Written evidence submitted by Right To Life UK (MSE0104)

Right To Life UK

 

Right To Life UK is a charitable organisation focused on life issues – abortion, assisted suicide and embryo research. We protect and defend the right to life of every human being from conception to natural death through our work across education, politics, the media and through a large network of people in constituencies across England, Wales, Scotland and Northern Ireland. We are committed to an evidence-based approach to life issues, uniting people from different political ideologies and philosophical beliefs (including those who are non-religious, religious, or agnostic).

Introduction

 

Right To Life UK welcomes the Health and Social Care Select Committee inquiry concerning the safety of maternity services in England. The safety and well-being of both mothers and babies should be of paramount importance in our society; both lives matter and our healthcare policies and practices must equally cater for their respective needs. Though the call for evidence rightly draws attention to, inter alia, past and present work on improving maternal safety across the country, the importance of women’s access to full information regarding their possible pregnancy outcomes, and the crucial role of the Healthcare Safety Investigation Branch in investigating and improving maternal safety, it would be remiss not to consider the impact of the temporary allowance of the taking of both sets of abortion pills at home without an in-person clinical consultation on maternal health in this country. Our submission seeks to highlight a number of grave concerns, reflected both in the medical research and material reality surrounding the practice of so-called ‘at-home’ medical abortions across England since the introduction of the temporary provision by the UK Government at the end of March this year.

Background to ‘at-home’ medical abortion

 

In the midst of the COVID-19 crisis, the UK Government approved temporary measures to allow ‘tele-medicine’ or ‘at-home’ medical abortions up to 9 weeks and 6 days’ gestation.[1] This is the largest change to abortion law since 1967 and was done without any parliamentary scrutiny or public consultation. It allows for consultations with a doctor over the phone or video (eg Facetime/Skype),[2] subsequent to which both sets of abortion pills (one mifeprisone/six misoprostol) can be sent out or picked up from a clinic,[3] so the woman/girl would effectively perform a ‘DIY’ (do-it-yourself) abortion at home.[4] A pro-abortion amendment to the Domestic Abuse Bill before the House of Commons sought to make these changes permanent for women who were victims of domestic abuse. Diana Johnson MP proposed an amendment to the Domestic Abuse Bill to allow women in domestic abuse situations to continue to access ‘tele-medicine’ abortions on a permanent basis. The amendment would have also expanded the temporary provisions to allow surgical abortions to occur outside of the currently approved locations.[5] Fiona Bruce MP proposed an amendment to Diana Johnson’s amendment outlining that the Government should undertake ‘an inquiry into the safety, number, and impact of abortions carried out under the temporary coronavirus crisis provisions’ before any change to make the temporary abortion provisions permanent.[6] The Government have agreed to facilitate a public consultation on ‘at-home’ abortion before the temporary order expires.[7]

Dangers of ‘at-home’ medical abortion

Removal of abortion from a clinical environment

 

The designated location for use of abortion pills under the Approval of a Class of Places Act is meant to be the home, yet there is nothing to stop abortion pills being taken at other locations, or by other individuals.[8] Self-administration of abortion pills removes any control over who takes the pills, where they are taken, whether they are taken, when in the process they are taken, or if another adult is present for support. It is not clear how the NHS or independent clinics could ensure the pills are taken at home, by the individual they are provided to, and within the appropriate time frame (currently, surgical abortions can only take place in hospitals or other clinical settings approved by the Secretary of State). The removal of abortion from a clinical environment along with any medical professional directly overseeing the abortion process is liable to increase the likelihood of complications.

 

A nationwide undercover investigation concluded in early July found evidence of abortion providers putting women at significant risk, seemingly by not carrying out basic checks before sending abortion pills by post, showing that the scheme is open to abuse and facilitating abortions beyond the legal time limit.[9] In the investigation led by a former Global Director of Clinics Development at Marie Stopes International, all eight volunteers were able to acquire mifepristone and misoprostol using false names, dates of birth, and gestational dates.[10] In one case, pills were provided to a volunteer who gave a date that could only have led to a termination beyond the legal ten-week limit for ‘at-home’ abortions. Clearly this service can be manipulated by a third party to obtain abortion pills without scrutiny, which is a serious concern when it comes to, for example, underage sexual abuse victims, as well as individuals who may seek to put abortion pills in a woman’s food or drink. The investigation also reveals that abortions that are fully paid for by the taxpayer could be provided unchecked to women who are not eligible for NHS funding for healthcare. The investigation’s ‘mystery client exercise’ found the ‘at-home’ abortion scheme is being used to offer abortions on demand for effectively any reason that could be interpreted as negatively impacting the woman’s mental health. For example, BPAS have posted abortion pills to women for reasons including wanting a beach body on holiday.[11] In the video, a BPAS call handler can be heard telling the woman ‘any reason other than the sex of the baby is a valid reason’ to have an abortion, but added they needed to ‘attach’ a legal reason.[12]

