The pandemic revolutionised abortion access. Why should we say goodbye to pills by post?

Ending a pregnancy in England has always required at least one visit to a clinic but the pandemic changed all that with the government approving at-home abortions. Now it’s considering changing it back, writes Sophie Gallagher

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The law laid out in the 1967 Abortion Act remained largely unchanged for decades. Despite revolutions in technology and science, if you needed to terminate a pregnancy in England, it required a face-to-face meeting with a clinician and both of the two stages to be administered in a hospital or clinic. In 2018, this was amended slightly so that the second pill (misoprostol) could be taken at home. But getting the first tablet, mifepristone, always meant a visit to a licensed service.

Then came the Covid-19 pandemic. The NHS was sent into crisis and once-in-a-lifetime emergency planning was put in place across all healthcare. The government flip-flopped over what to do about abortion provisions – approving at-home early medical abortions and then backtracking with a statement that said the policy had been “published in error” – before finally agreeing that, only as a temporary measure, telemedicine would be acceptable.

For those in the first nine weeks and six days of pregnancy, they could now have both pills sent by post (following a telephone or e-consultation) without having to leave the house. Given the country was in a national lockdown, it was justified as fundamentally practical, the pandemic providing a shield of pragmatism against any potential political or moral outrage. The new bill was passed on 30 March 2020, but with the strongest of caveats: it was only a stopgap until the pandemic ended, or for a maximum of two years, whichever date came first.

In late February, 23-year-old Twyla from London found out she was six weeks pregnant. She has long known she does not want children and knew she wanted to terminate the unplanned pregnancy. Yet she felt ashamed and embarrassed by the situation and wanted access to the services straight away. “I felt stupid, only careless people get knocked up, right,” she says, and went online to order the pills. They arrived three days later.

“With telemedicine I felt in control and respected. It truly felt like it was my decision, my process, no probing, questions with agendas or judging eyes,” she explains. “I decided when I wanted to do it, who was going to be there and was in my own home. I’ve read about women who have had to take some of the pills at a clinic, and have started bleeding in the cab or on the bus on their way home. F**k that. Imagine.” For Twyla, telemedicine provided accessibility and space to make a decision based on her own wants and needs rather than external pressures.

Under this system patients are able to self refer for an abortion and are then offered a consultation, which adheres to the same standards and safeguarding as the pre-pandemic pathway. Enough information and time is provided to give informed consent and counselling is available on request. For those where the gestational period of the foetus is unclear, or there are outstanding questions, patients are asked to attend a scan.

I’ve read about women who have had to take some of the pills at a clinic, and have started bleeding in the cab or on the bus on their way home

For many, the primary benefit of pills by post is accessibility – in terms of both mental barriers, like lessening fear of judgement, or practical obstacles like finding childcare or paying for travel. Sara, 30, from Leicestershire had an abortion during lockdown. She already has three children. “I was able to safely administer the medications provided whilst being in the comfort of my own home and being looked after by my other half. We didn’t have to find childcare or worry about getting to a clinic and back again. It was so straight forward.”

The move to telemedicine has not slowed demand for abortions: early data from January to June last year shows there were 109,836 abortions in England and Wales. This compares with 105,540 in 2019. Although the service is only available for pregnancies up to 10 weeks, this targets a huge number of abortions that happen every year in the UK. The proportion performed at under 10 weeks has gradually increased since 2010, when it was 77 per cent of the total. From January to June 2020, half were performed before seven weeks and 86 per cent before 10 weeks.

As well as addressing a key demographic – those looking for help early on in their pregnancy – telemedicine also opens up the service to those who might otherwise have struggled to access it in person, like those suffering domestic violence or in abusive relationships. Claire*, 25, Norfolk, has had two abortions – one during the pandemic and one before. “Pills by post really liberated my abortion experience in so many ways. It took the stress off... I was in a very toxic situation and needed my abortion to be as low key as possible. It was discrete and simple.”

Claire says if this service had been available the first time round it would have “saved her” having to go for a surgical treatment later in her pregnancy. “If pills by post were an option all the time it would be a liberation for women who need discrete treatment,” she says.

