Early medical abortion at home - future arrangements: consultation analysis

Appendix A Campaign Synopsis

Right to Life - Standard Campaign Response

In total, 2,780 standard campaign responses were received which followed the Right to Life template. Below is an overview of the content from these responses.

Q1a. Impacts of the current arrangements for EMAH (put in place due to COVID-19) on women accessing abortion services? - Safety

In response to the quantitative element of this question, respondents stated the impact would be 'negative'.^[13]

Respondents provided a very lengthy response at this first question covering various topics as follows:

• EMAH can lead to complications that put women's health at risk - respondents outlined the range of complications, described instances of these having happened, and suggested there was a risk that complications were under-reported;
• Risk of coercion & inability to identify domestic abuse - it was felt that the lack of verification of patients' identity left the current arrangements open to abuse/fraudulent use, and that teleconsultation methods were not suitable to identify coercion, abuse, or those feeling forced into abortion by others. It was felt that in-person consultations provided a safe space for women to discuss their situation, thus creating an essential safeguard;
• Impossible to accurately diagnose gestation electronically - it was highlighted that it is impossible to verify gestational age via a teleconsultation and patients could provide inaccurate information in this respect. Again, respondents highlighted the complications that could occur as a result of EMAH being undertaken beyond the recommended/legal gestational limits;
• Risk of complications increases as gestation increases - it was highlighted that the websites belonging to abortion providers note the risk of complications increases with gestational age. Respondents also stated that the rate of hospitalisation for complications increases with gestational age. It was felt that the current arrangements made it too easy for patients to, intentionally or unintentionally, provide an inaccurate date for their last menstrual period (LMP), thus placing their health and safety at risk. As such, respondents called for in-person appointments to be required before the medications are administered;
• It is not guaranteed that recommended protocols for taking abortion medication will be followed - it was suggested that the current arrangements placed the responsibility on the patient for monitoring dosing intervals and managing their preferred administration method, as well as monitoring various other aspects related to side-effects and complications. However, it was felt that the inability to verify an accurate gestational date may result in a patient applying misoprostol in a potentially unsafe manner, thus heightening the risks of medical complications. Further, they suggested that there was poor compliance with the adherence to instructions for self-administered medical treatments generally. In addition, they argued that there was a distinct lack of high-quality research study designs in EMA and risks of bias in existing data on EMAH;
• Testimonials from women who suffered complications and/or negative experiences of EMAH - testimonials from three women who had experienced complications or negative experiences during EMAH were presented. The respondents acknowledged that some of the effects and complications would have been the same in a clinical setting, however, they argued that having access to immediate medical support would be more appropriate patient management; and

Across most of the concerns raised, multiple sources were provided to corroborate the claims being made. This included UK Government statistics, research studies and reports (largely from Northern Europe/ Scandinavian countries), the results of mystery shopping studies which focused on obtaining EMAH medication from providers in England, the views of various medical professionals, and newspaper reports.

Q1b. Impacts of the current arrangements for EMAH (put in place due to COVID-19) on women accessing abortion services? - Accessibility and Service Quality

In response to the quantitative element of this question, respondents stated the impact would be 'negative'.

Respondents highlighted that not all individuals would be able to access telemedicine and felt that it had a disproportionately negative impact on accessibility for the most vulnerable populations.

In addition, respondents suggested that patients who did not have a good level of English and those with mental health problems and disabilities were disproportionately excluded by telemedicine. It was indicated that individuals may not feel comfortable talking about their mental health online, or may not be in an environment where they are safe to talk about their psychological wellbeing. Further, it was argued that some women would likely need far greater support (advice, psychological support, etc.) than could be provided during a teleconsultation. Respondents felt that women's health and safety was not been prioritised by EMAH. It was felt that in-person checks were crucial to provide the highest standard of care, particularly for those struggling with mental health issues or domestic abuse.

Respondents also cited polling which showed women wanted more, not fewer, safeguards around abortion across a number of key areas. In particular, the polling indicated a preference for in-person verification that each patient seeking an abortion is not under pressure from a third party, and that every woman requesting an abortion should be seen in-person by a qualified doctor.

