Jonathan Lord and Louise McCudden: We strongly reject claims about the dangers of at home abortions

23 Jul

Jonathan Lord is a consultant gynaecologist in the NHS and Medical Director of MSI Reproductive Choices UK, and Louise McCudden is an Advocacy and Public Affairs Adviser at MSI Reproductive Choices UK.

In March 2020, with Covid-19 limiting health service access, the Government made a bold but sensible decision: across England, Scotland, and Wales. It was agreed that both mifepristone and misoprostol, instead of only the latter, would be approved for home use.

These are the two medicines used in abortion care. In other words, early medical abortion could now be completed at home, following a telephone consultation with a clinician. This service, known as telemedicine, has now been running smoothly for over a year. Numerous peer-reviewed studies hail it as a success.

This week, Dr Melody Redman made a series of claims about the service on ConservativeHome: that clinicians oppose the service, that women don’t want it, and, perhaps most egregiously of all, that abortion providers are relaxed about offering a service which jeopardises safety. In all these assertions, Dr Redman is mistaken.

First of all, telemedicine wasn’t suggested by the sector merely as a response to Covid-19. This has long been the direction of travel in abortion care. Dr Redman cites 600 medics expressing concerns about telemedicine. But conspicuous by their absence from her article are the official views of bodies like the National Institute for Clinical Excellence (NICE), the Royal College of Obstetrics and Gynaecology,) and the Royal College of Midwives. These bodies recommend telemedicine. NICE calls it “an improvement” in abortion care.

Peer-reviewed studies show that telemedicine is safe, effective, and often preferred. As far as complications go, studies suggest that telemedicine, if anything, results in a small drop in complications. This could be because telemedicine reduces waiting times, so more treatments happen at an earlier gestation. Abortion is a common, safe procedure with a low complication rate in general, but it’s still true that the earlier the gestation, the safer it is.

It’s not only clinical bodies that back telemedicine. Dr Redman may well be sincere in her safeguarding concerns. But it’s no surprise to us, seeing the service operate up close, that End Violence Against Women Coalition, Rape Crisis England and Wales, and the Women’s Aid Federation of England agree telemedicine should stay.

Many vulnerable clients benefit from the option of telemedicine. For instance, there are women in abusive households who can safely receive discretely packaged abortion medicine at home but can’t safely attend a clinic. As predicted by safeguarding experts, the availability of telemedicine coincided with a drop in online pill sales from informal, unregulated providers – and during the pandemic, countries with no regulated “at home option saw a rise in these sales. Being forced to buy pills from these sources can mean abortion with no safeguarding, no counselling and no aftercare at all – and, shockingly, a risk of life imprisonment.

MSI UK’s safeguarding team members are deeply conscientious, highly skilled professionals. We would never support telemedicine if it hindered our ability to protect vulnerable clients. Dr Redman implies, by reminding readers that we are a “leading abortion provider”, that MSI isn’t an impartial voice in this debate. It’s true that as a provider, we’re not impartial on the question of abortion rights. We are unapologetically pro-choice, and we are proud to be a leading abortion provider. That doesn’t make us biased; it means we know what we are talking about.

Dr Redman is right to say that domestic abuse, including reproductive coercion, has risen during the pandemic. But she only mentions the dangers of forced abortion. It is more common to be coerced into keeping a pregnancy than ending one. As an unapologetically pro-choice organisation, we fight all reproductive coercion. No credible analysis of reproductive coercion or any other form of domestic abuse concludes that a sensible solution would be greater barriers to reproductive healthcare. The best way to fight reproductive coercion is more choice, more autonomy, more privacy, and more flexibility in access, not less.

As for the claim that 92 per cent of women want to be seen in person, this is not what peer-reviewed studies show, and nor is it what we hear from our clients. When those using the service were surveyed, two thirds said they preferred telemedicine, regardless of Covid-19 (when we factor in Covid-19, that rises to 80 per cent). But in any case, even if the figure were true, why remove the option? With nine in 10 adults describing themselves as pro-choice, this is, or should be, a clinical decision, not a political one. We don’t say telemedicine is right for everyone. We simply want to offer choice.

The truth is, theres consensus among clinicians and regulators that telemedicine is safe, compassionate, and it is often preferred. It’s more efficient for the health system as a whole, despite providers still offering a full pathway that includes safeguarding, counselling, and aftercare. No matter the obfuscations and rhetorical insinuations of those who disapprove of at home abortion, there are simply no clinical or safeguarding justifications for taking the choice away.

