Early medical abortion at home - future arrangements: consultation analysis

Future Arrangements

The consultation document sought views on respondents' preference for EMA provision once COVID-19 was no longer a significant risk. The options presented included:

• Retaining the current arrangements, i.e. allowing women to proceed without an in person appointment and take mifepristone at home, where this is clinically appropriate;
• Reinstating the previous arrangements, i.e. women would be required to take mifepristone in a clinic, but could still take misoprostol at home where this is clinically appropriate; or
• Other suggestions.

Q7. How should early medical abortion be provided in future, when COVID-19 is no longer a significant risk?

Preferred Future Arrangements

	All Respondents		Excluding Right to Life Campaign
	Number	Percent	Number	Percent
a) Current arrangements (put in place due to COVID-19) should continue	935	17%	935	34%
b) Previous arrangements should be reinstated	3360	61%	580	21%
c) Other	1151	21%	1151	42%
Not answered	91	1%	91	3%
Total	5537	100%	2757	100%

When asked about their preferred future arrangements, 61% of all respondents felt that the previous arrangements should be reinstated. However, this was again largely driven by the Right to Life standard campaign responses, with only 21% of respondents preferring this option when this campaign group was removed from the analysis. Rather, 42% of respondents preferred 'other' arrangements and 34% preferred that the current arrangements should be continued when the Right to Life standard campaign responses were excluded.

A total of 4,282 respondents provided qualifying comments, most of which were provided by those who preferred to reinstate the previous arrangements (n=3,004). However, it should be noted that this was driven largely by the Right to Life campaign responses, with 'other' options preferred by the majority (n=1,144) when these were excluded. Further, these Right to Life respondents also outlined a preference for 'other' arrangements in their qualitative response despite selecting 'Option B' at the closed question element.

Retaining the Current Arrangements

Of those in favour of retaining the current EMAH arrangements post-COVID-19, 72 respondents provided additional qualitative comments (consisting of 55 individuals and 17 organisations). Typically, these respondents felt that EMAH was patient-centred, safe, effective, and accessible and as a result they saw no legitimate clinical or medical reason why this service should be withdrawn. Indeed a few suggested that removing this process would be a 'backwards step':

"The current arrangements should be retained permanently. The service is safe, effective, and accessible - and enabling women in Scotland to make the right choice for them regardless of geographic, economic, or social constraints." (Individual)

Several did caveat, however, that it would still be important to retain the option for face-to-face appointments and treatment where required or preferred, and that quick and easy access to a scan (including creating local links for this provision) would be beneficial where this is necessary.

In terms of wider infrastructure needed to support EMAH, a few organisations argued that provision must be standardised across Scotland, that full information must be made available to patients (including information about alternatives and/or other support available), and that suitable after-care services (such as mental health provision) must be funded and made available.

A few organisations also emphasised the importance of reviewing data and disseminating any learning going forward.

Reinstating the Previous Arrangements

Of those who indicated that they were in favour of reinstating the previous arrangements, 3,004 respondents provided supporting comments, consisting of 3,001 individuals and 3 organisations. Again, it should be noted that this consisted mostly of Right to Life campaign respondents who actually described 'other' arrangements (and have been incorporated under 'Other Arrangements' below). As such, 224 other respondents provided comments in support of reinstating the previous arrangements.

These respondents typically felt that the need to have in-person consultations and take the first pill in the clinic/hospital provided valuable safeguards, including:

• Confirming patient identity/who is taking the medication;
• Confirming gestation and any risk of ectopic pregnancies;
• Being more likely to identify the need for and/or provide access to psychological support;
• The provision of a time delay to allow the patient time to think about their decision/options; and
• To provide the safe-space needed to discuss the patient's situation and alternative options free from any external influences.

Some respondents felt it was important for there to be follow-up consultations, with several suggesting these should take place within one month, confirm the dates the medications were taken, log any side effects experienced, and identify and facilitate access to psychological support where required. It was considered crucial that this information be available within the patient's medical records for future reference, and that general data collection and analysis should inform service improvement.

Other Arrangements

Of those who indicated they would prefer 'other' arrangements to be implemented once COVID-19 was no longer a significant risk, 1,144 provided qualitative comments. Of these, 1,111 were individuals and 33 were organisations. A further 63 respondents who did not provide an answer to the closed element did, however, provide a qualitative comment, many of which were consistent with those outlined below. The 2,780 Right to Life responses are also outlined below.

A considerable proportion of respondents simply reiterated their concerns with EMAH, previous arrangements, or with abortion more generally without outlining any alternative suggestions regarding future arrangements. Many others stated that, going forward, all forms of abortion should be abolished and the Abortion Act 1967 repealed.

Where alternatives or suggestions related to future arrangements were provided these ranged from offering a mix of methods through to withdrawing the use of medical abortions entirely. The range of suggestions are outlined below:

• Offer a blended approach with both in clinic and at home options (or a mix of both) available, depending upon risk levels and the patient's preferences:

"A combination of both should be permitted. Where women wish and are happy to take the medication at home, I see no significant detriment to this. However, for those who would be more comfortable doing so in a clinic, I believe this should also be an option." (Individual)

• At least one in-person consultation should be required (with a few suggesting this should include an ultrasound scan) but both pills could be taken at home if appropriate;
• Both pills to be taken within a clinic/hospital setting;
• Full process to take place within a suitable medical facility;
• Greater psychological support provided;
• Greater information and support services made available so that those with a crisis pregnancy do not consider abortion to be their only option;
• Greater resources, as well as increased information provision and signposting, for adoption and support for families to keep their children;
• Greater resources put into sex education and contraceptives;
• Provide more information (with some suggesting the need for a public campaign) to inform women of the risks involved in having an abortion, including consideration of the potential for long-term psychological effects;
• Encourage the patient to see the pregnancy as a 'living child', so they understand the gravity of the decision;
• Greater restriction on eligibility for abortions (both medical and surgical), for example only available in exceptional circumstances, where all other options have been explored, or where the mother's life is at risk or in rape or incest cases;

"Abortions should not be made to be as easy as possible. It should actually be as difficult a process as possible and an action of absolute last resort." (Individual)

• Stop all medical abortions and only facilitate surgical abortions.

Preferences of those with Lived Experience

Forty-six respondents identified themselves as having had an abortion at some point in the past, or as having closely supported someone through an abortion. Of these, 21 (46%) felt that the current arrangements should be retained, six (13%) wanted the previous arrangements to be reinstated, and 18 (39%) suggested 'other' options. One respondent did not specify a preference.

Of those who selected 'other' arrangements:

• Five indicated a preference for either EMAH or all abortions to be ceased;
• Four wanted there to be a patient-made choice between in-person and at home provision;
• Four felt there needed to be better information given to women, particularly in relation to the risks associated with the procedure;
• Three wanted either the full procedure to take place in a clinic/hospital or for both sets of pills to be taken in a clinic/hospital, (a further two who preferred an end to all abortions indicated their belief that, should the practice continue, it would be better for EMA to take place in a clinic/hospital);
• One felt that one in-person appointment should be required; and
• Two did not outline any alternative approaches.^[11]