2017–19 governmental decisions to allow home use of misoprostol for early medical abortion in the UK

Should we Relax Abortion Reporting Requirements in Great Britain?

In Great Britain, abortion has long proven to be contentious in the context of policy making, with it remaining a criminal offence. Despite progress over the last decade to permit home use of abortion medications and remote consultation, we have seen prosecutions in recent years. Regulatory frameworks such as this have been framed as 'abortion exceptionalism', such that termination of pregnancy is far more tightly regulated than comparable healthcare. One example of this exceptionalism is the strict abortion reporting requirements found in Great Britain. Per these requirements, any doctor providing abortion care must notify the relevant Chief Medical Officer or Public Health Scotland of each and every termination, including a startling amount of information about the patient. The extent of these requirements raises serious questions in relation to patient confidentiality and is, I suggest, an outlier in these terms. Further, it is questionable whether such reporting can be in any way said to be in the public interest. I begin by outlining the Abortion Regulations 1991, which apply in England and Wales, before considering the updated Scottish approach brought about by the Abortion (Scotland) Amendment Regulations 2021. I then move to examine the abortion reporting requirements against our general conception of patient confidentiality, highlighting the discordance. I ultimately argue that the requirements are not adequately justified and represent yet another, often forgotten, example of abortion exceptionalism in Great Britain. Thus, I suggest that all three nations that comprise Great Britain ought to further revise their approach to abortion data.

Structural stigmatisation of abortion in the health system: Perspectives of abortion care-seekers, providers, managers, and funders in England and Wales

Abortion has been legally permitted in England and Wales for over fifty years, yet this health service continues to be stigmatised within the health system. Stigma is a dominant focus of abortion research, but a structural stigma framework is rarely used to understand how abortion stigma is produced at a macro-level. This study explored how structural abortion stigma is produced and experienced in the health systems of England and Wales, and its influence on person-centred care, including choice of abortion methods. Data from in-depth interviews with abortion care-seekers in 2022-23 and from key informant interviews with abortion care providers, managers, and commissioners in 2021 were analysed using reflexive thematic analysis. From the perspectives of key informants, structural abortion stigma is produced through the avoidance of abortion by decision-makers, the permitting of conscientious objection, and the exclusion of abortion from mainstream healthcare. These factors create health system pressures which increase abortion service fragility. The resulting vulnerability of abortion services reduces access to person-centred care, including abortion method choice, which can reinforce individual-level stigma. There are tensions between care-seekers' experiences of specialist abortion care as less stigmatising, while the 'abortion clinic' becomes a site of stigma due to its segregation from mainstream healthcare. This research contributes to a structural understanding of abortion stigma by identifying some of the mechanisms through which structural stigma is produced within health system institutions, and how these forms of institutional stigma might be resisted or dismantled. Power is essential to the (re)production of structural stigma within the health system, which can reinforce individual-level stigma for both care-seekers and providers. Restrictions on method choice and the increasing reliance on medication abortion can be a product of structural abortion stigma, and these limitations on method choice can also reproduce stigma at the individual level.

Abortion Access and the Benefits and Limitations of Abortion-Permissive Legal Frameworks: Lessons from the United Kingdom

This paper argues that abortion access is an important subject for bioethics scholarship and reflects on the relationship between legal frameworks and access to care. The author uses the example of the United Kingdom to examine the benefits and limitations of abortion-permissive legal frameworks in terms of access. These are legal frameworks that enable the provision of abortion but subject to restrictions. An abortion-permissive regime-first in Great Britain and then in Northern Ireland-has gone some way to improving access to care over time. However, aspects of the regime (that lead to its description as permissive rather than supportive of abortion) have the potential to endanger abortion access in the future and so legal reform is necessary.

Improvidence, Precaution, and the Logical-Empirical Disconnect in UK Health Policy

The last decade has seen significant developments in UK health policy, with are largely claimed to be evidence based. However, such a characterisation ought, in many cases, to be questioned. Policies can be broadly understood as based primarily on either a logical or empirical case. In the absence of relevant empirical evidence, policymakers understandably appeal to logical cases. Once such evidence is available, however, it can inform policy and enable the logical case to be set aside. Such a linear policy process is not always the reality, and logical cases often continue to guide policy decisions in direct opposition to empirical evidence. In this paper, I discuss two recent examples of this disconnect between logical and empirical cases in UK health policy. The first-organ donation-illustrates an example of a significant policy change being made in opposition to the evidence. I refer to this as the improvidence approach. The second-abortion-provides an example of policymakers not making a change that has extensive supporting data. I refer to this using the more recognisable language of the precautionary approach. Ultimately, I argue that both the improvidence and precautionary approaches are examples of problematic public policy where policymakers provide no explicit justification for going against the evidence.

