Let’s make it easier to take the abortion pill

On Friday 28 January, the High Court in London will hear a challenge to the way that early medical abortion is provided. The British Pregnancy Advisory Service (BPAS), a non-profit-making charity that works in partnership with the National Health Service, is hoping to obtain a ruling that will make it easier for women to use the abortion pill.

A judgement in BPAS’ favour won’t affect who can and can’t have an abortion; it will only change the way that medication is given to women who meet the existing legal and medical requirements. The challenge could hardly be more modest. It simply attempts to introduce a more sensible, rational, clinically evidenced way to give abortion medication to women who have already been deemed fit to use it. The change to existing practise is so slight that it’s surprising that a court judgement should be needed. It’s even more surprising that the Department of Health should have engaged a leading QC to oppose it.

EMA (Early Medical Abortion, aka the abortion pill) is a simple and safe procedure which is commonly used throughout Britain for abortion in the first nine weeks of pregnancy (that’s 63 days after the first day of the woman’s last period). The treatment involves taking two sets of pills, up to 48 hours apart, to induce a miscarriage. Its use has been encouraged by the Department of Health and the NHS because it is suitable for use as soon as a pregnancy is confirmed and, in their own words, ‘Department of Health policy is that women who are legally entitled to an abortion should have access to the procedure as soon as possible’.

So, what’s the problem? At issue is a clash between the phrasing of the Abortion Act and the way that medical practice has advanced since the Act became law in 1968. The Act (S1(3)) specifies that ‘any treatment for the termination of pregnancy’ must be carried out in a hospital or clinic. The Department of Health insists that this means not only that the pills must be prescribed and given to the woman while she is in clinic premises, but that she must physically take them on-site.

So, a woman needing to use Early Medical Abortion attends a clinic on one occasion to be given the first tablets of mifepristone, which block the pregnancy hormones and trigger the expulsion of the embryo. Then, usually a day or two later, she must return to the clinic to take the second tablets of misoprostol, which will cause uterine cramping and bleeding. Once the tablets are taken, the woman then returns home where she will experience her miscarriage, coming back to the clinic in due course for a check up and confirmation that the abortion has worked. During the time she is at home, a woman has round-the-clock access to telephone advice from a nurse or doctor and clear instructions on what to do if things don’t go to plan. It’s a protocol that works for the more than 17,000 women each year who request EMA from BPAS clinics alone. And the number is growing.

In effect, managing an Early Medical Abortion at home is like managing a natural miscarriage – except with EMA you know what’s coming and can prepare for it. And, importantly, it isn’t usually associated with the grief of the spontaneous end to a wanted pregnancy. Many women describe the cramping and bleeding as ‘a relief’ because it’s confirmation that their pregnancy is over. When you’re pregnant and you don’t want to be, what you most want is your period. EMA isn’t a period – but it’s probably the closest thing to it that there is.

In other countries, such as the US, France and Sweden, women are given the misoprostol tablets – ready to take at home when the time is right – on their first visit. This means they are saved the unnecessary cost and inconvenience of a second clinic visit and, crucially, they are spared the anxiety of worrying that they will start to cramp and bleed on the way home.

The misoprostol isn’t dangerous. Indeed women who have suffered an incomplete early miscarriage are given the same medication to take at home in recognition of the fact that at such a sensitive time it is preferable for a woman to be in the comfort and privacy of her own home.

To require women to return to a clinic just to take a set of tablets on the spot, and then to travel while at risk of starting to miscarry, makes no sense. In Sweden, which has a law similar to ours, legislators got round the problem by deciding pragmatically that the abortion treatment should be defined as only the medication taken first, but UK officials rejected this solution. Even many politicians have managed to understand the issue. Three years ago, a report by the House of Commons Science and Technology Committee on developments relating to the Abortion Act noted that there was ‘no evidence relating to safety, effectiveness or patient acceptability’ that should stop legislation allowing the second stage to be taken at home.

BPAS has been advised that the law could be interpreted differently to allow some of the abortion medication that has been prescribed and issued in a clinic to be administered by a woman at home. This would be in keeping with almost every other area of medical practice. When a doctor treats you for high blood pressure, he or she prescribes the drugs that will alleviate your condition, and you take them as directed. So it should be with abortion. And so we are going to court, asking simply for a court declaration that, in Early Medical Abortion, treatment should be defined as the prescribing and issuing of the necessary drugs, but not necessarily administration.

In the BPAS protocol, the first medication would still be taken in the clinic, but the second could be taken at home, just as it is in other countries where this method is available.

Those of us who provide abortion services know we must comply with the law. But, within that, services should be shaped by best clinical practice. It is wrong to compromise women’s care through unnecessary restrictions imposed by officials who fear criticism from those who oppose abortion in principle. Where abortion is legal, it is our job to make sure women do not suffer unnecessary anxiety or discomfort.

We are looking forward to hearing what arguments are mustered against our case. In the past we’ve been told that although what we say makes sense, it could be seen as making abortion easier, and so will be controversial and is best avoided.

BPAS sees it differently. Medical practice should be shaped by clinical evidence not political or bureaucratic convenience. It is offensive and wrong to expose abortion patients to additional anxiety only because officials fear controversy. No woman ever wants to have an abortion. It is the solution to a problem she wishes she didn’t have.

No abortion provider wants to take officials to court – but there are some challenges we have to make.

Ann Furedi is chief executive of BPAS, the British Pregnancy Advisory Service.