To the Northern Ireland Health Minister Robert Swann,
We, the undersigned, firstly wish to remind you and your colleagues in the Department of Health of the widespread opposition from healthcare workers in Northern Ireland to the recent liberalisation of abortion legislation, and appeal again for politicians in Stormont to legislate against the anti-democratic and heavy handed actions of the Westminster Government. We lament the deaths so far of more than seven hundred unborn children through the existing medical abortion process.
We find it sadly ironic that, at a time when the whole of society is constraining itself to prevent sickness and death for our at-risk friends and family, there is a push to expedite the ending of the lives of its most vulnerable member, the unborn child. At a time when precious healthcare resources are being sidelined for the rightful and necessary treatment and prevention of COVID-19, it is foolish to set aside funding and resources for a form of treatment that provides no improvement in healthcare outcomes, indeed in many cases providing worse outcomes, and is essentially ideological in nature.1
We want to commend your Department on its clear statements concerning the dangers of taking both sets of abortion pills in a medical abortion outside of a clinical environment without direct medical supervision and without an ultrasound scan to verify accurate gestational age. In particular, we support the statement that ‘services should be properly delivered through direct medical supervision within the health and social care system’.2 We call on you to reject pressure from abortion advocates to legalise ‘at-home’ medical abortions outside of a clinical environment. Instead we urge you to increase and improve the medical, social, and financial supports available for women undergoing unplanned pregnancies. We will briefly outline our serious concerns regarding the safety and acceptability of the self-administration of medical abortions outside a clinical environment for women’s physical and mental health.
1. It is shockingly poor clinical practice. ‘At-home’ abortion services are an abandonment of procedure, not an alternative procedure. It is difficult, if not impossible, to properly assess the suitability of a patient remotely – there is no way of reliably confirming pregnancy or gestational age. Montgomery-compliant informed consent - the gold standard for ensuring that patients understand the reasons, risks, benefits, and long-term consequences of a procedure, including having enough time and information to make good choices3 – is exceptionally difficult to obtain remotely. Separating abortion from a clinical environment with direct medical supervision has led to the current situation where abortion providers in England, Scotland, and Wales – disturbingly – cannot ensure that the pills they prescribe are taken by the individual they are provided to within the appropriate time frame. For example, in an investigation led by public health consultant Kevin Duffy, a former Global Director of Clinics Development at Marie Stopes International, all twenty-six 'mystery shoppers' were able to acquire mifepristone and misoprostol using false names, dates of birth and gestational dates.4 In one case, pills were provided to a 'mystery shopper' who gave a date that could only have led to a termination beyond the legal 10-week limit for ‘at-home’ abortions.
The temporary provisions in England, Scotland, and Wales have already placed the health of many women and girls at risk, especially since there is no way to verify accurate gestational age via telephone without an in-clinic ultrasound. Furthermore, the concerns highlighted by the investigation and others have tragically become all too real. A leaked email from an NHS England and NHS Improvement Regional Chief Midwife on the ‘escalating risks’ of home abortion disclosed several incidents including potentially fatal ruptured ectopic pregnancies and resuscitation for major haemorrhage, that a woman at 32 weeks of pregnancy was able to receive ‘at-home’ abortion pills, and that there are three police investigations linked to late ‘at-home’ abortions, including a ‘murder investigation as there is concern that the baby was live born’.5 In addition, media reports in May 2020 revealed that the case of a baby aborted at 28 weeks using abortion pills at home was subject to a police investigation, and that 8 similar cases of ‘at-home’ abortions occurring beyond the ten week limit were under investigation by the abortion provider BPAS.6
2. It is unsafe for patients. This concerning trajectory of incidents is unsurprising given the evidence that there can be more complications from taking abortion pills than surgical abortions even in a supervised medical setting. A study of over 42,000 women receiving abortions under seven weeks’ gestation found that the rate of complications was four times higher in medical abortions than in surgical.7 A number of maternal deaths have been reported from uterine infection and undected ruptured ectopic pregnancy following early medical abortions, including from cases of septic shock.8
3. It puts vulnerable women at risk. In addition to increased risk of medical complications, self-administration removes the opportunity to ascertain if abuse or coercion is involved, as it is impossible to guarantee over the telephone whether an abusive party is present. 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 scandals.10 A 2014 study on the incidence of coerced abortion in abusive relationships found that one third of participants reported pressure to abort,11 whilst another study found that seven out of thirteen women in domestic violence situations experienced pressure to abort.12 Indeed, these very concerns were highlighted by the Health Minister Lord Bethell prior to his Government’s U-turn on the issue following pressure from abortion providers: ‘We believe that it is an essential safeguard that a woman attends a clinic, to ensure that she has an opportunity to be seen alone and to ensure that there are no issues… Do we really want to support an amendment that could remove the only opportunity many women have, often at a most vulnerable stage, to speak confidentially and one-to-one with a doctor about their concerns on abortion and about what the alternatives might be?’.13
4. The public doesn't want it. Polling suggests that ‘at-home’ abortion policies which remove current safeguards are not in line with the majority of British women’s views. 77% of women in a ComRes poll agreed that doctors should be required to verify in person that a patient seeking an abortion is not experiencing coercion,14 whilst another poll from ComRes showed 92% of women agreed that a woman requesting an abortion should always be seen in person by a qualified doctor.15 If women want more, not fewer, safeguards on abortion to protect from abuse, our Governments should surely reflect this in their policymaking.
Transforming homes into unsupervised abortion clinics has been a far cry from prioritising women’s physical and mental health. We do not believe it right to treat pregnant women, who may already be vulnerable to abuse and coercion, as the inaugural subjects of a science experiment in any part of the United Kingdom, including Northern Ireland.
Strikingly, several women across the United Kingdom have spoken out in public about their traumatic personal experiences of ‘at-home’ abortion. One particular nurse, having suffered extreme complications from an ‘at-home’ abortion that left her needing life-changing surgery, recently shared: ‘I’m actually quite shocked that the UK, with all of our research and expertise would approve this. . . It just feels like we are going backwards and that covid is an excuse to not treat women with respect.’16 Another woman commented: ‘You do pass a lot of blood and I was warned I might see the foetus, so I sat on the toilet and didn't look. I ended up lying in the bath trying to keep the pains at bay and I didn't get much sleep that night. It was a lot worse than I'd expected. The pain, the physical process was horrible’.17 A separate anonymous patient described how she thought she ‘was going to die’ on experiencing intense pain, cramps, vomiting and feverish symptoms after taking abortion pills at home. She was also unable to ring for advice in the presence of her partner, whom she described as ‘very controlling’.18 Such disturbing accounts of ‘at-home’ abortion should alarm all stakeholders in the healthcare of women across the United Kingdom.
In short, women and children in Northern Ireland deserve better care than these unsafe and unacceptable ‘at-home’ abortion schemes. It is our duty to provide the best possible medical holistic care, and to signpost to the best possible social, practical and financial assistance in their time of need, especially during the difficult times of an unplanned pregnancy. Rather than seeking to further liberalise our laws with the introduction of ‘at-home’ abortion, the Assembly should move to bring forward legislation to repeal the extreme abortion legislation imposed on Northern Ireland by Westminster as soon as possible, along with increased support for women in situations of unplanned pregnancy that provides for the needs of mother and child with full and appropriate provision for their physical and mental health.