Q1c. Impacts of the current arrangements for EMAH (put in place due to COVID-19) on women accessing abortion services? - Waiting Times

In response to the quantitative element of this question, respondents stated the impact would be 'negative'.

It was suggested that the reduced waiting times which had been facilitated by EMAH was not a positive outcome. Firstly, it was suggested that gestation was not being validated by ultrasound scans, and that women may be providing intentionally or unintentionally incorrect information on their gestation. These potentially inaccurate gestations could invalidate the claim that EMAH leads to abortions being undertaken at earlier gestations. Further, it was suggested that the data itself did not fully support the claim that EMAH had led to women having earlier medical abortions. Rather, they felt that changes reflected a pre-existing longer-term trend. As such, they felt the data presented did not justify the extension of the current arrangements.

The Right to Life standard responses noted that the effects of COVID-19 on abortion practice had yet to be thoroughly examined, and indicated that it was as yet unclear what impact the pandemic had had on who is getting pregnant, the prevalence of pregnancy and who is choosing abortion. Therefore, they suggested that, even if the data were reliable, the availability of EMAH may have had little to do with earlier termination rates.

Respondents stressed that expediency was an inappropriate measurement for a life-changing decision. They felt that prioritising speed and procedural efficiency disregarded the duty of care owed to women facing unplanned pregnancies. Rather, it was considered vital that women should be offered independent psychological support and a consideration period of 48-hours. They highlighted a study which indicated that 93% of women agreed that those considering abortion should have a legal right to independent counselling from a source that had no financial interest in the decision (although it should be noted that NHS Boards provide all early medical abortions in Scotland and their psychological support services have no financial interest in women's decisions on abortion).

Q2. Impact of the current arrangements for EMAH (put in place due to COVID-19) on those involved in delivering abortion services?

In response to the quantitative element of this question, Right to Life standard respondents stated the impact would be 'negative'.

It was felt that removing in-person consultation fundamentally altered the relationship between patient and physician. They highlighted research on nonverbal communications which suggested that the majority of communication (55%) is done through body language,^[14] and therefore, teleconsultations may hinder communication between patient and medical practitioner. They also noted that a survey on GP remote consultations (published in December 2020) showed that most of GPs surveyed felt that remote consultations with patients were hindered by technical difficulties.^[15] Respondents suggested communication challenges are accentuated in cases where there may be a language barrier, wherein the physician and patient may not be confident that they have understood each other and that the patient has provided fully informed consent.

In addition, respondents felt it was not evident how medical professionals are equipped to ensure that a woman is providing informed consent for an abortion of her own free will - potentially placing health professionals delivering abortion services in a difficult and compromising position.

The final area of concern focussed on the medical professional's responsibility, both for the procedure in general, and in particular for the disposal of the fetal tissues. Further, they suggested it was not clear from the consultation paper whether the registered medical professional would still be legally responsible for the procedure while it happens at home.

Q3. What risks do you consider are associated with the current arrangements for EMAH? How could these risks be mitigated?

Similar to Q1a, the Right to Life standard respondents provided a significantly lengthy response at this question. Three main issues were discussed, as outlined below:

