Every Monday EFC busts myths and takes names, cutting through the misinformation, disinformation, and straight up nonsense to bring you the facts. For today's Myth-Busting Monday, following a ruling on this issue in the High Court, we ask is it really better for women to have to make multiple clinic visits to have an Early Medical Abortion?
It may seem intuitive that a clinic is the best place for an Early Medical Abortion (EMA), but there is no medical evidence to support this. Given the lack of evidence for current EMA protocols, it is hard to see what benefit there is in forcing women to come into the clinic for the second part of their abortion medication unless a) we think women are too stupid to remember to take their medication at home or b) we think we should make the process as hard as possible for them. Like many sexual health organisations in the UK Education For Choice would like to see access to abortion made as straightforward as possible. Today's ruling was a lost opportunity to do this.
What was the court case all about?
When a woman has an Early Medical Abortion she requires two separate kinds of medication. The first, mifepristone, causes the lining of the womb to start to fall away. The second, taken 24-48 hours later, is called misoprostol. This medication causes the cervix to soften and stimulates contractions that accelerate and complete the process of miscarriage.
The protocol in the UK (because of the way in which the 1967 Abortion Act has been interpreted) is that women must return to the clinic for an additional visit 24-48 hours after taking the first medication and must take the second stage of the medication in the clinic.
Bpas – the independent abortion provider - took a case to the High Court to request a ruling that the wording of the Abortion Act could be interpreted in such a way that a woman having received the first part of the EMA treatment at the approved clinic could have the choice of taking the second part of her medication at home. The judgment, published today, did not support this new interpretation.
At home / in the clinic – what’s the difference?
For some women it may be preferable for her to take misoprostol and complete her abortion in a clinic, away from the responsibilities or lack of privacy she may experience at home. For women who are young, vulnerable or have additional health issues, having some professional care in a clinical setting may be more appropriate than going home.
For other women it is preferable to experience the completion of her abortion in the comfort of her own home, rather than on a hospital ward. This may be because she is just happier at home, because she has difficulty travelling to a clinic, because she has caring responsibilities at home that are hard to rearrange, or for any number of reasons. Women in the US, France and Sweden are routinely given the second part of their abortion medication to take at home and there is no evidence that they either forget to take the medication or that they find this experience unacceptable. For many women, a return visit (which, including consultations, may be her third or fourth visit) to a clinic is burdensome. They would be happy and able to take home the second part of the abortion medication and follow the instructions on the prescription as to when and how to take it – as people all over the country do with medication every day (even women apparently manage this process !).
Education For Choice and our colleagues in Voice for Choice ,the UK pro-choice coalition, think that once a woman has made the decision to have an abortion, the process should be as straightforward as possible for her. We do not believe there is any intrinsic benefit in requiring all women to return to a clinic to receive the second part of her medication. We would like women to have a choice as to whether they undergo the second part of their abortion on a ward with professionals on hand, or at home.
Is it safer to come back to the clinic for an abortion?
Those opposed to giving women misoprostol to take home often assume that it is safer for her to be given it in a clinical setting, but the latest evidence-based guidance on induced abortion from the Royal College of Obstetricians and Gynaecologists supports the provision of misoprostol at home. In 2007 the House of Commons Science and Technology committee scrutinising the Abortion Act, concluded that there was no reason regarding ‘safety, effectiveness, or patient acceptability’ that should prevent Parliament from allowing women to take the medication at home.
So what actually happens in UK clinics and does it provide any real benefits over letting the woman take the medication at home?
Depending on the clinic there are a range of different EMA protocols in place. The most common are:
Give the woman the pill/insert the pessary on the clinic premises, but allow her to leave immediately. The woman may feel this is a wasted journey, but at least she may be able to get home before the bleeding begins.
Give the woman the pill/insert the pessary and require that she stays on the premises for a set amount of time (normally based on the average time it takes to complete an early medical abortion). She may complete her abortion during this time and be discharged, or may be discharged before her abortion has taken place in which case – with every passing hour – the likelihood of the bleeding beginning on her journey home is increased. Women have reported beginning bleeding and cramping on public transport which is surely the worst case scenario.
Education For Choice and our colleagues in Voice for Choice the UK pro-choice coalition think that once a woman has made the decision to have an abortion, the process should be as straightforward as possible for her. We do not believe there is any intrinsic benefit in requiring all women to return to a clinic to receive the second part of her medication, but would like women to have a choice as to whether they undergo the second part of their abortion on a ward with professionals on hand, or at home.
In today’s ruling the judge made it clear that it is up to the Secretary of State for Health to define the places in which an abortion can take place, and that this definition can be informed by ‘changes in medical science’. He ruled that the Secretary of State has “the power to approve a wider range of place, including potentially the home, and the conditions on which such approval may be given relating to the particular medicine and the manner of its administration or use.” In the light of today’s ruling and all the evidence from countries where misoprostol is routinely taken at home, we hope that the Secretary of State for Health will approve ‘the home’ as a place in which abortion medication can be taken.