Briefing on the proposal to regulate termination of pregnancy in early pregnancy (12 weeks): Medical abortion
Summary
Medical abortion or abortion via medication (pills) is routinely and safely used throughout the world in the first 12 weeks of pregnancy. It is an early, safe and effective alternative to surgical abortion that generally involves the use of two medicines (mifepristone and misoprostol1) to end a pregnancy. In countries where abortion care is legal, these medications can be prescribed by a doctor and can be taken at home during the first nine weeks of pregnancy. After that time, they are normally taken under medical supervision, that is accessed through a doctor, a clinic or a hospital.2 Medical abortion is very effective and has become the most common method of abortion before 12 weeks.
The inaccessibility of legal and safe abortion in Ireland exposes women and girls to significant harms not experienced by women in countries where access to abortion is lawful.3 A woman who opts not to continue a pregnancy is forced outside the Irish healthcare system and the entire burden of accessing care is placed on her shoulders, rather than on the healthcare system where it belongs. At least 3,265 women travelled to Britain to access a legal abortion in 2016.4 However, not all women can travel for abortion care. The ability to travel for abortion care implies that a woman has the money for travel and for treatment, a passport to get in and out of the country, and that she is physically well enough to make the journey.
Women in Ireland are increasingly accessing abortion in early pregnancy using abortion pills. These are purchased online, unregulated and taken at home in a clandestine manner and are currently illegal. While no one knows exactly how many women and girls take medical abortion pills, at least 1,748 women and girls living in Ireland ordered abortion pills from just one online provider—Women on Web—in 2016. Another online provider – Women Help Women – reported that 878 women used its service in 2017, an increase of 190% on 2016. In the first quarter of 2018, 323 women have accessed a medical abortion, a 90% increase on the same period last year.6
While the option of medical abortion is generally safe and effective, it cannot be considered acceptable healthcare as it does not reflect an active preference, but the lack of safe options and alternatives. Those using abortion pills do so without medical guidance and are less likely to seek medical help if they experience any complications in part due to fear of legal prosecution and a potential 14-year prison sentence for accessing illegal abortion.7 Under the Protection of Life During Pregnancy Act 2013, any woman who uses pills to end a pregnancy, and anyone who assists her, could face prosecution and a maximum 14-year sentence.8
Factors driving the increase in self-use of medication obtained from online providers
Women living in Ireland who decide not to continue with a pregnancy are increasingly turning to online providers of abortion pills—even though it is illegal to take them in Ireland—rather than travelling to the UK. There are many reasons why.9
Cost is a significant factor. Importing abortion pills is more affordable than financing a journey to the UK to access safe and legal abortion as a private patient. Making this journey also involves the need to organise practicalities, such as time off work for the woman and her partner, and in many cases childcare. The journey itself can be arduous, especially for women who live outside the major cities, who may face many hours of travel to get to an airport and many hours more for the onward journey to a clinic in an unfamiliar city. And these women must then make the return journey while still recovering from the procedure Others cannot leave the state—for example because of migrant status, age, lack of necessary travel documents or disability—and simply have no other option. In these circumstances, it is not surprising that some women feel they can better protect their privacy and dignity by self-managing an abortion in their own home.
Health risks
- The World Health Organization (WHO) informed the Joint Oireachtas Committee (JOC) that clandestine self-use of abortion pills without back-up care services fails to meet the criteria of what the WHO regards as safe. While medical abortion is very safe when provided within a clinical setting, online providers are unregulated. A woman has no way of knowing if any information she receives is accurate, nor if the medication ordered is effective or safe.10
- Women inadvertently risk accessing medication which could be inactive, inadequate or potentially harmful. A woman must use the medication without the supervision of her doctor or with only limited online support. She must take all the responsibility for her medical safety and well-being during a period of extreme stress and anxiety.
- Complications of medication abortion are rare, but if they do arise, fear of prosecution makes women fearful of going to their doctors or presenting at a hospital. Women are increasingly presenting with complications after taking products whose pharmacological content or safety is unknown.
- There is no continuity of health care for these women nor for those who are forced to travel to seek abortions in other countries. This puts their health at risk and causes unnecessary trauma for women. Additionally, there is no follow-up contraceptive counselling and care that normally accompanies a legal abortion.
The Case for Removing the 8th Amendment
Removing the 8th Amendment from the Constitution will pave the way for women to access safe and legal abortion in the first 12 weeks of pregnancy. It will provide a safe, regulated alternative to, and eliminate the risks associated with, the use of online abortion pills outside the law. It will also address the harms experienced by women who travel abroad to access abortion.
Access to early abortion care in the first 12 weeks of pregnancy will address the needs of all the women and girls in Ireland who are currently ordering online abortion pills illegally.
The continued prohibition of abortion will only lead to further growth in women accessing illegal abortion pills online and expose them to under-regulated providers, lack of follow-up care including contraception, fear of seeking medical care for complications, stigma and fear of prosecution.
Notes
1. Both medications are on the WHO list of Essential Medicines. See World Health Organization Model Lists of Essential Medicines. 20th Edition, March 2017. http://www.who.int/medicines/publications/essentialmedicines/20th_EML2017_FINAL_ amendedAug2017.pdf?ua=1
2. See British Pregnancy Advisory Service (BPAS) overview of medical abortion: https://www.bpas.org/abortion-care/abortion-treatments/the-abortion-pill/abortion-pill-up-to-10-weeks/
3. Sally Sheldon. “How can a state control swallowing? The home use of abortion pills in Ireland.” Reproductive Health Matters 2016; 24(48): 90-101.
4. Figures released by the Department of Health UK. Available at https://www.gov.uk/government/collections/abortion-statistics-for-england-and-wales
5. Aiken ARA, Gomperts R & Trussell J. Experiences and Characteristics of Women Seeking and Completing At-home Medical Termination of Pregnancy Through Online Telemedicine in Ireland and Northern Ireland: A Population-based Analysis. British Journal of Obstetrics & Gynaecology. 2017: 124(8): 1208-1215.
6. See Women Help Women: https://womenhelp.org/en/blog
7. Abigail Aiken, “Opening Statement to the Joint Oireachtas Committee on the Eighth Amendment to the Constitution” October 11th 2017 http://www.oireachtas.ie/parliament/media/committees/eighthamendmentoftheconstitution/Opening-Statement-by-Professor-Abigail-Aiken,-University-of-Texas.pdf
8. Protection of Life During Pregnancy Act 2013. Section 22
9. See Sheldon (2016) and Aiken (2017)
10. WHO Briefing for the Joint Committee on the Eighth Amendment of the Constitution. Available at http://www.oireachtas.ie/parliament/media/committees/eighthamendmentoftheconstitution/Opening-Statement-by-Dr.-Ronald-Johnson-and-Dr.-Bela-Ganatra,-WHO.pdf