The British Pregnancy Advisory Services (BPAS) is a British reproductive healthcare charity that offers pregnancy counselling, abortion care, miscarriage management, contraception and STI testing to 100,000 women each year via our clinics in England, Wales, and Scotland.
We advocate for women’s reproductive choice, the provision of accurate and balanced information, and the right to make their own choices about their bodies and treatments including during pregnancy and birth.
This response focuses mainly on the issue of ‘how to ensure that positive changes that have taken place in health and social care as a result of the pandemic are not lost as services normalise’.
During the Covid-19 pandemic, amendments have been made to abortion law in England, Scotland, and Wales to enable women to receive pills for Early Medical Abortion remotely rather than having to attend a clinic. This is in line with best practice internationally and recommended by the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, and the British Society of Abortion Care Providers.
This is a positive change which has increased ease of access to care for women who may otherwise find it difficult to attend a clinic – including those in remote areas, those with work or care commitments, and those with health issues which prevent travel – reduced waiting times, and has a real potential to reduce the cost to CCGs of providing early medical abortion services.
This change has been immensely successful and well-received, and women should continue be allowed to access early abortions remotely post-Covid.
The Abortion Act 1967 provides the framework for legal abortions in England, Scotland, and Wales. One of the requirements of a legal abortion is that it is performed in an NHS hospital or on a premises licensed for the purpose by the Department of Health and Social Care.
Under modern clinical practice, Early Medical Abortions are provided using two medications which can be safely taken at home with few serious side-effects and a high level of efficacy. Remote provision is supported by clinical bodies and was one of the recommendations of the recent Royal College of Obstetricians and Gynaecologists’ Better for Women report.
The law, however, requires that the Secretary of State for Health and Social Care must specifically approve women’s homes as a premises at which a lawful abortion can take place before remote provision of this care is legal. This is based not on clinical practice or safety, but on the law as passed in 1967.
Prior to March 2020, the law enabled women to take the second medication (misoprostol) at home, but required them to attend a licensed premises to take the first medication (mifepristone).
From 24th March 2020, the law was changed to allow abortion providers in England to provide mifepristone and misoprostol for a woman to end her pregnancy at home up to 9+6 weeks’ gestation.
Abortion providers and medical bodies are clear that this form of provision is safe, efficacious, and preferable for many women. However, the Department of Health and Social Care has suggested that this change the law may be time-limited in the same way as other Covid-specific changes. We believe that this would be the wrong decision – and that women should be able to access care remotely in future.
BPAS campaigned to amend the law around abortion to enable remote provision early in the Covid-19 crisis. This was as a result of a number of issues with abortion services, including –
The BPAS Pills by Post service launched on 8th April, and as of the first week of May, around 2/3rds of the abortions BPAS is currently providing are telemedical Early Medical Abortions.
Women who contact BPAS undergo treatment which includes the following:
Pregnancy options discussion. All three options for a pregnancy are discussed – continuing with the pregnancy and having the baby, continuing with the pregnancy and pursuing adoption, or terminating the pregnancy.
Consultation. Trained nurse and midwife practitioners book an appointment for a telephone or video call to discuss with women their medical history, their reasons for wanting an abortion, the date of their Last Menstrual Period, and their treatment options. If a woman is unsure about the date of her last period or has other reasons for not being sure about her gestation, clients are asked to attend a clinic for an ultrasound scan. If a woman’s medical history indicates that she may have an ectopic pregnancy, she is referred to her local Early Pregnancy Assessment Unit for appropriate treatment.
Counselling. Clients are able to access counselling both before and after an abortion if they would like. Counselling is not time-limited and women can return at any point after a treatment with BPAS to ask for post-abortion counselling. Despite this, requests for counselling are very low as the vast majority of women have discussed their pregnancy with friends or family prior to presenting to BPAS.
Contraception. Contraceptive counselling is provided and clients who proceed down the remote provision route can receive Combined Oral Contraceptive, the patch, the vaginal ring, or the Progestogen-only Pill in the post along with their abortion medication.
Medication. After ensuring a client meets the criteria for provision of remote services and they have undergone a consultation, mifepristone, misoprostol, codeine, their ongoing contraceptive of choice, and a low-sensitivity pregnancy test is posted to the address provided through with a tracked delivery.
Aftercare. BPAS has a 24-hour aftercare line that clients can call at any point to ask questions or report any medical issues. The line is staffed by BPAS nurses and midwives and provides answers on questions such as how to take the medication, what to do if there has been a lack of bleeding 24 hours after taking the medication, and how to manage pain.
Self-assessment follow-up. Women who have Early Medical Abortions, remote or not, perform their own assessment to ensure their abortion has been successful. This includes taking a pregnancy test two weeks after they took the medication – and contacting BPAS if it comes back positive so that they can access further treatment with us.
Early Medical Abortion is a safe and effective form of abortion treatment which consists of taking two medications (mifepristone and misoprostol) 24-48 hours apart. This combination is effective in 99 in 100 cases, serious complications are rare, and both medications are on the World Health Organisation’s list of Essential Medicines.
There is no clinical reason to take mifepristone in a clinic, and this is not standard practice in many countries around the world. There is also no clinical reason for a face-to-face consultation, and indeed many abortion consultations are provided over the phone as standard practice.