Difficulty of verifying accurate gestational age


It is vital to establish an accurate gestational age to ‘ensure women take the recommended dose and regimen of medications, and in the appropriate setting’, yet, intentionally or unintentionally, women may report their gestational age incorrectly.[13] A 2017 study by abortion advocates found that ‘Outside the research setting, women who seek and receive medical pregnancy termination through telemedicine services… are asked by the service to obtain ultrasound examinations to ensure their eligibility… approximately one‐third who were followed up after receiving treatment had pregnancies which were of 10 weeks of gestation or greater by ultrasound’.[14]


Given there is no way to verify how far along a woman is over the phone/video/other electronic means, there is a higher risk women will be given an inaccurate diagnosis when being diagnosed in that way and therefore prescribed abortion pills even if they may be too far along for said pills. A systematic review of studies on the home use of mifepristone and misoprostol published in October 2020 concludes that there is not enough evidence to support the safety of home use of mifepristone and misoprostol beyond ten weeks of pregnancy.[15] This reinforces how crucial it is to determine accurate gestational age so that women are not endangered by being prescribed ‘at-home’ abortion pills beyond ten weeks of pregnancy. Reports in the media have made known the case of a baby aborted using ‘at-home’ abortion pills at 28 weeks, and 8 similar cases of ‘at-home’ abortions occurring beyond the ten-week limit are under investigation by the British Pregnancy Advisory Service.[16]

Difficulty of detecting abuse or coercion

 

Self-administration of ‘at-home’ abortion pills removes an opportunity to ascertain if abuse or coercion is involved. This poses a threat to vulnerable women and girls who are at risk from an abusive partner, sex-trafficking, or child-sex abuse, as ‘at-home’ abortion could be used by their abusers as a means to more easily cover up trafficking or abuse scandals.[17] It goes against the very argument previously made by the abortion industry who argued that abortions should be provided at approved locations to protect women from abuse and coercion. A 2014 study on the incidence of coerced abortion in abusive relationships found that one third of participants reported pressure to abort,[18] whilst another found that 7 out of 13 women in domestic violence situations experienced pressure to abort.[19] Such coercion would be impossible to detect without a face-to-face consultation as there is no guarantee with a telephone or video call that an abusive party is not listening in.

Risk of complications from ‘at-home’ medical abortion negatively affecting women’s health

 

There is evidence that there can be more complications from taking abortion pills than surgical abortions. A Finnish study of over 42,000 women receiving abortions under seven weeks’ gestation found that the rate of complications was four times higher in medical than surgical abortions.[20] A number of maternal deaths have been reported from uterine infection and undected ruptured ectopic pregnancy following early medical abortions, including from cases of septic shock.[21]  Research suggests that mifepristone may have direct pharmacologic effects that increase risk of mental health issues and complications such as infection.[22] Teratogenic effects such as clubfoot, limb and cranial nerve abnormalities have been reported in pregnancies that continue to birth following the taking of misoprostol.[23] Rh-negative women who take abortion pills may not receive prophylactic Rhogam, resulting in isoimmunisation in future pregnancies (the mother produces antibodies that harm the baby’s blood cells).[24] Medical abortions also present greater risk to women who live in rural areas and have more limited access to emergency services.[25]

 

Furthermore, hospitalisation rates are worse for medical abortions. Vaginal bleeding or spotting lasts on average 9-16 days following a medical abortion, while up to 8% of patients bleed for 30 days or more.[26] The rate of hospitalisation for complications increases with gestational age: a study of 18,000 women found an 8% rate of surgery for medical abortion failures in the first trimester, and an almost 40% surgery rate in the second trimester.[27] A 2018 study has found that among medical abortions under 12 weeks gestation, the complication frequency increased significantly, from 4.2% in 2008 to 8.2% in 2015’.[28] The first reason the study suggests for this concerning increase in complications is medical abortions being performed at home; and concludes that the cause of this is unknown but it may be associated with a shift from hospital to home medical abortions.’[29]

 

A leaked email from a Regional Chief Midwife at NHS England and NHS Improvement has revealed that women had to attend the Emergency Department for a range of incidents including ‘significant pain and bleeding related to the process through to ruptured ectopics’, ‘major resuscitation for major haemorrhage,’ and incidents involving the ‘delivery of infants who are up to 30 weeks gestation.’[30]

 

