Dr Jonathan Lord, medical director at MSI Reproductive Choices, reports to The Guardian that he is aware of up to 30 “deeply traumatic” cases where women have been investigated by the police, after being accused of managing their own illegal abortion, with some suffering “life-changing harm”. For me, there is little doubt that these heart-rending stories will be front and centre when it comes to the next abortion decriminalisation debate, now expected in Parliament during February.
Lord thinks that NHS healthcare professionals are responsible for the recent increase in the number of police investigations. He and his work colleagues have, on behalf of the Royal College of Obstetricians and Gynaecologists, published a new guideline reminding these professionals that there is no obligation to report a crime and warning that “they must abide by their professional responsibility to justify any disclosure of confidential patient information or face potential fitness to practice proceedings.”
Announcing this new guideline, Dr Ranee Thakar, President of the RCOG, said: “We firmly believe it is never in the public interest to investigate and prosecute women who have sought to end their own pregnancy. These women should be treated with care and compassion, without judgement or fear of imprisonment.”
We will hear a lot more of this ‘Compassion not judgement’ in the lead up to the debate. We should not shy away from these stories nor deny the reality of the trauma suffered by these vulnerable women, even if the numbers are small and even if the law has been broken.
In lobbying for reform, I am considering these three points:
Patient confidentiality
I agree, healthcare professionals must protect patient confidentiality, even if this means not reporting a woman to the police when an illegal abortion is suspected. I take this position because I would also not expect, nor approve of, a counsellor at a Crisis Pregnancy Centre reporting a client who discloses having had an illegal abortion.
Crown Prosecution Service guidelines
In response to The Guardian, a CPS spokesperson said: ““These exceptionally rare cases are complex and traumatic. We carefully consider the personal circumstances of those who end their pregnancy outside the legal parameters and address these as sensitively as possible.”
They need to try harder; the presenting problem in each of the harrowing stories cited by Lord et al, is the trauma caused by the heavy-handed and insensitive approach taken by the police and courts. We should expect the authorities to update investigation, prosecution, and sentencing guidelines in response to these claims of harm; improving how cases are handled is a much safer approach to improving care for these vulnerable women, compared to the unintended consequences of abortion decriminalisation.
Medical regulation
Thakar and Lord suggest that abortion needs to be removed from criminal law and placed under medical regulation. That is interesting, because surely abortion is already a regulated medical procedure, even if some of the existing regulations are not followed or enforced.
I have said many times that I think the best solution to the problems cited by Lord would be to rescind the approval of telemedicine abortion and pills-by-post. Whilst we wait for that, here are two regulations that could help in reducing the number of later-gestation self-managed medical abortions, and thus in turn reduce the number of women being investigated.
Gestation greater than expected
Lord says some women who had been investigated had been later in their pregnancy than they realised when they had terminations. Now we have to assume that he is not referring to abortions provided by MSI-RC at one of its facilities; these are most likely to be cases of self-management at home, using pills-by-post after 10-weeks gestational age and due to complications arising, the women have presented at a local NHS hospital. In the past we have seen such cases of gestation greater than expected, GGTE, having been reported to the Care Quality Commission.
The RCOG should update its guidelines to remind professionals that they must report GGTE to the CQC; they can do so without breaching patient confidentiality and this would help regulators to better understand the scale of the problems arising from the self-administration of abortion pills after the safer and legal limit of 10-weeks. After all, the RCOG’s own guidelines endorse the World Health Organisation guidance that self-management after 12-weeks is unsafe and not to be recommended.
Good faith opinion
Department of Health and Social Care guidance says: Certifying registered medical practitioners are expected to have enough evidence to justify that they were able to form a good faith opinion that, if the medicine prescribed for the termination of the pregnancy is administered in accordance with their instructions, the pregnancy will not exceed 10 weeks at the time when the first early medical abortion pill is taken. When questioned about this,
Maria Caulfield, Parliamentary Under-Secretary (DHSC) noted: “If there is any uncertainty about the gestation of the pregnancy, the woman should attend an in-person appointment. If she does not attend in-person, the doctor would not be able to form an opinion in good faith that the pregnancy is below 10 weeks gestation and therefore would not be able to prescribe abortion pills for home use.”
Effective enforcement of this regulation and taking action against any doctors who are found to prescribe pills-by-post beyond 10-weeks GA, would result in fewer women using these pills at later gestations and subsequently presenting with complications at an NHS hospital, and so fewer cases that might need to be investigated either by the police or the regulators.
Percuity 