• Risk of abortion coercion - it was felt that coercion would be impossible to detect without an in-person consultation as there was no guarantee that an abusive party was not listening into a teleconsultation. It was suggested this may be particularly concerning for women from minority ethnic cultures who may be pressured into seeking a sex-selective abortion. Further, it was suggested that self-administration of abortion medication removes any control over who takes the pills, where they are taken, whether they are taken, when they are taken (both in terms of gestation and the administration requirements of the medication), or if an additional adult is present for support. Respondents felt that in-person services provided a substantial safeguard against this mismanagement, and so should not be bypassed;
• Risks to women's physical health - respondents highlighted that various doctors, NHS staff, Government departments, Ministers and spokespeople had raised concerns about the possible physical complications linked to EMAH, and outlined their concerns and/or instances which included significant pain and bleeding, haemorrhage, rupture of the uterus, ruptured ectopics, sepsis, resuscitation for major haemorrhage, endometritis and toxic shock syndrome associated with Clostridium sordellii, and death. Respondents also identified a study from Finland which suggested that the rate of complications was four times higher in medical than surgical abortions (it should be noted that this was, however, not based on Scottish data).^[16] In relation to ectopic pregnancies, they highlighted that it was possible to have an asymptomatic ectopic pregnancy and therefore ultrasound scanning should be standard practice before EMA (which would also assist in verifying gestational date). It was also claimed that some women who are Rhesus D negative may not receive prophylactic Anti-D, which could result in isoimmunisation in future pregnancies, where the mother produces antibodies that harm the developing fetus' blood cells.^[17]
• Risks to women's mental health - it was proposed that many women may be unsure of their decision, may be being coerced into the abortion, may not fully understand the potential distress caused by the procedure, and, in order to avoid these potential issues, require more in-depth face-to-face psychological support than possible during a teleconsultation. Respondents advised that research had suggested that mifepristone may have direct pharmacologic effects that increase risk of mental health issues as it releases inflammatory cytokines that have been implicated in causing depression. Testimonials were provided from two women outlining their perceived psychological trauma of the procedure. Further, respondents suggested that it was not in the commercial interests of service providers to offer time and space for psychological support, and they felt that entrusting the mental health of women to the providers who "financially benefit from abortion" seemed irresponsible.

Ultimately, respondents felt that the best way to mitigate these risks was to immediately withdraw the temporary provision of EMAH, and require an in-person consultation prior to women receiving a medical abortion.

As at Q1a, numerous references were provided to support the arguments being offered. Sources included UK Government studies, journal articles, news reports, elements of the Abortion Act 1967, and abortion providers and NHS Inform Scotland websites and guidelines.

Q4. Views on the potential impacts of continuing the current arrangements for EMAH on equalities groups?

In response to the quantitative element of this question, respondents stated 'yes'.

Respondents discussed impacts on various groups, including:

• Pregnant women;
• The embryo or fetus (referred to as 'unborn children' by respondents);
• People with disabilities; and
• Conscientious objectors within the medical profession.

Impact on pregnant women - respondents felt that EMAH presented great risks to women's physical and mental health. They argued that removing face-to-face consultations would negatively impact the consultation experience and decision-making process of women who would otherwise rely on in-person communication due to impaired hearing or vision, as well as those suffering debilitating mental health conditions and those exposed to coercion. They also noted that pregnant women were more likely to suffer from domestic abuse, and suggested that EMAH provided abusers with easier access to abortion medication, and placed pregnant women at risk.

Impact on 'unborn children' - respondents stressed that the fact the fetus up to 12 weeks gestation was not recognised as a protected age category or equality group in the consultation was extremely concerning. They felt it was important to highlight the impact that continuing EMAH would have on the rights of 'unborn children'. They noted that last year the second highest number of abortions were recorded in Scotland since the Regulations were introduced, and that data showed abortions were continuing to rise and are at an all-time high in England and Wales. They considered this to be "a grave healthcare failing for the UK that denies the right to life of unborn children as a protected equality group".

Impact on medical professionals with religious affiliations - It was suggested that EMAH may negatively impact medical professionals who hold religious beliefs which would prevent them from facilitating an abortion procedure. It was noted that the Abortion Act 1967 ensured conscientious objection rights for any medical professionals engaged in direct participation. The respondents believed it was unclear what would be considered 'direct participation' for those supporting the provision of EMAH. For example, would someone be able to opt-out of being required to post abortion medication to a woman's home? Respondents stressed that clarity around this was urgently needed.

Q5. Views on potential impacts of continuing the current arrangements for EMAH on socio-economic equality?

In response to the quantitative element of this question, respondents stated 'yes'.

The respondents noted that, again, consideration was only being granted to the born rather than the unborn. They also suggested that equal access to what they perceived to be a dangerous process was the wrong measurement of success.