Women have started speaking out regarding their personal experiences of complications following ‘at-home’ medical abortions. Courtney Barnes, 27, noted: ‘You do pass a lot of blood and I was warned I might see the foetus, so I sat on the toilet and didn't look. I ended up lying in the bath trying to keep the pains at bay and I didn't get much sleep that night. It was a lot worse than I'd expected. The pain, the physical process was horrible’. The Mail goes on to report, ‘There was no routine follow-up call with a doctor or nurse to check how things had gone, just a text a couple of weeks later reminding her to use her pregnancy test.’ . . . It's not a position any woman would want to be in. Is Courtney still pregnant and, if so, what effect has the procedure had on the foetus?[31] A 39-year-old who preferred to remain anonymous described that she thought she ‘was going to die’ on experiencing intense pain, cramps, vomiting and feverish symptoms after taking abortion pills at home. She was also unable to ring for advice in the presence of her partner, whom she described as ‘very controlling’.[32] A nurse, having suffered extreme complications from an ‘at-home’ abortion that left her needing life-changing surgery, recently shared, ‘I’m actually quite shocked that the UK, with all of our research and expertise would approve this. . . It just feels like we are going backwards and that covid is an excuse to not treat women with respect.’[33] As reported in the Sunday Telegraph, she claims that after being told the pain would be no more than a bad period pain and that 98% of women do not experience complications’, she not only experienced ‘excruciating pain’ that left her feeling like she was going to die, but also had heavy bleeding that continued for ten days after the abortion.[34]

 

She further claims that ‘she received no follow-up from Marie Stopes and that she was told that their counsellors are busy and she cannot get an appointment.’ Upon going to a hospital, she discovered ‘she still has products of conception inside her which has a blood supply. She has since had surgery and is keen to start a support group connecting women who have had similar experiences.’[35] She is considering legal action for medical negligence.[36] Existing studies on the long term complications of mifepristone and misoprostol do not show evidence that there is no long-term impact on the woman’s health.[37]

 

Although there is little empirical research on the psychological fall out from abortions completed at home, anecdotal evidence shows that the psychological risks associated with medical abortions completed at home can be severe, partly because women usually see the fetus, which they then have to flush away themselves. It is not hidden from them in the way a surgical abortion keeps the fetus from the view of the woman. Moreover, the reminder of the abortion is always in the home, not in an anonymous clinic that can be left behind. As reported by the BBC, concerns have been raised in Wales over the negative impact on women’s health of not being able to access face-to-face abortion counselling.[38] One woman (Ms Jones), being unable to schedule a face-to-face appointment before her 24th week of pregnancy - the latest a woman can legally have an abortion in the UK, shared, ‘I can't put into words how many hours, days, months, I was just thinking: “I don't know what to do”.’[39] Another woman (who wished to remain anonymous) disclosed’she was not offered clear advice and support when she decided to have an abortion in Cardiff last year,’ stating ‘It would have been nice if the doctor or nurse had given me the chance to talk about that stuff [guilt and shame she experienced].’[40]

Conclusion


Recent polling from ComRes shows that women want more not fewer safeguards around abortion across a number of key areas.[41] Specifically, 77% of women agreed that doctors should be required by law to verify in person that a patient seeking an abortion is not under pressure from a third party to undergo the abortion.[42] Other evidence similarly suggests that there is support for greater restrictions on abortion practice: a poll from March 2014 showed that 92% of women agreed that a woman requesting an abortion should always be seen in person by a qualified doctor.[43]

 

‘At-home’ abortions have undermined healthcare for pregnant women and their unborn children by prioritising convenience over care. The temporary provision has abandoned safe procedure, placing the lives and safety of women in danger. Any inquiry into the safety of maternity services in England must reflect upon these increased threats to women’s health, and recommend their immediate suspension.

 

 

November 2020


[1] Prior to the change, women seeking a termination would have to visit a clinic for an assessment from a healthcare professional – something the Government had said was an ‘essential safeguard’ before their U-turn on the issue. See: Coronavirus Bill - Hansard.

[2] 30032020 The Abortion Act 1967 - Approval of a Class of Places.

[3] Abortion provider Marie Stopes’ website states: ‘Following your consultation, you will have the choice of either collecting the pills from your preferred clinic or having them posted to you.’ See: https://www.mariestopes.org.uk/resources-abortion-pill/?gclid=EAIaIQobChMIrtDOz5fP6gIVhe7tCh073wnDEAAYASAAEgKNgPD_BwE#receivetheabortionpill3136fd7e5-683e-4f43-89de-c7a033ada131. Another abotion provider, BPAS, states ‘If treatment is suitable and safe, you will receive abortion pills by post a few days later, or we can book you for an alternative treatment in clinic.’  See: Abortion Pill Treatment at Home.