Melody Redman: Abortions at home must only be a temporary measure

17 Jul

Dr Melody Redman is a clinical genetics registrar, with a background in academic paediatrics.

In March 2020, temporary provisions were introduced to permit women in the first 9 weeks and 6 days of pregnancy to take both medical abortion pills at home. The pills are sent through the post, after a remote consultation with an abortion provider. Prior to this, the administering of the first of the two required pills for medical abortions could only take place in approved hospitals or abortion clinics.

This emergency ‘at-home’ abortion scheme was introduced because of fears about limited in-person access to clinics during the coronavirus pandemic, with the mantra at the time being ‘Stay Home and Protect the NHS’. The UK, Welsh, and Scottish Governments have recently undertaken consultations on whether to end these measures or make them permanent, and the publication of their respective decisions is imminent.

Unsurprisingly, this push to permanently permit ‘at-home’ abortion has been spearheaded by the UK’s two largest abortion providers: MSI Reproductive Choices (formerly Marie Stopes) and the British Pregnancy Advisory Service, who are lobbying for the scheme to be made permanent. Given that 59.3% of UK abortion clinics are rated by the Care Quality Commission as ‘Requires Improvement for Safety’, how then can we trust them to ensure the safety of women ‘at-home’?

Last month, I along with over 600 other medics signed an open letter demanding an end to the scheme. Our letter expressed grave concerns over examples of the pills being used beyond the 10-week limit for home medical abortions, and in some cases after the 24-week legal limit for surgical terminations. The letter also highlighted a string of other safety and safeguarding issues related to issuing abortion pills without a face-to-face consultation.

Indeed, ‘at-home’ abortions rely on women accurately remembering the first day of their last period, which only around 50% of us do. This date is then used to estimate how far through the pregnancy the woman is. The Department of Health & Social Care has confirmed that pregnancies beyond the legal limit for ‘at-home’ abortions are being terminated at home, putting women at higher risk of complications.

It appears that data on the effects of ‘at-home’ abortions is being significantly and systemically under-reported. A Freedom of Information (FOI) request to the Care Quality Commission revealed that between April and November 2020, 11 women using the scheme, who had a gestational date beyond the legal limit for early medical abortion, required hospital treatment for complications. FOI requests have similarly since shown women suffering from serious issues (including sepsis, haemorrhage, and trauma to pelvic organs) after taking the pills.

Worryingly, an undercover investigation (led by a former director of MSI Reproductive Choices) revealed the lack of basic checks carried out by abortion providers before issuing pills-by-post. The investigation saw volunteer clients being sent abortion pills despite using false identities and gestational dates, including a date that could only have led to an abortion beyond the legal limit for ‘at-home’ abortions.

The removal of a mandatory in-person consultation also hinders clinicians’ abilities to flag up signs of coercion and abuse. An alarming seven per cent of British women have been pressured into an abortion by their partner or husband, a figure that likely increased under lockdown, during which there was a 49% increase in calls to domestic abuse services.  This is a serious concern; 87% of GPs are worried about ‘unwanted abortion arising from domestic abuse’ when no in-person consultation is required.

As a doctor, I know that telephone consultations can work well for some things, but there are huge limitations. I cannot control the environment on the other side of the phone, unlike in a safe clinic space. I cannot tell if my patient is next to an intimidating partner. I cannot ‘eyeball’ them to see if they appear frightened, have a black eye, or are heavily pregnant. Abortion consultations are not as simple as phoning your GP for advice on your reflux. They are intimate and challenging discussions, with life-changing physical and psychological ramifications.

Savanta ComRes polling of the general public reveals a high number of serious concerns. We are so often told to simply ‘trust women’ when it comes to liberalising abortion laws. Why then should we ignore the 92% of women who agreed that a woman seeking an abortion should always be seen in person by a qualified doctor?

‘At-home’ abortions were a hasty, temporary measure, introduced at a time when it was feared women should not attend an abortion clinic. This should not be a permanent solution. When making the difficult decision to pursue an abortion, we must be sure that women get a face-to-face consultation. Let us give women the space, the safety and the specialist assessment they deserve. I therefore implore the Government to bring this temporary policy to an end with immediate effect.

Sally-Ann Hart: ‘DIY’ home abortion puts women and babies at risk, and ministers should end it

29 Jan

Sally-Ann Hart is the MP for Hastings and Rye and was a councillor in Rother.