They believed that EMAH may increase inequality in health outcomes experienced by socio-economically disadvantaged groups, including homeless women. Firstly these socio-economically disadvantaged groups may face problems in accessing technology or with not having a fixed postal address, and secondly it was believed that opportunities may be missed to pick up on health issues in those who are not engaging with routine GP check-ups.

They suggested that women living in poverty or concerned about falling into poverty may be more likely to seek abortion. Respondents reported that abortion rates were more than two times higher in the most economically deprived areas in Scotland than the least deprived. This cited statistic was considered to imply that women in poorer areas were more at risk from EMAH (referenced in the standard response as unsafe 'DIY' home abortions) under the current arrangements.

As such, they felt that in-person assessments should be mandatory for all women, especially those in vulnerable socio-economic circumstances and those lacking technological access and aptitude, who they suggested were disproportionately vulnerable to the dangers of EMAH.

Q6. Views on potential impacts of continuing the current arrangements for EMAH on women living in rural or island communities?

In response to the quantitative element of this question, respondents stated 'yes'.

Respondents felt that pregnant women living in rural and island areas with limited access to healthcare were greatly disadvantaged by EMAH, due to the risk of serious complications. It was noted that the population of rural Scotland faced particular challenges in terms of access to key services, including hospital outpatient services.

While they felt the risks had been shown to be great for all women, they considered they were potentially greater in rural and island areas. One example offered was if a woman had underestimated the gestational date and suffered complications, it would be much harder for her to gain rapid access to emergency services. As such, they felt that women should be required to attend a clinic for the EMA, and that this would be especially vital for those living in rural or island communities who may not have immediate medical assistance available should they suffer from serious complications. They suggested that prolonging the EMAH arrangements for women in these areas reinforced the health access divide between urban and rural populations.

Ultimately, they argued that face-to-face consultation should be compulsory for those living in rural or island communities, given the perceived advantage they reported in communication and care over EMAH.

Q7. How should early medical abortion be provided in future, when COVID-19 is no longer a significant risk?

In response to the quantitative element of this question, respondents stated 'Option b - Previous arrangements should be reinstated - in other words women would be required to take mifepristone in a clinic, but could still take misoprostol at home where this is clinically appropriate'.

Respondents felt the previous arrangements should be reinstated, at the very least. Preferably, however, both mifepristone and misoprostol should be taken in a clinic, to ensure they are taken properly, at the appropriate time and in the correct manner.

Perceived challenges related to the current arrangements were outlined. These challenges included women being responsible for managing the 'standard dosing interval' and other aspects of self-administration, identifying and supervising their own 'symptoms of significant anaemia' along with any other side-effects or complications, the inability to verify an accurate gestational date which may result in a patient applying misoprostol in a manner unrecommended for their health, and the lack of verified gestation date would also hinder a patient's capacity to make a fully informed decision concerning the risks of different methods for applying misoprostol at home.

They suggested that taking both pills in a clinic would provide an added measure of safety so that, should the patient experience a complication, medical care would be immediately accessible. It was proposed weight for this argument was given by the Scottish Abortion Care Providers guidelines previously advising the patient has another adult present when undertaking EMAH,^[18] with the respondents arguing that appropriate medical support would be the optimal management.

Respondents also suggested that the options presented had not met the 'validated impact assessments' advised by principle C of the UK Government's Consultation guidelines. They note that no evidence was given to explain concerns identified in the consultation document (e.g. risks due to not having an appointment in person such as the difficulties of judging gestational date or establishing the presence of coercion), and concluded that these concerns were reason enough to prohibit EMAH. Given the absence of critical information concerning the problems introduced by the implementation of EMAH they felt that this question could not be fairly answered by any respondent relying upon the consultation paper for evidence of the impacts of the competing options. With access to wider research, they felt that both forms of abortion (both the current arrangements and previous arrangements) posed serious risks to women, as well as 'resulting in the death of an unborn human being'.