing the risk of complications. It was felt that EMAH was better tailored to patient needs and thus improved equality, particularly in relation to access, for women and pregnant people:

"…maximising the options for delivery of abortion care is likely to offer the most opportunity for tailored care... Developing services that are gender-sensitive and intersectional requires the experiences and realities of diverse groups of women to be understood as these factors shape the capacity and resource to access reproductive healthcare in specific ways. The design of services is critical in ensuring that every single person who needs it can access safe and free abortion." (Organisation, Women's and Abortion Support)

Disabled People

It was suggested that access to the service may be reduced for some disabled people, including those with hearing or sight impairments, and certain mental health issues. It was felt that teleconsultation methods would negatively impact the consultation experience and decision-making process for these women. It was also believed they may be more at risk of forced or coerced abortions.

Again, however, many others disagreed and felt that EMAH had created a more equitable and inclusive service by improving access for particular groups of disabled people. Similarly, it was suggested that women with certain mental health issues may benefit from EMAH, such as those who would find it difficult to travel to a clinic, cope with a face-to-face discussion or function in a clinical environment. It was felt that the current arrangements removed transport barriers and provided greater confidentiality (and provided equality in this respect with others) for those who would otherwise have to rely on others for transport or support to access the clinic and in-person consultation. Several argued that disabled people often faced discrimination when it came to accessing and experiencing reproductive services, but these new arrangements improved and facilitated access.

Several disabled people who responded to the consultation were in favour of the proposal to make the current arrangements permanent as they felt it would improve access for people in the disabled community who would find it difficult or impossible to access a clinic for an abortion.

Religion or Belief

In line with one of the concerns raised at Q2, many respondents felt that there was an impact for medical staff (and potentially post office staff and couriers) who may object to abortion on the grounds of religion or belief, but who may have to participate in the packaging and delivery of the medication. For example, it was felt that more ancillary, administrative and managerial staff could become involved in the distribution of the abortion medication, some of whom may be conscientious objectors, and it was felt they should benefit from Article 9 of the European Convention on Human Rights which protects freedom of conscience.

Others felt that the proposals to continue with EMAH went against their religious or pro-life beliefs - however, this typically applied to all forms of abortion rather than being related to the specific proposals in the consultation, other than these perhaps making it easier to access and thus potentially increasing rates of abortion.^[4]

Several respondents felt that women from particular faiths and religions would be more at risk of forced or coerced abortions given the lack of in-person consultation. Others however, believed that the current arrangements could be helpful in supporting women within faith communities to access early abortion more discretely and within the timescale permitted by some religions.

Some in favour of EMAH suggested that the privacy offered also meant the service was more accessible to those from particular religious backgrounds where there is disapproval of pregnancy outside marriage and/or abortion, meaning the woman may be divorced, shunned or harmed as a result. As such, attending a clinic in person may be difficult and generate significant anxiety:

"Some women will live in a religious or cultural community which does not support sexual activity outwith marriage and/or abortion. Telemedicine and EMAH supports women to access care discretely from their home setting, without the perceived risks and anxieties of attending a sexual health or pregnancy related service." (Organisation, Healthcare Provider)

Minority Ethnic Groups

It was suggested that EMAH meant there was a risk of introducing inequality for some minority ethnic groups. A few respondents highlighted that some minority ethnic groups were more likely to experience deprivation, and that this could predispose them to poorer health outcomes, which could be exacerbated by the lack of in-person care provided by the current arrangements:

"…the lack of direct physical medical input which this legislation creates will place women from minority ethnic groups at higher risk of complications." (Individual)

Conversely, others felt that the current arrangements would make it easier for minority ethnic groups to access the service.

Some respondents suggested that EMAH would create communication barriers and problems in instances where the woman did not speak English fluently. It was felt that it could be difficult for the woman to understand all the information being provided via a teleconsultation, and would also be difficult for the practitioner to know if the woman had fully understood the information. However, others highlighted that interpreters can be involved in teleconsultations and that in-person appointments can still be requested/required. (It should be noted that the SACP guidelines make clear that women should be seen in person if they are not able to understand all the information given.)

Age

A few respondents registered concern that the current arrangements could impact young girls negatively. The lack of verification of the patient's identity and details could result in those under 18 requesting the medication and being alone when they are taken, and/or for the abuse of those aged under 16 to remain undetected. Again, other respondents disagreed, highlighting that providers were alert to the wider sexual and reproductive health needs of younger patients, and that services can still opt for in-person appointments in such circumstances (SACP guidelines are also clear that those under 16 should normally be seen in person). It was also noted that as patients can access the service via their mobile phone, this may make it more accessible to younger patients and reduce the need for an in-person appointment which they may find more difficult to attend.