The Department of Health and Social Care (DHSC) recently launched its public consultation on whether to make home use of both abortion pills a permanent measure in the UK.

‘At-home’ abortions – which the media and critics have termed ‘DIY’, or ‘do-it-yourself’ abortions – were introduced on 30th March 2020 in the most radical change to abortion law since 1967. After a phone call with an abortion provider, women can now be sent Mifepristone and Misoprostol pills to take at home without direct medical supervision in order to end their pregnancies.

Originally sanctioned as a temporary measure to reduce transmission of Covid-19 during the pandemic, abortion campaigners and providers are pushing to make ‘at-home’ abortions permanent.

But given the risk of serious complications, coercion from abusive partners, and inability to verify gestational age over the phone, the Government should immediately withdraw the temporary order. Should it and the consultation continue, however, I can only hope we see the concerns of those responding to the consultation taken seriously by our Government.

Before reviewing the serious complications that have occurred in relation to ‘DIY’ home abortion, it is prudent to refute recent claims in the New Statesman of a relative lack of medical complications for ‘DIY’ home abortion. Indeed, this article rather serves to highlight the serious problem of systemic underreporting of such issues.

DHSC data show only one complication following ‘DIY’ home abortion from April to June this year for the whole of England and Wales. Unbelievably, this would mean that the average rate of complication for medical abortions at a similar gestation over the past five years was over seventeen times higher than the complication rate for ‘DIY’ home abortions earlier this year. This is not only highly unlikely – that complications would radically reduce in a home setting versus a medical setting – but, some may say, ridiculous.

Indeed, evidence from a Freedom of Information (FOI) request demonstrates clearly the current issues related to reporting complications when abortions take place outside a clinical setting. The data from the FOI request shows seven women were admitted to University Hospital Lewisham alone for complications following medical abortion between the end of March and the beginning of September this year.

If both Departmental and hospital records were true, this is a shocking leap from just one complication nationwide in the three months from April to June to a further six complications in the same locality in the two months from July to September. There is either a serious problem with sharply rising complications in Lewisham since the end of June, or a substantial issue with the overall quality of reporting and recording the real impact of medical abortion on women’s health when abortions take place at home.

Serious complications can certainly arise when abortion is removed from a clinical environment. One Swedish study from 2018 of almost 5,000 induced abortions over eight years (from 2008 to 2015 inclusive) found that the complication rate for medical abortions before 12 weeks’ gestation almost doubled from 4.2 per cent in 2008 to 8.2 per cent in 2015, concluding that the significant surge in complications “may be associated with a shift from hospital to home medical abortions.”

Requiring the first pill to be administered in a clinic provided essential safeguards for women, not least as it allowed for an in-person examination or ultrasound to verify whether a woman was too far along in her pregnancy to be prescibed a medical abortion.

Tragically, we have already begun to see the effects of the absence of such safeguards. Police have been investigating the death of an unborn child who was aborted at 28 weeks – four weeks past the legal limit for surgical abortion and a shocking 18 weeks past the limit for abortions at home. Notably, abortion provider BPAS stated they were investigating the case along with eight other known incidents of babies who were aborted past the 10 week legal limit for ‘at-home’ abortions.

Only this year, a study (funded by NICE) found that for later gestational dates, greater dosage of misoprostol may be required to achieve a complete abortion. As such, there ‘may be more pain or bleeding associated with the expulsion of a larger/later pregnancy’. This clearly highlights a need for accuracy in determining gestational age, particularly if the woman expels the pregnancy at home.

Further concerns are highlighted by a leaked NHS email from a Regional Chief Midwife on the ‘escalating risk’ around the ‘pills by post’ service in May 2020, which revealed that a woman received abortion pills at 32 weeks of pregnancy. The email goes on to note that there were 13 incidents under investigation linked to ‘at-home’ abortions, and “3 police investigations”, one of which “is currently a murder investigation as there is a concern that the baby was live born.”

If such troubling incidents occurred within weeks of the ‘DIY’ home abortion ruling, making it a permanent feature of our healthcare system would clearly be a disservice to women in the UK.

In addition, many women in domestic abuse situations may be coerced by their partner into having an abortion. If we remove the requirement of a face-to-face consultation, there is no guarantee that a patient can speak freely without the coercive party listening in. Indeed, Health Minister Lord Bethell iterated these concerns on behalf of the Government when the Coronavirus Bill was brought to the House of Lords on 25 March, recognising 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 having an abortion by an abusive partner.”

