The Success Of At-Home Abortion During The Pandemic Has Shown Us Another Way

Photographed by Meg O'Donnell
In 2019, before the coronavirus pandemic, 23-year-old Alana* from Kent found out that she was pregnant. It was a complete accident: she had been using condoms when one broke. Knowing the emergency drill, she went straight to an NHS drop-in to get the morning after pill. But that failed her too. 
Alana knew she couldn’t have the baby, it wasn’t the right time. Halfway through her second year at university in Birmingham, she had just come home for the Easter break. Her boyfriend was on a lads' holiday in Krakow. She knew he wouldn’t be alone so she didn’t want to text him about it. Instead she sat with the knowledge that she was pregnant for four days and told him over FaceTime when he got back. 
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"He agreed I’d done the best thing by waiting," she reflects, "but those four days were horrible. I felt like I was going behind his back." Alana estimates she was around three weeks pregnant at the time, based on the tests she took and the date of her missed period. "Finding out was so shit," she says. "When I look back now, I realise how much societal stigma is attached to an unexpected and unwanted pregnancy. I had internalised all of that and piled it on myself. I felt stupid, even though I know now that I did everything I could to prevent it."
Abortion has been legal in most of the United Kingdom since 1967 but shame and stigma persist regardless. Alana describes feeling "guilty" and like her situation was something she needed to "keep secret because it was shameful."

Ending a pregnancy is a time-sensitive matter.

Ending a pregnancy is a time-sensitive matter before you even factor in the mental health implications of living with a pregnancy that you know you don't want to carry to term. Alana’s feelings of shame and stress were compounded when she rang around different abortion providers in her area to see if she could get an appointment. "I wanted to see if I could get an appointment to sort things out asap and realised how long the wait was," she explains. "It just made me feel even more vulnerable."
In Kent, Alana was looking at a wait of roughly four weeks in her hometown. "The wait was so long that it meant it would actually be term time again by the time of the appointment," she explains. This was despite the fact that, according to current NICE (National Institute for Health and Care Excellence) guidelines, while "waiting times can vary" around the country, nobody should "have to wait more than two weeks from their initial appointment to having an abortion." As the Royal College of Obstetricians and Gynaecologists (RCOG) notes, this should mean that providers are "aiming to provide women with an initial appointment within one week of requesting one and undertaking the procedure within one week of the appointment." It's worth noting that some parts of the country stipulate an even faster turnaround for those who need this service; NHS Wales says that women living there shouldn't have to wait more than five working days.
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If she had waited four weeks, Alana would have been around seven weeks pregnant. Because the limit for an early or medical abortion is nine weeks, she felt this was cutting it fine. 
"I called different providers – the NHS, BPAS and Marie Stopes – but the wait was roughly the same," she explains. "I was worried about being away from home, I was worried about my housemates back in Birmingham finding out and I was overwhelmed by the logistics of it all but I had no choice."
When faced with an unwanted or problematic pregnancy, you can visit your GP or local sexual health clinic to get a referral but you can also refer yourself for an initial appointment by contacting one of the UK’s two main abortion providers: the British Pregnancy Advisory Service (BPAS) and MSI Reproductive Choices (formerly Marie Stopes). If you are in the early stages of pregnancy (generally before nine weeks) then you can have a medical abortion. This involves taking two pills – mifepristone and misoprostol – 24 to 48 hours apart to induce a miscarriage. Under the 1967 Abortion Act, prior to the pandemic it was necessary to attend a clinic in order to obtain and take these pills. Another option, which tends to happen after nine weeks (although you can have a medical abortion after nine weeks in some circumstances), is a surgical abortion, which can involve one of two more invasive procedures carried out under anaesthetic. It's not hard to see why time matters: missing the cut-off for an early medical abortion means you may have to undergo an altogether different and more invasive procedure.
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The longer I waited, the more anxious I felt. Waiting meant the pregnancy was hanging over me. It was constantly in the back of my mind and I couldn't stop worrying. It would have been better for my mental health if I could have been booked in sooner.

