The way early medical abortions are conducted was amended as a result of the COVID-19 pandemic. From the end of March 2020, eligible women were able to take both pills required for an early medical abortion (EMA) in their own homes following a telephone or video consultation with a doctor or nurse, and without the need to first attend a hospital or clinic for an in-person appointment. Both pills could either be collected from a clinic or local pharmacy, or be delivered to the patient. After six months of operating these new early medical abortion at home (EMAH) procedures, the Scottish Government launched a public consultation, seeking views on whether the arrangements should be made permanent, or whether it would be preferable to revert back to the previous arrangements.
In total, 5,537 substantive responses were received and analysed. This included 5,465 responses from individuals and 72 from organisations. Several campaigns were run, largely by pro-life organisations, plus one pro-choice campaign co-ordinated by a few different organisations. The largest campaign was run by Right to Life and generated 2,780 standard responses, accounting for approximately half of all responses.
Impact of the Current EMAH Arrangements on Women
Respondents were asked to comment on the impacts of the current EMAH arrangements on safety, accessibility and convenience of service, and waiting times for women.
|All Respondents||Excluding Right to Life Campaign|
|Safety||Accessibility & Convenience||Waiting Times||Safety||Accessibility & Convenience||Waiting Times|
Across all measures, most respondents felt that the impacts were negative, with around two thirds to three quarters of all respondents giving this rating. However, the results were more mixed when the Right to Life standard campaign responses were excluded, with more equal proportions suggesting the EMAH arrangements had a positive or a negative impact across each measure.
Most of the safety concerns centred on, or resulted from, the lack of any in-person appointments. It was felt this could limit/complicate opportunities to:
- Confirm the identity of the patient and that they have a safe home situation to undertake the procedure;
- Assess mental health or emotional issues, and identify any potential medical complications (for example, ectopic pregnancies);
- Identify abuse or coercion generally, or to detect forced abortions;
- Confirm gestational age to establish eligibility for EMA; and
- Assess the patient's understanding of the procedure, their expectations and the risks for potential longer term emotional impacts.
There was also a strong sense that the EMAH approach did not provide the necessary levels of safeguards for the patient's emotional wellbeing, and could leave them isolated, making the procedure more traumatic.
Both the convenience and the reduced waiting times were also felt to have had a negative impact by some. They considered that the ease of access trivialised the procedure, with respondents worried that women may not fully understand/ appreciate the potential trauma and long-term impacts involved. Others were concerned that women may feel more rushed into making the decision and taking the medication, and not given/take the time to seek information on alternative options.
Conversely, those who felt the EMAH arrangements had a positive impact argued that this improved accessibility and reduced waiting times, which in turn allowed the procedure to take place at an earlier gestation. It was highlighted that earlier intervention reduced the risk of complications and made it safer for women. Reduced waiting times were also felt to have a positive impact on women's mental health as it reduced anxiety over that period, while not having to attend a clinic/hospital meant that women could avoid any pro-life campaigners who were outside clinics. Overall, it was felt that being able to conduct the entire procedure from home reduced the anxiety, stress, stigma, and trauma experienced by women when accessing abortion services.
It was also suggested that the EMAH arrangements often facilitated safer access to services for women in abusive/coercive relationships by making the process more discrete, private and confidential. Some also indicated that women may be more likely to disclose abuse from the comfort of their own home compared to the formal setting of a clinic or hospital.
Accessibility barriers, both financial and physical, were also considered to have been removed by EMAH arrangements, including costs and access to suitable transport to/from appointments, the need for childcare, the need to take time off work, etc.
Impact of the Current EMAH Arrangements on Service Providers
The consultation also asked for feedback on the impacts of the EMAH arrangements on those involved in delivering services. Again, two thirds (66%) of all respondents felt that the impacts would be negative, with the proportions of those identifying positive (30%) and negative (31%) impacts becoming more equal when the Right to Life standard campaign responses were removed.
The main suggested negative impact for service providers was a depleted relationship between the doctor or nurse and their patient due to the use of teleconsultations. It was felt that it would be less clear to health professionals if a patient was fully informed before making their decision, or if they were being coerced into an abortion. Further, it was suggested that the lack of personal consultation would hinder NHS staff's ability to conduct informed health and risk assessments. It was also suggested that the current arrangements may not lend themselves to good patient care, or protection of workers' mental health (linked to the risk of being held accountable for patient safety and any misuse), thus eroding professional standards of care.
Those who perceived there would be a positive impact on service providers focused primarily on flexibility and efficiency. They suggested the EMAH made services more accessible, responsive and efficient, and thus enabled service providers to make time savings while still offering quality care to women seeking an abortion. The telemedicine approach was seen as less time intensive, therefore allowing practitioners to allocate more time to caring for patients with greater medical or support needs. Further, it was noted that current EMAH arrangements enabled the procedure to take place at lower gestation, resulting in fewer complications requiring attention from medical providers, again freeing up time to be spent with other patients.