Furthermore, if a woman is in a domestic abuse situation, leaving her to perform her own abortion at home only helps her abuser by enabling her to remain in an abusive situation.

Accounts from women of their experience of the ‘pills by post’ system should further compel the Government to immediately suspend this temporary order. For example, a nurse who suffered extreme complications from ‘DIY’ home abortion that left her needing life-changing surgery disclosed that she experienced ‘excruciating pain’, and heavy bleeding that continued for ten days after the abortion. Claiming Marie Stopes failed to provide follow up care, she also shares: “I’m actually quite shocked that the UK, with all of our research and expertise would approve this”.

In addition to physical complications, other women have expressed concern at the ease and speed with which they were able to acquire these life-changing pills. One woman describing her experience stated: “I wasn’t ready. It all seemed so fast. I was expecting to speak to lots of people, to be offered counselling.” Yet ‘greater capacity’ and ‘shorter waiting times’ have been lauded by proponents of ‘at-home’ abortion as prime reasons for extending the scheme, perhaps due to the notion that telemedical abortions free up NHS resources.

This is the kind of language used to discuss routine health appointments and hip replacements; that this narrative is currently being used to frame the life-changing decision to abort a child – the termination of a human life – is truly disturbing. Tragically, this same language is replicated in the newly launched UK public consultation, where participants are encouraged to reflect on ‘at-home’ abortion services in the context of ‘workforce flexibility, efficiency of service delivery’ and ‘value for money’.

Opposition to ‘DIY’ abortion schemes is widespread across the UK. Hundreds of healthcare professionals recently signed an open letter to the Health Minister of Northern Ireland to highlight the dangers of removing essential safeguards around abortion. Additionally following the launch of the Scottish Government consultation on ‘at-home’ abortion in October, Chairman of the Scottish Council on Bioethics Dr Antony Latham highlighted the increased health risk if ‘DIY’ home abortions are introduced on a permanent basis, stating ‘significant bleeding and sepsis are not uncommon.’ He further notes that the removal of in-person consultation opens the door for abortion coercion.

Finally, polling suggests that in-person assessment during the abortion process is highly valued by women in the UK; in one poll 77 per cent of women agreed that doctors should be legally required to verify in person that a patient seeking abortion is not being coerced, while another poll showed that 92 per cent of women agreed that a woman seeking an abortion should always be seen in person by a qualified doctor.

‘At-home’ abortions are not safe, and must not be euphemised as abortion ‘care’. Contrary to representation from abortion activists and providers, extending the ‘at-home’ abortion policy is not a given, and the public consultation has been launched with the option to ‘end immediately’.

Safe and effective healthcare is central to our British values: this irresponsible policy must be revoked before more lives are put at risk. I encourage all reading this to respond to the consultation – and select ‘end immediately.’

Neil O’Brien: Why closing the marriage gap between rich and poor is a vital mission for social justice

27 Jul

Neil O’Brien is MP for Harborough.

Our daughter just had her last day at nursery. In the autumn she’s off to school. We’re sponging second-hand uniform from friends. It feels like just the other day I was driving home after her birth, flakes of snow streaking through the headlights.

Our baby son can suddenly crawl fast. He wants to climb the stairs, and chew any bits of cardboard he finds lying around.

My sister has unearthed a trove of old black and white family photos. There’s lots of things that catch the eye: Glasgow’s housing estates looking shiny and newly-built; the funny looking cars; the endless cigarettes. The bigger families too: my gran with her two children from before the war, and two after.

It set me thinking about family. Ten years ago we talked about it a lot. David Cameron’s criticism of “Broken Britain” highlighted work by the Centre for Social Justice on family breakdown and poverty. The most eye-catching pledge during his leadership campaign was a marriage tax break.

Over the last five years there’s been a lot of other things doing on, to say the least.  But as the new government starts to set out its domestic agenda, family should be part of it.

Politicians are nervous talking about family. It’s not just bad memories of the 1990s, when we screwed up and sounded like moralising hypocrites against a backdrop of sleaze.

It’s a deeper fear of sounding critical of friends and relations. We all have close friends who have been through everything: raising kids alone, divorce, abortion, bereavement and so on. I think of a friend who has raised two wonderful kids alone. Another single friend helped look after a young person when no-one else would. I don’t know how anyone manages to do it single-handed: they’re amazing people.

Some worry family policy will be about condemning them, or that politicians want to try and trap unhappy couples together. It mustn’t be about either. Instead, it has to be about two different things.