Alana
For years, medical experts at RCOG, BPAS and MSI Reproductive Choices have been calling on politicians to make early medical abortion more accessible. This would make an enormous difference to all women but particularly those with childcare responsibilities, key workers or, indeed, those on zero-hour contracts for whom it can be difficult to take time out to attend multiple appointments. For some time, the consensus has been that women should be able to take mifepristone and misoprostol at home after a telephone consultation with a doctor (known as telemedicine).
In April last year, because of the pandemic, this change was finally realised. However, the Department of Health left people in no uncertainty that these changes to abortion legislation were temporary and only to "stop the spread of coronavirus", not because they were in women’s best interests. Prior to the telemedicine service being approved, anyone seeking an abortion needed to attend in person to receive a clinically unnecessary ultrasound scan and take the medication used to bring about an abortion within the clinic. Under the coronavirus guidelines, consultations were encouraged to take place by telephone or video call and medication could be taken at home, with an ultrasound scan only being required if needed. According to the largest ever study of UK abortion care carried out by researchers at the University of Texas at Austin, BPAS, MSI Reproductive Choices and the National Unplanned Pregnancy Advisory Service, allowing women to have abortions at home throughout the pandemic has provided a safe, effective and more accessible service. It has even reduced waiting times.
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The study analysed the outcomes of more than 50,000 early medical abortions that took place in England, Scotland and Wales between January and June 2020, both before the telemedicine service was introduced and after. The aim was to compare data and see how the telemedicine service compares to the service before. The study found that:
- The effectiveness of the treatment remained the same for abortions carried out through the traditional service and the telemedicine service.
- There were no cases of significant infection requiring hospital admission or major surgery. Contrary to misleading claims, no person died from having an early medical abortion at home.
- Eighty percent of women said telemedicine was their preferred option and they would choose it in the future.
In response to the widespread support for these changes to the delivery of early medical abortions, the government opened a consultation – which closed on 26th February – to decide whether to make the changes permanent. Last month it was announced that at-home cervical screening tests are to be trialled in a bid to cut waiting times which, experts say, risk more people dying from cervical cancer. The move has been described as a "gamechanger" for cervical cancer screening which will save lives. Why not also continue with at-home abortion?
Professor Dame Lesley Regan, chair of RCOG’s abortion task force, told Refinery29: "There is no medical reason not to make the current telemedicine service permanent. Waiting times from when the woman had her consultation to her treatment improved from 10.7 days to 6.5 days."
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This is significant. Refinery29 sent Freedom of Information (FoI) requests to NHS Clinical Commissioning Groups (CCGs, the bodies which manage local NHS services) and NHS Trusts across England to find out their average waiting times for both surgical and early medical abortions before the pandemic. We've decided to publish the results on International Women's Day because they have shown that change is possible. While some CCGs and Trusts said that they do not hold this information, the data from those who responded reveals that Alana’s area wasn't the only one missing the two-week waiting time benchmark. More than this, in some areas they were actually rising. 
Here are some of the worst areas where average abortion waiting times exceeded the suggested two-week period before 2020:
– In Brighton and Hove, the average waiting time for a medical abortion rose from 11.6 to 16.1 working days between 2016 and 2017. It has since dropped back down to 13.4 working days. 
– In the same area, the wait for a surgical abortion rose from 16.2 to 24.4 working days between 2016 and 2017 and was at 22.1 working days in 2018. 
– In Cambridgeshire and Peterborough, the average waiting time between first contact and first attended consultation appointment for an early medical abortion rose from 9.9 days in 2013 to 12.7 days in 2018. For surgical abortions, it almost doubled, rising from 12.9 days in 2013 to 23.5 days in 2018.
– In Hambleton, Richmondshire and Whitby the average waiting time for an early medical abortion rose from 14 days in 2013 to 21.2 days in 2018. For surgical abortions, it went from 18.7 days in 2013 to 24.5 days in 2015, 26.4 days in 2016, then down to 24 days in 2018.
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– In Harrogate and Rural District the wait for an abortion was 10.2 working days in 2016 but rose to 14.5 in 2017 and 16.8 in 2018.
– In Kernow, average waiting times had also risen. The average waiting time for a medical abortion rose from 9.9 days in 2013 to 12.9 days in 2018. For surgical abortions, it rose from 14.1 days in 2013 to 21.4 days in 2017 and 19.5 days in 2018.
- In Bexley waiting times for both medical and surgical abortions increased significantly, almost doubling between 2009-15. The average waiting time for a medical abortion rose from 3.8 days in 2009 to 12 days in 2017 and back down to 8 days in 2018. For surgical abortions, there was a rise from 5.4 days in 2009 to 12.3 days in 2012 and back down to 11 days in 2018.
In other areas, waiting times also increased but did not exceed the recommended two-week wait. And in eight areas (Sheffield, Luton, Somerset, High Weald Lewes Havens, Lewisham, Mid Essex, Southwark and Calderdale) waiting times actually improved. However, what this data shows is that in too many places, women were waiting longer than they should have been for an abortion. The success of at-home abortion throughout the pandemic has shown us that there is another way.
"The longer I waited, the more anxious I felt," Alana says. "Waiting meant the pregnancy was hanging over me... It was constantly in the back of my mind and I couldn’t stop worrying. It would have been better for my mental health if I could have been booked in sooner."
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Similarly, 23-year-old Natalie found out that she was pregnant at around five or six weeks after missing a period. She went straight to a sexual health clinic in south London where she was told to expect a 10-day wait. 
In the end, she says she waited 40 days from her first referral appointment to her termination. By this point she was 13 weeks pregnant and past the limit for a medical abortion. 

The impact of having to wait several weeks to get an abortion lasts much longer than the waiting time itself. Going through all the symptoms of pregnancy – the hormonal changes, sore breasts – when you know you're not going to carry it to term makes it so much worse.