[4] Please note, this term is used by both pro-abortion and pro-life campaigners in reference to the abortion being self-induced.

[5] https://publications.parliament.uk/pa/bills/cbill/58-01/0141/amend/domestic_daily_rep_0703.pdf. The amendment would have also expanded the temporary provisions to allow surgical abortions to occur outside of the currently approved locations.

[6] Ibid. Specifically, Fiona Bruce MP’s amendment stated ‘This section may not take effect until the Government has conducted an inquiry into the safety, number, and impact of abortions carried out under the temporary coronavirus crisis provisions where the place of abortion was the woman’s home, and has laid a Report on this before Parliament.’

[7] Abortion: Drugs: 20 Aug 2020: Hansard Written Answers.

[8] 30032020 The Abortion Act 1967 - Approval of a Class of Places.

[9] https://christianconcern.com/ccpressreleases/undercover-investigation-exposes-diy-abortion-service-as-unsafe-and-crossing-legal-boundaries/

[10] Ibid.

[11] BPAS offers DIY abortion pills for summer beach body.

[12] Abortion for 'any reason' other than sex-selection, says BPAS; https://righttolife.org.uk/news/bpas-posts-diy-home-abortion-pills-to-woman-who-wanted-beach-body/.

[13] Abortion pills outside medical supervision? That’s just the start; A research agenda for moving early medical pregnancy termination over the counter - Kapp - 2017.

[14] A research agenda for moving early medical pregnancy termination over the counter - Kapp - 2017.

[15] https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/aogs.14025.

[16] Police investigate death of baby after woman took home abortion drugs; Police probe 'abortion by post' of 28 week old baby four weeks past limit.

[17]  https://righttolife.org.uk/news/diy-abortions-cover-up-14-years-of-sexual-abuse/; Of note, in an expert witness statement for a UK Court of Appeal legal challenge against ‘DIY’ home abortions, Dr Gregory Gardner, a longstanding GP and honorary clinical lecturer at the University of Birmingham said: ‘It will be difficult if not impossible to verify by phone or video whether a woman is undergoing any kind of duress to have an abortion. “There does not seem to have been any consideration given to this in the proposed change in policy. There will be women who need delicate counselling to discover coercion or other forms of abuse.’ See: STATEMENT OF GREGORY GARDNER I, Gregory Gardner of WILL SAY AS FOLLOWS: 1. I, Gregory.

[18] The role of intimate partners in women's reasons for seeking abortion.

[19] https://pubmed.ncbi.nlm.nih.gov/16845768/.

[20] Immediate complications after medical compared with surgical termination of pregnancy.

[21] Fatal Toxic Shock Syndrome Associated with Clostridium sordellii after Medical Abortion; Septic shock due to Klebsiella pneumoniae after medical abortion with misoprostol-only regimen; Toxic shock syndrome due to Clostridium sordellii: a dramatic postpartum and postabortion disease; Group a Streptococcus causing necrotizing fasciitis and toxic shock syndrome after medical termination of pregnancy; Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion.

[22] For example, mifepristone blocks glucocorticoid receptors, which is linked to increased risk of infection. Mifepristone also releases inflammatory cytokines that have been implicated in causing depression, see: Medical Abortion: What Physicians Need to Know.

[23] Misoprostol and Teratogenicity.

[24] Medical Abortion: What Physicians Need to Know.

[25] Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland.

[26] Ibid.

[27] Immediate adverse events after second trimester medical termination of pregnancy: results of a nationwide registry study.

[28] Complications related to induced abortion: a combined retrospective and longitudinal follow-up study.

[29] Ibid. Historically, mifepristone and misoprostol were contraindicated in the US unless there was ready access to medical facilities for emergency services due to the ‘black-box warning’ that surgical intervention may be necessary, see: Medical Abortion: What Physicians Need to Know.

[30] https://righttolife.org.uk/abortion-200729-nhs-email/.

[31] Abortions by post got rushed lockdown approval, but what is the truth?.

[32] Ibid.

[33] https://www.telegraph.co.uk/news/2020/10/13/nurse-criticises-judges-diy-abortion-ruling-excruciating-pain/.

[34] Ibid; Nurse considering legal action after 'DIY' abortion left her needing life-changing surgery.

[35] Ibid.

[36] Ibid.

[37] Medical Abortion: What Physicians Need to Know.

[38] https://www.bbc.co.uk/news/uk-wales-5442371.

[39] Ibid.

[40] Ibid.

[41] Abortion polling for Where Do They Stand?

[42] Ibid.

[43] Christian Institute – Abortion Survey and www.righttolife.org.uk/polling.