First, helping people with children financially, and with practical help, particularly during the difficult years with small children. Having no money on top of no sleep and endlessly crying babies makes it harder to sustain relationships.

Second, it should be about support and building up the social capital that many middle class people in politics take for granted. Indeed, it’s about healing a split in our society.

Let me explain.

Politicians who are serious about reducing poverty and spreading opportunity can’t avoid thinking about families and households.  Last year 23 per cent of children in couple households were below the fixed poverty line, after housing costs, compared to 38 per cent of children in lone parent households.

Controlling for other factors, A CSJ report found those who experience family breakdown when aged 18 or younger are twice as likely be in trouble with the police or spend time in prison, and almost twice as likely to underachieve educationally. They’re more likely to suffer mental health issues.

One part of family policy should be direct help families with children. I’d love to see us recognise children in the tax system, as we did until the 1970s: our tax system is unusually family-unfriendly. We should help working families with children on Universal Credit keep more what they earn before it gets tapered away. The CSJ has called for higher child benefit for parents of young children.

But we need to go deeper, and recognise that the links between family breakdown and low income run in both directions. Over recent decades a quiet revolution has taken place, and richer and poorer people now live in very different family structures.

Between 1979 and 2000, the proportion of households with dependent children which were lone parent households grew from 11 per cent to 25 per cent, then remained at that level, dipping a bit in recent years to 22 per cent in 2019. Since 1979, the proportion which are married couples fell from 89 per cent to 61 per cent.

There are few countries in Europe where children are less likely to live with both parents than Britain. It’s more likely that a teenager sitting their GCSEs will own a smartphone (about 95 per cent) than live with both parents (58 per cent).

But these headline stats conceal a massive social split, which starts at the point of birth and widens out.

For those in the top socioeconomic group, 75 per cent of children are born to parents who are married; another 22 per cent are jointly registered to parents cohabiting; 2 per cent are jointly registered to parents living apart, and just 1 per cent registered by one parent only.

At the bottom end of the scale, 35 per cent are born to married parents, 38 per cent to cohabiting parents, 21 per cent jointly to parents living apart and 6 per cent registered by just one parent.

These huge differences weren’t always there. For people at the top, family life looks similar to their parents’ generation. For people on lower incomes, society looks utterly different. A marriage gap has opened up, and society has been splitting apart into different family structures for rich and poor.

In the 1970s, mothers of pre-school children were equally likely to be married whether they had a degree or not, and 90 per cent plus were. By 2006 for mothers with a degree that was down to 86 per cent, but for non-graduate mothers it fell to 52 per cent.

Between 1988 and 2018 the proportion of jointly registered births which were to married parents fell from 90 per cent to about 77 per cent for the top socio-economic group. At the other end of the scale it fell from 70 per cent to 37 per cent.

Equally, it’s impossible to understand modern Britain without appreciating the different families people from different ethnic groups live in.

In 2011, among households with dependent children, for white households 53 per cent were married couples, 16 per cent cohabiting couples, 25 per cent lone parents, and 7 per cent other household types (mainly multigenerational households).

Among Indian households with dependent children, far more were married couples or multigenerational households.  68 per cent were married couples, 2 per cent cohabiting couples, 9 per cent lone parents and 21 per cent in multigenerational households.

Among black Caribbean households 28 per cent were married couples, 11 per cent cohabiting couples, 47 per cent were lone parents and 14 per cent in multigenerational households.

People of different ethnicities live in very different families, which influences everything else.

Most voters favour government taking action to support family life. But in Whitehall there’s scepticism: can the state do anything about these trends?

The truth is we don’t really know. As it happens, at the point when government stopped publishing its measure of family stability in 2016, the trend seemed to be moving back a little towards more children living with both parents.

Whitehall can be too pessimistic. Until Michael Howard, the consensus was that nothing could be done about rising crime. He proved the consensus wrong. Likewise, in the 1990s Whitehall had given up on helping lone parents into work. But successive reforms (under governments of all parties) doubled their rate of employment.

It’s not like there’s no ideas about how to help.  There’s masses and masses of recommendations gathering dust on think tank shelves, covering everything: tax, benefits, family hubs, relationship education in schools, birth registration, pre-and postnatal support…

My modest proposal is this: let’s do a major programme of controlled trials to test these ideas, and see what, if anything, makes a difference. Happily for the Treasury, experiments are cheaper than rolling things out nationally.

But we have to try. The costs are too high not to. They say the best time to plant a tree is 20 years ago, but the second best time is today. Let’s plant some seeds.