How the pandemic revolutionised abortion access in the UK.

This is my response to an article in the New Statesman on December 15th, 2020. My main concern is the assertion that abortion has become safer since the introduction of telemedicine in April. The article states that there has been just one complication in more than 23,000 abortions at home, and that is clearly wrong, I suggest that this number must be closer to 17, and that the rate of complications has not changed.

The headings below are clipped directly from the article.

Based on previous years’ data, we might expect at least 17 complications from 23,000 abortions, rather than just the one reported by the DHSC and referenced by the New Statesman. DHSC reports complications based on the data included by the abortion providers on the HSA4 forms submitted at the time of patient discharge. The noted drop in complications rate could be a result of timing, with the HSA4 forms now being completed before the self-administration of the abortion pills.

If the healthcare professional indicates any potential risk factors…

What needs to be understood about telemedicine is that healthcare professionals, when providing abortion by telemedicine, are reliant on their clients’ accurate and honest self-assessment and self-reporting of their medical history, current health status, and the first day of their last period. In our mystery client investigation, 26 out of 26 clients were able to obtain the abortion pills by post, for self-administration at home, even though all of the data they provided was generated specifically for the purposes of the investigation.

By June, more than half of all abortions took place at home…

We started making our calls in June and it became clear very early into our investigation that the default option being offered was pills-by-post, rather than an in-clinic consultation. This was to be expected given the COVID-19 lockdowns and the closure of some clinics, which after all was the reasoning behind the Secretary of State’s approval at the end of March. However, a close look at DHSC data for April-June shows the following:

Only one in every two women eligible for pills-by-post were actually offered or chose this option.

47,000 eligible women, 23,000 taking pills-by-post and 24,000 attending an abortion clinic.

Even with the approval for telemedicine abortion at home, and the noted trend towards earlier gestational age, only 43% of women having an abortion did so without first attending the clinic.

After approval of at home abortion, there were still more abortions which required in-clinic consultations than those fulfilled using telemedicine.

… a pregnancy could pass on the way home.

Before the COVID-19 emergency, women were already permitted to take the misoprostol, the 2nd part of the abortion treatment, at home after first taking the mifepristone at the abortion clinic. One consideration could be to revert to the prior arrangements in which women have to first have a professional assessment at the abortion clinic and then permit both tablets to be taken at home for those who prefer to do so. This would also overcome the noted difficulties around time off work and childcare.

The key issue being addressed in the ongoing government consultations is not necessarily about where the expulsion of the embryo takes place but is about the importance of the in-clinic consultation and the need for professional assessment of the woman’s eligibility and suitability for early medical abortion at home.

Data provided by the British Pregnancy Advisory Service (BPAS).

Any reduction in the harm caused to women by abortion is to be welcomed. It would be very helpful if BPAS was to make its full dataset available in the public domain, to enable peer review and independent analysis. Some of the reported results are at odds with its own website and official clinical data which indicate e.g., 3 incomplete abortions per 100 at 9 weeks and below when using these abortion pills.

…abortions are occurring earlier…

In Q2 2020, we find that during the COVID-19 lockdown provisions for abortion at home, there was a notable increase in the percentage of total abortions occurring at less than 10 weeks gestational age, though this trend had started in earlier years and is not directly attributable to this approval.

More interesting is the trend towards abortions at GA of less than 7 weeks.

2019 Q12019 Q22020 Q12020 Q2
3 – 636%40%43%57%
7 – 943%42%41%32%
<1079%82%84%89%
10 – 20+21%18%16%11%

There’s no doubt that waiting times are reducing and that abortion is happening earlier in the ‘reported’ gestation which, for most women, will mean a safer and less traumatic procedure. As noted above, when using telemedicine, abortion providers are reliant on women’s accurate and honest disclosure of their LMP to establish the gestational age of their pregnancies. Some women might get this wrong and some, like our mystery clients, might choose to mislead the abortion provider.

Another perspective might be that women are making their decision to have an abortion too quickly. Telemedicine consultations will typically involve no more than one hour of discussion on the phone between the woman and her abortion provider and only a few days between her first call and receiving the abortion pills at home.

A week or so of delay to take more time for client-centred counselling and consideration of other options would have very little impact on the time-sensitive safety elements associated with the abortion procedure but could have a valuable impact for some women who are considering a termination.

…after the 23,061 abortions performed between April and June… only one complication has been reported.

Every year 300+ women suffer abortion complications, including haemorrhage, sepsis, and uterine perforations. Is it possible that this year the number of complications will be less than 200? The ‘complications rate’ for early medical abortions has been 0.74 per 1,000 abortions for many years and so why would it suddenly drop by a factor of 17 times to just 0.043 per 1,000. (1/23,000)

Could this really be because abortion at home is so much safer than when the same medications are administered in a clinic setting?

Of course not, and even suggesting that is ridiculous.

So, what is happening?

My analysis is that the reason the DHSC is showing just one complication from 23,000 abortions is because of under-reporting by the abortion providers. The official HSA4 forms are being completed and submitted by abortion providers to the Chief Medical Officer before the self-administration of the abortion pills and so there are no complications to be recorded.

Abortion Providers tell women using telemedicine abortion at home  to decide for themselves if they need medical help.

“If you ever feel out of control with the pain or the bleeding or anything like that, you need to get yourself to hospital because they’ll be able to help you there, okay?”

BPAS Abortion Provider speaking with Anna

These complications are not being included on the HSA4 forms and are thus not being reported in the official DHSC data. I’ve written about this in full here.

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