Risks of the Current EMAH Arrangements and Possible Mitigation
Respondents outlined a long list of perceived risks associated with the current arrangements. Respondents felt there was a risk of serious complications arising as a result of the procedure and the doctor's or nurse's limited ability to assess and verify eligibility of the patient, use of the medication 'at home', and any signs of coercion. It was also suggested that EMAH would result in women being provided with less information around the risks or alternative options, as well as a reduction in the provision of/access to psychological support.
The main mitigation measure suggested by respondents was to offer patients a choice of in-person appointments or 'at home' consultation (although in-person appointments are already an option where the patient chooses it). It was also suggested that services should provide routine follow-up contact with patients for both medical and emotional purposes, that counselling should be offered pre- and post-procedure, and that a 'cooling off' period should be built into the approach.
Several other mitigation measures were also suggested by respondents, but were noted by others to already be in place. This included training on how to identify abuse and coercion; the provision of a 24/7 helpline; clear instructions for medication use, what to expect, and when to seek further assistance; and clear and robust questioning to gather the necessary information during a teleconsultation.
The consultation asked a series of questions which sought feedback on the impacts of the EMAH arrangements on equality groups, people in different socio-economic circumstances, and for women living in island and rural locations.
In relation to equality groups, impacts were noted for pregnancy and maternity, disability, religion or belief, minority ethnic groups, age, gender reassignment and sexual orientation, and marriage and civil partnership. Across most groups, those who identified positive impacts tended to feel that access had been improved, either by providing a more private and discrete service or due to the removal of financial and physical barriers, thus providing greater equality in access to healthcare. This argument was repeated for socio-economic groups and those living in island or rural locations. They also felt that EMAH was more patient-centred, and that patients had been empowered and allowed greater control over their treatment. Improvements in service were felt to be important for these highlighted groups as historically they had experienced disempowerment and exclusion.
For those who felt the impacts were negative, they reiterated the main risks of the procedure for the patient and suggested that this could create inequality in healthcare because women were not being provided necessary protection, medical attention or emotional support. They also felt that the risks were particularly acute for those living in island and rural locations where emergency medical support would be harder to access should they encounter complications. Respondents also suggested that the current arrangements could introduce communication and technological barriers for some patients (including those in particular equality and socio-economic groups), and leave some groups at greater risk of coercion, abuse, or forced abortion going undetected. Specific to religion and belief, some were concerned that staff who may be conscientious objectors could become involved in the distribution of the abortion medication. Further, in relation to socio-economic issues, some respondents worried that poverty could make women feel that an abortion was the only option and that the speed and ease of access via EMAH could result decisions being taken for financial reasons without sufficient consideration.
The consultation document sought views on respondents' preference for EMA provision once COVID-19 was no longer a significant risk. Overall, 61% of all respondents indicated they would prefer a return to the previous arrangements. However, when the Right to Life standard campaign responses were excluded, 42% would prefer 'other' arrangements to be introduced, 34% would prefer the current EMAH arrangements to be retained, and 21% would prefer the previous arrangement to be reinstated.
Other arrangements that were suggested included offering a blended approach of both 'at home' and in-person appointments depending upon risk levels and patient preferences, moving back to a more clinic-based setting, providing greater support/ information, or removing EMA or abortion provision entirely.
A number of other comments were made throughout the consultation responses which did not directly answer the set questions. These were generally related to compliance with the Abortion Act 1967, issues with abortion/EMA generally (rather than specifically linked to the current EMAH arrangements), and perceived gaps in the consultation.
While the number of respondents who were against EMAH was significantly higher than those in support of it, it should be noted that this was heavily impacted by the large numbers who had either submitted a campaign response or had been influenced by one of several campaigns organised by pro-life or faith groups. Further, a sizeable proportion of those against EMAH were also against any and all forms of abortion, and as a result, some of the concerns raised were applicable to abortion generally, rather than being specifically related to EMAH.
Key areas of concern were discussed in several areas across consultation responses, including perceived reductions in safeguards with regards to both the administration of the medication and the physical and psychological safety of the patient. Conversely, those who were largely supportive of the EMAH approach argued that it was safe, and provided a more accessible patient-centred service where women were afforded greater autonomy over their bodies and healthcare.
While it appears that there was a clear preference for the previous arrangements to be reinstated, this view was driven largely by the Right to Life campaign - and indeed most of these respondents suggested that they would prefer both pills to be taken in a clinic (so would not in fact represent a return to previous arrangements). The preferences for future provision as identified by other respondents, however, were mixed, but it was important that choice was provided, and therefore, it was felt that both in-person and at home methods should continue to be offered.