I was recently asked: “…do we really want women to spend more time in the care of abortion providers? Why would we campaign for that?” This was asked in the context of the public consultation into the ‘Future Arrangements For Early Medical Abortion at Home’, currently being conducted in Scotland.
My answer is unequivocal:
“Yes, we must campaign that all women seeking a termination of pregnancy should attend a clinic as part of their care pathway”.
I know that for some this will seem wrong and counter-intuitive; I know that some want to abolish abortion and think it’s wrong to tinker at the edges to reform it but please, hear me out.
This consultation in Scotland, and the one(s) which will follow in England and Wales, do not present an opportunity to debate the legal access or right to an abortion, but rather will be used by the Government to elicit public views on whether or not to make permanent the current COVID-19 arrangements, which allow a woman to self-administer both pills for early medical abortion at home after a remote telemedicine consultation and without needing to visit the clinic.
The critical question being asked is: How should early medical abortion be provided in future, when COVID-19 is no longer a significant risk? [select one of the options below]
a) Current arrangements (put in place due to COVID-19) should continue – in other words allowing women to proceed without an in-person appointment and take mifepristone at home, where this is clinically appropriate.
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.
c) Other (please provide details).
Let’s be very clear, if we do not campaign for answer b) or c) above, then the status quo will rule and the current DIY, abortion at home telemedicine regulations will become permanent – and none of us want to see that.
There are compliance issues and potential risks of harm from solely relying on telemedicine before enabling a woman to self-manage her abortion at home. In recent months, there have been a number of press pieces telling how women have suffered; witness statements given in court, a leaked NHS email, and official data from the DHSC have all highlighted compliance and safety issues.
There are two aspects of the clinic visit which we need to consider and then judge if these are worth campaigning for:
- When using telemedicine, abortion providers are solely relying on their clients’ accurate and honest self-assessments of the gestational age of their pregnancies and declarations of their relevant medical history. It is so much better when, during a clinic visit, the abortion provider makes a professional, clinical assessment of each woman’s eligibility for early medical abortion at-home.
- It is much easier to uncover issues of coercion or abuse when client and provider are sitting together face-to-face. It is essential that every woman who is considering and presenting for an abortion, has the opportunity to receive client-centred counselling, during which she can engage with her own personal issues and have time to consider all of the options open to her.
After listening to more than 80 calls between our Mystery Client Survey volunteers and abortion providers, I am not persuaded that telemedicine providers are discussing options and there’s certainly no significant effort to explore the circumstances and issues which have led their client to them on the day. Telemedicine providers are all too often simply following a set script of questions, and rarely actually respond to the woman presenting to them.
The level of client-centred interaction is so much better when face-to-face in the clinic. I was told a few days ago:
as many as 17%, one-in-six, women who present at a BPAS clinic decide not to proceed with the abortion.
Campaigning for even better client-centred counselling in-clinic as part of the abortion care pathway is worthwhile if it means that all women will get the quality of personal care they deserve and some women may, as a result, decide not to proceed with an abortion. This essential client-centred counselling will be lost if the DIY regulations become permanent.
We should campaign for a mandated return to the previous arrangements in which a woman must visit a clinic for a professional assessment before being consented and prescribed an early medical abortion at-home. Telemedicine has a part to play in the overall process; it is appropriate and time-saving to use the telephone for the initial contact, to gather some basic information and client data, and to make the appointment for the clinic visit. The telephone is also the most appropriate means of post-abortion follow-up, and we should be campaigning for such outbound calls, from the abortion provider to each of their clients, to be mandated in the approved guidelines.
Campaigning for reform, for a return to clinic-based abortion care, might be unappealing but that does not mean it is the wrong thing to do.