A few respondents argued that it may be challenging to ascertain if those under the age of 18 were providing fully informed consent. Others noted that informed consent may be an issue where patients were not proficient in English or for those with a learning disability:

"…it is unlikely that they will have the same capacity for decision making, voluntariness and the ability to make balanced decisions as more mature adults. This means that they may not be able to give appropriate informed consent for certain momentous decisions requiring mature reflection." (Organisation, Other)

Other Equality Groups

Issues raised by respondents in relation to other equality groups included:

• Gender Reassignment and Sexual Orientation - EMAH was felt to have a positive impact on the transgender and wider LGBTI community due to the privacy it offered. Both transgender-men and non-binary people were reported to experience the typically female gynaecological healthcare setting as a barrier to access. It was highlighted that LGBTI people face more discrimination when accessing reproductive services, with EMAH seen as a positive step to overcome discrimination.
• Marriage and Civil Partnership - A few respondents felt that relationships were strained and negatively impacted by abortion generally, and the 'secrecy' that can accompany EMAH specifically. One respondent cited evidence which estimated 40-50% of relationships end following abortion.^[5] A few indicated that they felt that the current arrangements and the consultation excluded the father from consideration.

Impact on Socio-Economic Equality

Q5. Do you have any views on potential impacts of continuing the current arrangements for early medical abortion at home (put in place due to COVID-19) on socio-economic equality?

Impact on Socio-Economic Equality

	All Respondents		Excluding Right to Life Campaign
	Number	Percent	Number	Percent
Yes	4576	83%	1796	65%
No	344	6%	344	12%
I Don't Know	352	6%	352	13%
Not Answered	265	5%	265	10%
Total	5537	100%	2757	100%

When asked if they had any views on the potential impact of continuing the current arrangements on socio-economic equality, most respondents indicated that they did (83% in total or 65% when excluding the Right to Life standard campaign responses). Overall, 4,590 provided qualitative comments, of which 564 (12%) suggested the impacts would be positive in nature and 3,840 (84%) felt they would be negative. Others again noted a desire to end all abortion practices or the temporary arrangements, or to continue with the current arrangements, or suggested that impacts would be felt by all women regardless of socio-economic status.

Positive Impact

Most respondents who felt the impact would be positive highlighted the many hidden costs and financial barriers to accessing in-person abortion services, including transport, overnight costs for those who have to travel significant distances, organising time off work/loss of income, and childcare costs. These barriers make it harder for those with lower financial means or without independent incomes to access abortion services. As EMAH reduced the need to travel and enabled women to control the timing of their abortion to avoid conflict with work and caring responsibilities, it was considered to provide greater equality of access to the service for those with low incomes and from lower socio-economic backgrounds:

"Accessing abortion from home will increase choice for those in lower socioeconomic groups who may not be able to travel, take time off work or pay for childcare to attend a clinic in person." (Individual)

Insecure employment and zero hour contracts were also seen as a barrier to women attending in-person appointments, both in relation to the loss of income in the short-term but also potentially more long-term impacts. It was noted that turning down shifts to attend appointments followed by several days off to complete the procedure could result in a longer-term impact on their earning potential - it was suggested there was a risk that a woman could see a significant reduction in her subsequent shifts or could even find she would not be offered further shifts. As the current approach reduced the need for time out of work, it was felt this positively benefited those in these typically lower paid and more insecure jobs, as well as those working multiple jobs or undertaking shift work.

It was suggested that the current arrangements help to ensure women can access regulated, safe and supportive abortion services rather than turning to unregulated providers. Respondents suggested that those who experienced financial barriers to accessing NHS services would be more likely to seek an alternative source, but that they may then be reluctant to come forward in the event of complications for the fear of being arrested. It was suggested they would be less likely or unable to benefit from the safeguarding, psychological support and contraceptive services provided by regulated providers:

"By removing many of the barriers created for socio-economically disadvantaged groups, for example, by removing the need for travel, the need to take time off work, and to pay for childcare, and allowing women to take the medication in their own home, the EMA at home model facilitates better access to safe, regulated abortion care for socio-economically disadvantaged groups." (Organisation, Professional Bodies)

A few respondents suggested that the current arrangements could have longer-term impacts on women's socio-economic wellbeing. It was highlighted that reducing rates of unintended pregnancy could improve educational attainment, participation in the labour market, and reduce the risk of women and children living in poverty:

"Taking control of when one becomes a mother gives women the freedom to work and improve their own economic position, unfettered by unplanned pregnancies or children." (Individual)

Several respondents highlighted data which showed that women from the most economically deprived areas were twice as likely to use abortion services compared to the most affluent areas,^[6] and suggested this meant that supporting them to access the services was highly important. Respondents also argued that attempts to revoke temporary approval changes would disproportionately affect women of lower socio-economic status.

