Early medical abortion at home - future arrangements: consultation analysis

Other Comments

A number of respondents provided comments and discussion on issues which were not directly related to the consultation questions or specifically related to the current EMAH arrangements. These were generally related to compliance with the Abortion Act 1967, issues with abortion/EMA generally, and perceived gaps in the consultation. These issues are outlined below.

Divergence from the Abortion Act 1967

Several respondents felt that the current EMAH arrangements, and the proposal to make these permanent was moving further away, or too far away, from the original intentions of the Abortion Act. It was felt this was intended to ensure the procedure was conducted or overseen by qualified medical professionals and should not be something that women undertook themselves. However, there was a sense that EMAH removed many of the safeguards and controls, and that medical professionals could not now be considered to be supervising the procedure (as is required by the law):

"The women relying on posted abortion pills have been abandoned. There is no person-to-person contact. No effective, competent consultation. No secure follow up, when there are difficulties. One of the reasons why abortion was legitimised in the first place was to avoid back street abortions. Home abortions don't appear to be much different." (Individual)

It was also suggested that the Abortion Act 1967 was not intended to improve accessibility or to provide abortions 'on demand', but was designed to make the procedure safer. As such, it was felt that EMAH was no longer in keeping with the letter or spirit of the law, and they noted that the majority of abortions were now carried out for what they termed 'social' reasons and because the pregnancy was an 'inconvenience' rather than due to truly life threatening conditions for the mother:

"I totally believe that there are exceptional circumstances where aborting life can and perhaps, regretfully, should be used. But never for convenience, for budgeting, for 'freedom of choice' etc." (Individual)

"The vast majority of abortion in Scotland is preventable "social" abortion." (Organisation, Pro-Life or Faith Group)

Rights of the Fetus

Many respondents (typically those opposed to EMAH and abortions more generally) felt that the consultation had overlooked or excluded the rights of the fetus or unborn child. Generally, they believed that life begins at conception, and therefore the unborn child has the right to life and that they should have their rights protected by the Government. They also felt that the Government had a responsibility to protect the most vulnerable (in this case the unborn child), and those with no voice of their own. There was a strong sense among these respondents that by excluding consideration of the fetus within the consultation, and moving to a system of EMAH, this failed to recognise that a human life was being taken by the procedure, and it was perceived that this cheapened the value of human life:

"Life itself is being set aside as something with no recognisable value." (Individual)

"Telephone/video conferencing reduces the protection for the unborn child written into the original legislation." (Individual)

Inappropriate Use

In addition to concerns that EMAH did not comply with the requirements of the Abortion Act 1967 and was being used too widely, many felt that that it was being used inappropriately. They generally felt that it was being used as a method of contraception, which they considered to be inappropriate.

Many respondents reported that fetuses with fetal anomalies were often aborted. In particular, it was suggested that abortions were routinely undertaken for non-life threatening disabilities, such as Down's Syndrome, and that clubfoot and cleft lip were other conditions which could trigger the decision to terminate a pregnancy. It was felt by some respondents that this was discriminatory and sent wider societal messages that such life was of less value. While it should be noted that this was an issue for abortion generally, and not specific to the current arrangements, a few did suggest that the lack in-person contact involved in EMAH could allow such selective abortions to increase (however, it should be noted that the diagnosis of such conditions would only be made following an in-person appointment).

Similarly, some respondents felt that the current arrangements, and any continuation of these, risked increasing sex-selective abortions (it should be noted, however, that abortions are not permitted under the Abortion Act 1967 for sex-selective purposes). It was suggested that some scans/tests could determine the sex of the baby at under twelve weeks, and this could result in some people electing, or being forced, to have an abortion on this basis. In situations where a woman is coerced or forced into a sex-selective abortion, it was felt that the lack of in-person consultation could result in such instances going undetected.

Issues/Risks from EMA Generally

Throughout the consultation responses, some respondents discussed issues, concerns or risks that would be expected to arise from EMA generally, and/or were common issues for both the previous and current arrangements. These related to physical and mental health risks.

In relation to physical health, many noted that EMA was a painful and traumatic experience for women, which carried the risk of excessive bleeding, haemorrhaging, ruptured ectopic pregnancies, incomplete abortion, infection/sepsis, renal failure and, in extreme circumstance, death. It was felt that women would not know when the pain or bleeding experienced was outwith normal limits, which could lead to delays in seeking urgent medical attention. This was considered to be particularly risky for women who were alone with no one to help and support them. Indeed, a few noted that, while the former Scottish Abortion Care Providers guidelines stated that women should not be alone when taking misoprostol (i.e. the second pill),^[12] the at-home method of administration meant there was no way to ensure this requirement was adhered to (however it is important to note that current 2020 SACP guidelines note it is optional for women to have someone with them). A few also suggested that women may have difficulty falling pregnant in future, that the procedure could result in disabilities in future children, or that there was a risk of the premature birth of viable babies if the pills were not used appropriately or within the recommended/legal gestation periods.

In relation to mental health risks, it was felt that women would find it particularly traumatic to expel and then dispose of the fetus themselves. This issue also raised wider hygiene concerns. A key concern was that the at-home approach introduced the potential for inappropriate disposal of fetal tissue. Again, as women were already passing their pregnancy at home under the previous arrangements, this is not a new issue created by the move to the EMAH arrangements.

