To the Prime Minister, First Minister of Scotland, and First Minister of Wales,

We, the undersigned, write to call on your respective governments to end the ‘at-home’ abortion schemes currently in place in England, Scotland, and Wales. In the midst of public consultations by each government on whether to make the temporary ‘at-home’ abortion policy permanent, we outline our concerns to you on the serious risk these temporary measures present to women’s health and welfare.¹

Separating abortion from a clinical environment with direct medical supervision has ensured that abortion providers cannot guarantee that the pills are taken by the individual they are prescribed for within the appropriate time frame. Specifically, self-administration of abortion pills removes any certainty over who takes the pills, where they are taken, at what gestation they are taken, and whether an additional adult is present in case of complications.

Furthermore, a nationwide undercover investigation, which concluded in early July, found evidence of abortion providers putting women at significant risk by not carrying out basic checks before sending them ‘at-home’ abortion pills. ² In the investigation, led by public health consultant Kevin Duffy, a former Global Director of Clinics Development at Marie Stopes International, eight ‘mystery shoppers’ were able to acquire mifepristone and misoprostol in twenty-six different requests by using false names, dates of birth, and gestational dates.³ In one case, pills were provided to a mystery shopper who gave a date that could only have led to an ‘at-home’ abortion beyond the legal 10-week limit. Despite assurances from the Care Quality Commission in November 2020 that “all three providers [MSI, BPAS, and NUPAS] have strengthened their screening process following the initial concerns,”⁴ a second mystery client investigation conducted between November 2020 and January 2021 found that there has been no change in the behaviour of abortion providers towards the screening of gestational dates.⁵ Clearly this service can be manipulated by a third-party to obtain abortion pills without scrutiny, which is a serious concern in relation to, for example, underage sexual abuse victims and women at risk of being coerced into an abortion.⁶ Indeed, the Northern Ireland Department of Health has warned that women “are at risk” if they choose to pursue self-managed abortion, adding that “The Department’s view is that services should be properly delivered through direct medical supervision within the health and social care system.”⁷

As there is no way to verify accurate gestational age via telephone without an in-clinic ultrasound, the temporary provisions in England, Scotland, and Wales have already placed the health of many women at risk. The concerns highlighted by the investigation have tragically materialised, alongside a number of other disturbing developments. According to a leaked “urgent email” sent by a Regional Chief Midwife at NHS England and NHS Improvement on the “escalating risk” around ‘DIY’ home abortions,⁸ police have opened a murder investigation into the death of a baby who they believe was born alive despite the mother taking ‘DIY’ home abortion pills.⁹ The email also revealed a woman received ‘at-home’ abortion pills who was then found to be 32 weeks pregnant, that there were 3 police investigations linked to late ‘at-home’ abortion (including the aforementioned murder investigation), and that a further 13 incidents were under investigation.¹⁰

In addition, media reports in May 2020 revealed police were investigating the case of a baby aborted at 28 weeks using abortion pills at home, and that 8 further cases of ‘at-home’ abortion occurring beyond the ten-week limit were under investigation by BPAS.¹¹ As they occurred within a period of two months, from one region alone, these cases likely represent the tip of an iceberg of unreported incidents that have occurred across Scotland, England and Wales since 1 April 2020.

This concerning trajectory of incidents is unsurprising given the evidence that there can be more complications from taking abortion pills than from surgical abortions, even in a supervised medical setting:

• A Finnish study of over 42,000 women receiving abortions up to 9 weeks’ gestation (63 days) found that the rate of complications was 4 times higher in medical than surgical abortions.¹² Furthermore, the rate of haemorrhage was found to be over 7 times higher and the rate of surgical evacuation was over 3 times higher for medical than surgical abortions.¹³
• A 2018 Swedish study of nearly 5,000 induced abortions over eight years from 2008 to 2015 found that the complication rate for medical abortions before 12 weeks’ gestation (7.3%) was substantially higher than that for surgical abortions (5.2%)¹⁴. It discovered that the complication rate for medical abortions before 12 weeks’ gestation almost doubled from 4.2% in 2008 to 8.2% in 2015, concluding that the significant surge in complications, while unknown, “may be associated with a shift from hospital to home medical abortions.”¹⁵

Furthermore, it appears that likely that medical complications from ‘at-home’ abortion are being underreported. Data for England and Wales from the Department for Health and Social Care show only one complication following an ‘at-home’ abortion (out of a total of 23,061 abortions) during the period April to June 2020.¹⁶ Unbelievably, this would mean that the average rate of complications for medical abortions for similar gestations (3-9 weeks) over the past five years was over 17 times higher than the complication rate for ‘at-home’ abortions earlier this year, which seems highly unlikely.¹⁷ Given the provider may fill out the form within the 14-day time frame before the woman has actually self-administered misoprostol, and indeed abortion provider BPAS themselves recently found that some women wait more than a week after receiving mifepristone and misoprostol before using them, it seems highly unlikely that all complications would be noted on the form.¹⁸

In addition to increased risk of medical complications, self-administration makes it much more challenging, if not impossible, to ascertain if abuse or coercion is involved on the basis of a phone or video call. This poses a threat to vulnerable women and girls who are at risk from an abusive partner, sex-trafficking, or child-sex abuse, as ‘at-home’ abortion could be used by abusers as a means to more easily cover up trafficking or abuse.¹⁹ Indeed, Health Minister Lord Bethell told the Lords on 25th March 2020 before the Government’s U-turn on ‘at-home’ abortion: “The bottom line is that, if there is an abusive relationship and no legal requirement for a doctor’s involvement, it is far more likely that a vulnerable woman could be pressured into have[ing] an abortion by an abusive partner.”²⁰

Finally, recent polling in England found that an overwhelming majority of the general public, especially women, are concerned about the safety, quality, and legal issues arising from ‘at-home’ abortion.²¹ Specifically, 86% of women were concerned about women being at risk of being coerced into an abortion by a partner or family member during the ‘at-home’ abortion process, where a doctor does not see the woman in person, and 83% of women were concerned by the possibility of abortion pills being falsely obtained for another person. 84% of women were worried about women having a medical abortion beyond ten weeks of gestation, given that the risks of complications from medical abortions increase with gestational age. Similar results were found in a poll of the general public in Scotland.²²

Similarly, according to polling from February 2021, the ‘at-home’ abortion policy has raised significant concern among GPs:²³ 86% of GPs surveyed were concerned about women having a medical abortion past the legal limit of ten weeks’ gestation, a concern that was highest among female doctors (91%). 86% were concerned that women were at risk of being coerced into abortion by a family member or partner, and 87% were concerned that women were at risk of unwanted abortion arising from domestic abuse by partners controlling or monitoring their actions.

In sum, ‘at-home’ abortion has undermined healthcare for pregnant women and their unborn children by prioritising convenience over care. Its introduction has not fundamentally altered longer-term trends in abortion practice which were already trending towards earlier and increasingly medical abortion when viewed over a twenty-year period. Rather, the temporary provision has abandoned procedure, placing the health and safety of even more women in danger. Given the complications women have suffered at home since the implementation of this temporary order, as well as the inherent difficulties in verifying gestational age and detecting abuse or coercion, we publicly request that the ‘at-home’ abortion schemes in England, Scotland, and Wales are revoked with immediate effect in order to protect the health and welfare of women.

Yours faithfully,