Negative Impact

Many respondents felt that poverty could make women feel that an abortion was the only option. As noted above, they highlighted statistics showing that those from lower socio-economic backgrounds were twice as likely to seek an abortion,^[7] which they suggested demonstrates that poorer women were forced into abortion by their circumstances. They argued that EMAH put poorer women more at risk from what they considered to be an unsafe process, a lack of medical and psychological care, a lack of access to information, and a lack of follow-up care and support, and therefore did not provide equality:

"Home abortions will disproportionately impact women on low incomes or in difficult circumstances, who may feel pressured to abort for financial reasons despite wishing to keep their baby. Poor women may also have less reliable access to support and resources than those from more privileged backgrounds, meaning they are only aware of alternatives to abortion when attending appointments - a process substantially curtailed by the current home abortion provisions." (Individual)

Respondents also argued that abortion should not be seen as a solution for poverty, and that the speed and ease of access could result in women taking the decision for purely financial reasons without having the time to fully consider their decision or alternative options. They suggested that women in deprived areas would be less likely to get the help they needed to deal with their circumstances and felt that more needed to be done to create the circumstances where women are supported to either keep the baby or access alternatives to abortion. It was felt that EMAH did nothing to help address socio-economic inequalities:

"Allowing continuation of early (or later) medical abortions at home does nothing to address social inequalities. Other political and social reforms are necessary to adequately address such issues." (Organisation, Pro-life and Faith Groups)

A range of other issues, linked to socio-economic equality, were discussed by respondents and are outlined below:

• Some suggested women of lower socio-economic status could be more likely to suffer from domestic abuse or be victims of people trafficking. Therefore, it was felt they would be placed at greater risk of coerced or forced abortions, or could be at greater risk of sexual abuse as the abuser could end the pregnancy and conceal the abuse more easily via EMAH. It was also felt that the current arrangements provide missed opportunities to identify such abuse;
• Some suggested homeless women would be disadvantaged, either due to a lack of technology or fixed home address, as well as it being a missed opportunity to pick up on health issues that may not otherwise be addressed for women who are not engaging with routine GP check-ups (however the Scottish Government approval and SACP guidelines are clear that women can only have abortions at home if it is the place where they are ordinarily resident, so homeless women are required to attend a clinic/hospital);
• Some discussed the impact of the digital divide, i.e. lack of access to the required technology and/or internet access, as well as a lack of private telephone facilities or a private space within the home as limiting access to EMAH for those from lower socio-economic households;
• A few highlighted that low socio-economic status often leads to lower health outcomes, and so women in lower socio-economic groups would be more likely to suffer from poorer health and have higher likelihood of complications - therefore being at greater risk from the EMAH arrangements; and
• A few suggested that those living in less-affluent areas, or with lower educational attainment levels, might not understand the information and instructions via teleconsultation (e.g. the way the medication should be administered, signs of complications, the risks of a home abortion), or be able to access emergency medical care or follow-up care should it be needed:

"These women may not have a car to get to the hospital, a phone or credit to make a call for help… when complications arise. This puts underprivileged women at greater risk of harm." (Individual)

Several respondents called for the Scottish Government to publish abortion rates/data by area which would allow comparison by SIMD and also to present this data by in-person versus telemedicine methods of facilitation (however, it should be noted that Public Health Scotland does already publish abortion rates by SIMD in its annual abortion statistics).

Some respondents reiterated their concerns over the risks and impacts on women generally, without linking these specifically to socio-economic equality issues.

Impact on Women Living in Rural or Island Communities

Q6. Do you have any views on potential impacts of continuing the current arrangements for early medical abortion at home (put in place due to COVID-19) on women living in rural or island communities?

Impact on women living in rural or island communities

	All Respondents		Excluding Right to Life Campaign
	Number	Percent	Number	Percent
Yes	4762	86%	1982	72%
No	299	6%	299	11%
I Don't Know	289	5%	289	10%
Not Answered	187	3%	187	7%
Total	5537	100%	2757	100%

When asked if they had any views on the potential impact of continuing the current arrangements on women living in rural or island communities, most respondents stated that they did (86% of all respondents or 72% when the Right to Life standard campaign responses are removed). In addition, 4,797 provided qualitative comments, of which 648 (14%) suggested these impacts would be positive, while 3,939 (82%) outlined negative impacts. The remaining respondents again typically felt that the current arrangements should be kept or removed, or indicated that equal access to safe medical facilities/procedures should be available to all, without relating any reasons for these standpoints to the impacts on those in rural or island locations.