In April 2020, the Royal College of Obstetricians and Gynaecologists along with the Faculty of Sexual and Reproductive Healthcare, the British Society of Abortion Care Providers, and the Royal College of Midwives produced guidance entitled Coronavirus (COVID-19) infection and abortion care which provided a summary of early medical abortion care management during the pandemic in which remote consultation should be offered and ultrasound was only provided where necessary. BPAS’s Pills by Post provision is fully in line with this guidance.
Clients who have received remote treatment with BPAS reported that it was straightforward, that full information was provided, and that a face-to-face appointment was not necessary. Clients said:
“I feel that from my experience I received a lot of information regarding my choice. I was well-informed and felt confident to administer the medication, even without a face to face consultation.”
“I feel I had more than enough information the nurse I spoke to was understanding and helpful and non-judgemental. Thank you! I was confident during the time that I could call the BPAS number and I knew there was support available I didn’t feel alone in the circumstance.”
In the initial weeks of the pandemic, we saw a decline in demand as women were aware that they would have to attend a clinic to access services. After the change, we have seen significantly more women than usual – partially accounted for as delayed demand, partly from people who may usually have attended eg an NHS provider which is not currently providing care or remote care, and partly as an increase of women seeking abortions because of wider social and economic issues at this time.
During this time period, the largest online abortion pill provider Women on Web (which uses doctors to provide legitimate abortion pills from the Netherlands to women in countries where abortion is not available) saw a tripling in the number of British women seeking to access pills online. This service is illegal for women in Great Britain and women buying pills are committing a crime that carries a life sentence.
The roll-out of remote services has also provided a number of benefits for abortion providers:
Cost reduction. If abortion providers could be certain of longer-term legality of remote provision, services could be restructured to reduce costs and ensure that services were provided as cost-effectively as possible. Significant portions of the costs of provision are currently tied up in the running of localised early medical abortion clinics, and the clinically unnecessary provision of ultrasound scanning to determine gestation and pregnancy location. Shifting to the provision of remote services where appropriate would cut these costs, and enable CCGs to restructure payments to ensure that later surgical terminations were better-funded (to meet the cost of providing these specialised services) while having a positive effect on the overall cost envelope.
Reduced waiting times. Abortion is a time-limited intervention. NICE guidelines recommend that clients receive a consultation within a week of contacting a service, and treatment no more than a week after that. Since the roll-out of BPAS’s Pills by Post service, waiting times to consultation have halved and medication is posted out on the same day.
Workforce flexibility. Remote provision enables clinics and providers to deploy workers to where they are needed, as geographical location is not a consideration. This is particularly important where higher levels of staff absence are experienced as a result of sickness, and enables those workers who are shielding or self-isolating to work effectively from home. Without this flexibility, services in some areas were being forced to close and waiting times were increasing.
This change in law has meant the difference between women being forced to continue with unwanted pregnancies and being able to access the abortion they needed.
For some women, accessing abortion even outside the Covid-19 period is incredibly difficult. Women who are in coercive or abusive relationships are at particular risk of being unable to access legal abortion services because they may be unable to travel to specialised clinics for prolonged periods without their partner finding out. These women already often have no choice but to turn to methods outside legal provision such as purchasing abortion medication online. The largest online pill provider – Women on Web – already receive upwards of 2 requests every day for abortion medication from women in Great Britain who are unable to access care, which puts these vulnerable women at risk of criminalisation.
Going forward, bearing in mind the situation which we are expecting to live with for the foreseeable future, the ability to access care remotely will be particularly important to:
Of those women who received Pills by Post from BPAS who responded to a follow-up survey, more than 60% of women would have found it difficult to access abortion care. More than 90% of the women said that Pills by Post should continue to be available after lockdown ends. Their accounts included:
“I am an NHS frontline worker and having time off from my normal duties during this time would have been really difficult! I REALLY appreciate this service.”
“Currently having to spend lockdown with my strict parents (who had no idea about my pregnancy) and I don't drive and so it would've been impossible to get to a clinic.”
“As a single parent to my daughter without the pills by post service I would have found it very difficult to visit the clinic without being able to bring my daughter along so the pills by post service was extremely helpful for me.”
“It’s very discreet very easy and it you work full time it can be hard to find time off to go to appointments. Also, I didn’t need to explain to other people why I needed the time or where I was going.”
“It would have been very difficult and expensive for me to attend a clinic as the nearest is very far away from my home and I currently cannot drive so would have had to rely on public transport or taxis. As I did this without my husband’s knowledge as well, it would have been difficult to explain where I was going & why I was going for so long. The pills by post made my life a lot easier at this difficult time.”
“I have 7 children and there was only me and my husband who knew, he would of had to drive me to a clinic with all 5 younger kids as well, I thought it is a much better way of treatment as once I had the pill pack I could choose when I wanted to take the 1st one, just to make sure that is the choice I wanted to do, whereas if I’d attended a clinic I would of took it there and then even if I was having doubts.”
“It allows women to go through a very hard and upsetting experience in the total comfort of their homes rather than in a hospital. It makes the treatment even more accessible to women. I've never felt as lucky for living in the UK as in this circumstance considering the availability of BPAS and telemedicine.”