Natalie
"I can definitely say it impacted my mental health," she says now, reflecting on what she went through. "I do think the wait times played a huge role in this."
"The impact of having to wait several weeks to get an abortion lasts much longer than the waiting time itself. Going through all the symptoms of pregnancy – the hormonal changes, sore breasts – when you know you’re not going to carry it to term makes it so much worse. The hormonal changes, physical side effects, overthinking your decision – despite the fact you’re 100% sure you’re doing the right thing – these all intensify, the longer you’re left waiting," she adds. 
"Initially," Natalie says, "I was told the wait time should be no more than 10 days but in the end I had to wait six weeks and I’m only just processing the impact of that on my mental health."
The reason for not having at-home abortion prior to coronavirus can be traced back to the 1967 Abortion Act, which states that an abortion must be authorised by two doctors. As the campaigners who facilitated the 1967 Act have noted, this is a hangover from the fact that abortion was deemed taboo for a long time and is rendered a criminal offence because of a piece of legislation known as the Offences Against The Person Act. The Royal College of Obstetricians and Gynaecologists says there is no medical reason for two doctors to sign off and backs the full decriminalisation of abortion in England and Wales. 
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No woman wants to be pregnant for any longer than necessary once that decision has been made.

BPAS
It is clear not only that long waiting times were putting a strain on women and pregnant people, both physically and mentally, but that they could have been avoided in the case of early medical abortions through telemedicine. In turn, this would have taken pressure off services delivering surgical abortions. If at-home abortion were to become the norm, it would transform the lives of women who need it. Barriers to accessing such a vital service, like extended waiting times and being forced to make unnecessary trips to a clinic, mean that some women – particularly those in unstable work or in abusive relationships – are penalised and placed at risk.
Early medical abortions are extremely safe. Complications occur in less than 1% of abortion procedures. It is delays to abortion care – with long waiting lists for appointments in an already-overstretched healthcare service – which risk increasing complications. And so, like the introduction of at-home cervical screening tests, making at-home abortion a permanent fixture would improve quality of life for women and people with wombs. It would prevent the anguish that both Natalie and Alana experienced.
"One argument I hear time and again is that changing abortion laws makes it ‘easier’ to get an abortion and will lead to more women choosing to have one," Professor Regan concludes. "Indeed, some may believe that keeping abortion difficult to access, more unpleasant to undergo and more dangerous, will persuade women to continue their unwanted pregnancy. Well, reducing access to abortion doesn’t make it any less common but it does make it less safe."
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A spokesperson for BPAS said that "reducing waiting times are a very important part of providing an abortion service" because "once a woman is sure of her decision, she needs to be able to access care as soon as possible."
"No woman wants to be pregnant for any longer than necessary once that decision has been made," they added.
As for why waiting times might have been rising, BPAS explained: "Abortion is a service that relies on the dedication of a small number of healthcare professionals around the country – trying to treat clients as close to their community as possible, and to ensure that every woman has the opportunity and ability to consider her decision for as long as she needs. But the impact of that can be that seemingly small operational issues can have a big knock-on effect on the local and national service – meaning increased waiting times."
They added: "BPAS does everything it can to see women as fast as possible in what has been a challenging environment, and waiting times are decreasing all the time."
Professor Sharon Cameron, consultant gynaecologist and spokesperson for the Royal College of Obstetricians and Gynaecologists, said: "Clinical guidelines recommend minimal delay in the abortion care process. Ideally, women should have an initial appointment within one week of requesting one and the abortion within one week of the appointment. Abortion care services need to be improved to make it easier for women to access them."
Dr Patricia Lohr, medical director at BPAS, said: "Telemedicine is a safe, effective and patient-centred way of providing early medical abortion. Telemedical abortion care has protected women’s health and wellbeing during the pandemic, and women have told us how much they value the service and want it to continue so other women in the future can benefit. While other healthcare services have been suspended or seen significant increases in waiting times during the pandemic, access to abortion has not only been maintained but has improved, enabling women to end pregnancies at the earliest possible gestations."
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"At a time when the NHS is under severe strain, the ability to provide a better service that women prefer at a lower cost is rare. It would make no sense for the government to remove a service model that has clear benefits to the health and wellbeing of patients. The government are now in a position to secure a world-leading reproductive healthcare framework, and we urge the secretary of state to do so by making telemedical abortion care a permanent option."
A Department of Health and Social Care Spokesperson told R29:
“Safe and continued access to key services has been and remains our priority during this unprecedented period. The current temporary measures allow eligible women to take both pills for early medical abortion up to 10 weeks’ gestation at home, following a telephone or e-consultation with a clinician."
“The Government’s consultation on whether to make the current measure permanent has now closed. We will carefully consider all of the responses received, and plan to publish the Government’s response later this year.”
*Names have been changed to protect identities
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