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This is also the case for those who might be concerned about their legal status in the UK, such as migrants or asylum seekers, who may resist accessing NHS treatment through fear, or those who face language barriers. Ros Bragg, director of Maternity Action, tells The Independent: "From our work with migrant and asylum-seeking women, we are very aware of the financial, language and other barriers which impact on women’s access to healthcare. Where [telemedicine] is helpful for women in increasing access to care, there is no reason to stop it.”

Experts have said that telemedicine has also facilitated easier access for non-binary people or those in the LGBTQ+ community who find medicine exclusionary. Eloise Stonborough, associate director of research and policy at Stonewall, says: “Our research found one in seven LGBT people (14 per cent) avoid seeking healthcare for fear of discrimination, and one in eight LGBT people (13 per cent) have experienced unequal treatment because they are LGBT.

“Introducing more accessible abortion services has been revolutionary in helping women and people assigned female at birth to overcome barriers, and we urge the government to make these vital services permanent,” Stonborough adds.

Criticism of introducing abortions at home – groups including Christian Concern were against the policy – based on reduction in quality of care, or increased risk, does not tally with the lived experiences during the pandemic. A BPAS survey, published in the Contraception Journal, of 1,300 patients who underwent early medication abortions at home from May to July last year, found 97 per cent were “satisfied” or “very satisfied” with the experience, while 76 per cent said it was “straightforward”.

If the government were to revoke permission for telemedicine, women would once again turn to illegal online pills

When asked hypothetically if they needed another abortion in the future, most patients (78 per cent) said they would choose telemedicine again. “Satisfaction with telemedicine and home use of mifepristone and misoprostol is high,” concluded the report. Of course there are always risks with any medical procedure but complications are rare (a 2019 data set found complications were reported in 337 of 207,384 cases in 2019). During the at-home scheme, the government says it is “aware of a small number of incidents” which it is currently investigating.

To reverse the policy now would not only lose the accessibility benefits, and other bonuses like reduced waiting times, but experts also fear reversing the provision could have the dangerous unintended side effect of diverting more women to illegal methods of abortion. Prior to the pandemic, research showed on average two women per day in the UK sought their own online abortion medication due to obstacles accessing in-clinic care. Ending a pregnancy with pills purchased online remains a crime in England, with a potential prison sentence.

In an open letter to Matt Hancock, published on 14 May by a coalition of charities, it said requests for pills had fallen by 88 per cent with the advent of telemedicine in England. “Vulnerable women who may have previously used illegal pills have instead been able to access legal care, and in doing so have not risked criminalisation. If the government were to revoke permission for telemedicine, women would once again turn to illegal online pills,” it says.

The government now faces a decision about whether telemedicine stays or has to go. Between November 2020 and February this year it ran a six-month consultation asking whether the service should become a permanent measure, be ended immediately when the Coronavirus Act expires, or be continued for a period of a year or two years for further consultation.

There would be no justification to remove [it] unless there was a political desire to cause more distress

Jonathan Lord, medical director for MSI Reproductive Choices says that access to telemedicine is “one of the few positive outcomes of the pandemic’’ and that given the compelling evidence there “would be no justification to remove [it] unless there was a political desire to cause more distress and difficulty for women”. Dr Edward Morris, president at the Royal College of Obstetricians and Gynaecologists (RCOG) agrees there is “no medical reason not to make the current telemedicine service permanent”.

Dr Morris also warns of the power of “erroneous and misleading information circulating” about the service poisoning the narrative and “creating a toxic discourse”. Reports of similar rhetoric in the US have argued that in showing the successes of telemedicine it makes it much harder for anti-abortion lobbyists to reiterate the dangers and harms of abortion.

As the government weighs up its choice, those who have accessed the service largely speak to its accessibility, quality, and the power of choice it provides. For Twyla, she says lawmakers have “no business policing our bodies” when it comes to a service that is already “emotionally complex” for those in need. As society looks back on how the pandemic has upturned everything we knew about how we work, it is crucial to differentiate between those elements that should revert back and those for which the new normal provides a better future.

A Department of Health and Social Care spokesperson told The Independent: “Safe and continued access to key services has been our priority throughout this global pandemic. We have now completed a consultation on whether to make the current measure permanent and we are carefully considering all of the responses received. We will published our consultation response in due course.”

*Some names have been changed for anonymity