Another issue discussed by a few respondents, which related to EMA more generally, was where women may want to reverse their decision after taking the first pill. A few respondents suggested that greater levels of advice and information on this should be provided as the reversal process should be started within 48 hours of taking the first pill. However, a few others noted that the effectiveness and safety of this reversal treatment had not been proven.

Wrong Focus

Some respondents felt that abortions and EMAH did nothing to understand or support women with their underlying reasons for seeking an abortion. They noted this could often be as a result of personal difficulties, abuse or financial pressures, and which women would still not be supported to address or overcome by accessing abortion services:

"Women in crisis should be offered treatment and support for their reasons for wanting an abortion. Whether that is psychological trauma, their economical struggles and protection from abuse rather than encourage them to take a view that it is the baby that must be the problem. Abortion doesn't fix any of those problems." (Individual)

A few respondents claimed that the numbers of abortions taking place was very high and rising. As such, they felt that the Scottish Government should be more focused on understanding the reasons for this, tackling the root causes of abortion, and providing better holistic support to those experiencing 'crisis pregnancies' rather than continuing to support such high rates of abortion without question:

"This is a moment to reassess abortion services much more widely through the lens of protecting and promoting the human dignity of both women and their unborn children... Rather than simply widening access to abortion, there is an opportunity in the rebuilding of services to address the systemic reasons women are seeking abortions for example due to poverty or lack of relational support." (Organisation, Pro-Life or Faith Group)

Several believed that the move to EMAH would lead to increases in abortion rates due to the easier access and lack of alternatives this approach offered. However, they felt this created a disparity between the EMAH model for abortion and the rest of the COVID-19 response. It was argued that the COVID-19 response had generally been heavily focused on saving lives, yet they considered the EMAH response was making it easier for medical abortions to end the life of what they perceived to be 'unborn babies'.

In relation to COVID-19 restrictions, it was suggested that consideration needed to be given to access to contraceptives during the pandemic and restrictions that had been put on these (particularly long-acting reversible contraception (LARC)). It was suggested that access to these was extremely curtailed due to NHS reprioritisation, and therefore, it could be expected that there would be increased need for abortion services in the short to medium term as a result.

Lack of Robust Evidence

Several respondents highlighted that relevant data and evidence was not included within the consultation document. It was noted that problems were acknowledged without being supported by any data/evidence, and where other data/evidence were alluded to, no details were presented. This included feedback from NHS Boards on the experience of EMAH, and data relating to the medical and psychological safety concerns and unintended consequences of home abortions in Scotland (i.e. since the second pill (misoprostol) could be taken at home prior to the pandemic). It was argued that there was a lack of data/evidence on the impacts of taking the first pill (mifepristone) at home - i.e. one of the major changes of the EMAH approach. As such, respondents felt that greater data and evidence needed to be made available in order for the consultation to be considered fair, open and transparent, and for informed views to be developed regarding the impact of EMAH and its continued use:

"The Consultation is lacking quantitative evidence on the problems associated with medical abortion even though SG [the Scottish Government] recognises them, and so is flawed." (Organisation, Pro-Life or Faith Group)

It was suggested that the evidence that had been cited in the consultation document was incomplete, had not been fully analysed, came from a narrow range of sources, or was subject to potential conflicts of interest. In particular, it was suggested that data from abortion providers would be biased towards satisfied patients as those who had negative experiences would be less likely to engage with the service again. It was also highlighted that one study cited had been conducted by practitioners or academics involved in abortion or family planning and some argued that it could not, therefore, be considered truly impartial. Further, it was argued that robust and reliable data had not been presented which could provide reassurances around safety:

"The claim that the process is safe is not supported by substantial evidence, evidence that is alluded to is without academic reference and data supplied has, in the papers own words, 'not gone through the same robust checking process as official statistics.' Claims of safety cannot be made and should not be made… when it cannot be fully and accurately substantiated." (Individual)

Ultimately, several respondents felt that the EMAH approach had not been sufficiently researched or had proper scrutiny to warrant making it permanent at this stage. Rather, it was argued, it would be preferable to wait until more data was available from across the COVID-19 period before taking any decisions about future arrangements.

Consultation

A few respondents were concerned about the methods being utilised to consult and debate on such a significant issue/change. It was felt that a much wider and more meaningful debate was needed, with others suggesting that greater consultation needed to be undertaken with the medical profession in order to seek feedback and to better understand their experiences and concerns. A few raised concerns about the nature of the consultation questions being asked. It was felt that these focused on a narrow set of issues and did not provide sufficient weight and importance to key areas of concern.

Support for EMAH

Finally, it should be noted that several respondents did outline support for the EMAH approach, noting that it could be considered a positive and progressive step which had been demonstrated to be successful:

"This service is the gold standard in women's abortion care and [is] to be applauded... I strongly believe that the services must continue after the pandemic and that we should not reduce and make access more difficult to the delivery of abortion care in Scotland by denying women an option that has been proven to meet their needs." (Individual)

"The provision of abortion pills for home administration is a long overdue and progressive step forward. One which is in line with modern medicine and clinically safe." (Organisation, Women's or Abortion Support Group)