Positive Impacts

Most of those who identified positive impacts felt that EMAH was an effective way to tackle the access barriers and improve accessibility for women in remote, rural and island locations. Due to the lack of locally available services, the barriers noted with in-person models discussed included:

• The distance women need to travel to access services - this was an issue in relation to the time needed to be away from home or work and potentially being required to explain this absence. In addition, the need for extended childcare was highlighted, along with the potential for women to have to undertake long journeys home after the appointment when they would be in a more vulnerable condition (i.e. experiencing nausea, vomiting, bleeding and/or emotional distress);
• The cost of travel, possible childcare costs, and overnight accommodation were prohibitive, particularly for women living on islands which required ferries or flights to the mainland;
• Difficulties in accessing suitable transport, including a lack of public transport, needing multiple interchanges to access services, or inconvenient/unsuitable times of public transport services;
• The lack of privacy from attending the local hospital or accessing facilities on the mainland. It was noted that there was a high likelihood of seeing someone they knew at the local facilities, while being away from home for an extended period would require arrangements to be made and be noticed by others in small communities, and so women may need to explain their movements more. Collecting medication from the local pharmacy was also considered to impact on confidentiality and privacy for women living in small close-knit communities; and
• Local GPs being conscientious objectors was identified as a potential difficulty in some rural and island settings, particularly where they were the only GP and it was hard to find others who could provide the required referral:

"For those living in rural and island communities the longer distances of travel for in-person appointments, will have much greater financial impact. Also in close-knit communities individuals would previously have sometimes faced the difficulty of explaining the reasons for going to the mainland and being away. Allowing abortion medication to be delivered for home use gives the patient privacy and autonomy." (Individual)

Several respondents claimed that the most deprived women in island communities were the least likely to access abortion services, while the opposite was true for those on the mainland. It was argued that this showed that significant barriers (financial and logistical) existed for those living in remote, rural and island locations, which they considered the current arrangements went some way to alleviating.

Further, it was felt that EMAH reduced delays for women living in rural or island locations, both in the system itself and in women having the ability and/or confidence to seek the procedure quicker. As such, it was considered that the current arrangements ensured that EMA was feasible and safe for women in rural and island locations, and negated the need for higher risk, more invasive or unregulated options which may have taken place at a later gestation.

It was proposed that EMAH provided wider and more equal/equitable access to services for women who live in rural and island locations, as well as allowing them the same levels of control over their body and future:

"For those of us in very rural communities this is like a lifeline of equality." (Individual)

"Telemedicine and the availability of medication delivery will transform abortion care for women in rural and island communities. It will make it accessible, equitable and safer." (Organisation, Healthcare Provider)

Negative Impacts

Most of those who identified negative impacts highlighted that women in rural and island communities would be further away from emergency medical care should they encounter complications. They noted that serious complications can arise from EMAH, particularly in instances of later gestational use, but respondents highlighted that those living in rural and island locations were unlikely to be able to access emergency treatment in local medical facilities (should any exist), and so there would be a significant delay in accessing the necessary support:

"Medical complications do sometimes occur with these medical abortions and haemorrhaging could become life-threatening for those who are distant from medical facilities and without transport. This arrangement is therefore an added risk for those living in rural or island communities." (Individual)

Various evidence was cited to support their argument about efficient access to emergency medical care, including reports which highlighted the lack of definitive critical care services within a 45 minute drive across the islands and Highland Health Board areas,^[8] limited access to air/helicopter-based emergency services in some remote/rural/island locations^[9] (which can also be impacted by inclement weather), and statistics around the proportions of women who access medical interventions following EMA (although the data was not based on Scottish experiences).^[10] However, it should be noted that these issues would typically arise as a result of complications which would occur after taking the second pill, and so would have presented a risk under the previous arrangements as well. As such, the issues would be common for all EMAs (and indeed other major medical issues or emergencies) and are not a direct result of the current EMAH arrangements, which was the focus of the consultation.

It was suggested that provisions for, and access to, mental health facilities needed for aftercare or ongoing support were equally limited for women in rural and island communities. Further, it was felt there may again be less privacy and more associated stigma for women trying to access these services in small communities:

"If these women live in remote areas, they are unlikely to gain more support for their aftercare and mental health." (Individual)

A few respondents felt that women living in remote, rural and island areas may be more at risk of other factors which could impact on their decision/experience, such as abuse/coercion and isolation, as well as the lack of information provided about alternative options and the lack of support provided by EMAH. Therefore, several respondents felt that women in such areas may be more likely to feel there is no other choice but to have an abortion.

A few suggested that normalising abortion and increasing accessibility in such areas would result in declining populations locally due to declining birth rates. In practical terms, a few suggested that having good reliable internet access could be challenging in rural and island areas, as well as them being more likely to experience postal delays/disruption due to distance and/or weather, again limiting women's ability to access the service. Rather, several felt that in-person abortion services were preferable for women living in rural and island areas, but suggested that financial support could be provided to assist women to access these.

Overall, those who argued that EMAH had a negative impact felt that EMAH put women living in rural and island locations at greater risk, with any complications becoming more severe due to the delay in accessing assistance, and would, therefore, further entrench health inequalities and accessibility issues between rural and urban areas.