COVID-19 health policy evaluation: integrating health and economic perspectives with a data envelopment analysis approach

The COVID-19 pandemic is a global challenge to humankind. To improve the knowledge regarding relevant, efficient and effective COVID-19 measures in health policy, this paper applies a multi-criteria evaluation approach with population, health care, and economic datasets from 19 countries within the OECD. The comparative investigation was based on a Data Envelopment Analysis approach as an efficiency measurement method. Results indicate that on the one hand, factors like population size, population density, and country development stage, did not play a major role in successful pandemic management. On the other hand, pre-pandemic healthcare system policies were decisive. Healthcare systems with a primary care orientation and a high proportion of primary care doctors compared to specialists were found to be more efficient than systems with a medium level of resources that were partly financed through public funding and characterized by a high level of access regulation. Roughly two weeks after the introduction of ad hoc measures, e.g., lockdowns and quarantine policies, we did not observe a direct impact on country-level healthcare efficiency, while delayed lockdowns led to significantly lower efficiency levels during the first COVID-19 wave in 2020. From an economic perspective, strategies without general lockdowns were identified as a more efficient strategy than the full lockdown strategy. Additionally, governmental support of short-term work is promising. Improving the efficiency of COVID-19 countermeasures is crucial in saving as many lives as possible with limited resources.

The Case for Telemedical Early Medical Abortion in England: Dispelling Adult Safeguarding Concerns

Access to abortion care has been hugely affected by the COVID-19 pandemic. This has prompted several governments to permit the use of telemedicine for fully remote care pathways, thereby ensuring pregnant people are still able to access services. One such government is that of England, where these new care pathways have been publicly scrutinised. Those opposed to telemedical early medical abortion care have raised myriad concerns, though they largely centre on matters of patient safeguarding. It is argued that healthcare professionals cannot adequately carry out their safeguarding duties if the patient is not in the room with them. These concerns lack empirical support. Emerging evidence suggests that safeguarding processes may, in fact, be more effective within telemedical abortion care pathways. In this article, we address two specific safeguarding concerns: (1) that a remote consultation prevents a healthcare professional from identifying instances of abuse, and (2) that healthcare professionals cannot reliably confirm the absence of coercion during a remote consultation. We demonstrate that such concerns are misplaced, and that safeguarding may actually be improved in telemedical care pathways as victims of abuse may find it easier to engage with services. It is inevitable that some individuals will fall through the net, but this is unavoidable even with in-person care and thus does not constitute a strong critique of the use of telemedicine in abortion care. These safeguarding concerns set aside, then, we argue that the current approval that enables telemedical early medical abortion should be afforded permanence.

The impact of COVID-19 on abortion access: Insights from the European Union and the United Kingdom

Government policies on abortion are a longstanding topic of heated political debates. The COVID-19 pandemic shook health systems to the core adding further to the complexity of this topic, as imposed national lockdowns and movement restrictions affected access to timely abortion for millions of women across the globe. In this paper, we examine how countries within the European Union and the United Kingdom responded to challenges brought by the COVID-19 crisis in terms of access to abortion. By combining information from various sources, we have explored different responses according to two dimensions: changes in policy and protocols, and reported difficulties in access. Our analysis shows significant differences across the observed regions and salient debates around abortion. While some countries made efforts to maintain and facilitate abortion care during the pandemic through the introduction or expansion of use of telemedicine and early medical abortion, others attempted to restrict it further. The situation was also diverse in the countries where governments did not change policies or protocols. Based on our data analysis, we provide a framework that can help policy makers improve abortion access.

2020 developments in the provision of early medical abortion by telemedicine in the UK

The COVID-19 pandemic has necessitated the rapid implementation of telemedical health services. In the United Kingdom, one service that has benefitted from this response is the provision of early medical abortion. England, Wales, and Scotland have all issued approval orders to this effect. These orders allow women to terminate pregnancies up to certain gestational limits, removing the need for them to contravene social distancing measures to access care. However, they are intended only as temporary measures for the duration of the pandemic response. In this paper, we chart these developments and further demonstrate the already acknowledged politicisation of abortion care. We focus on two key elements of the orders: (1) the addition of updated clinical guidance in the Scottish order that suggests an extended gestational limit, and (2) sunset clauses in the English and Welsh orders, as well as an indication of similar intentions in Scotland. In discussing these two issues, we suggest that the refusal of UK governments to introduce telemedical provision of early medical abortion previously has not been based on health concerns. Further, we question whether it would be appropriate for the approval orders to be lifted following the pandemic, suggesting that to do so would represent regressive and harmful policy.

Legal and policy responses to the delivery of abortion care during COVID-19

Access to abortion care has long been a global challenge, even in jurisdictions where abortion is legal. The COVID-19 pandemic has exacerbated barriers to access, thereby preventing many women from terminating unwanted pregnancies for an extended period. In this paper, we outline existing and COVID-specific barriers to abortion care and consider potential solutions, including the use of telemedicine, to overcome barriers to access during the pandemic and beyond. We explore the responses of governments throughout the world to the challenge of abortion access during the pandemic, which are an eclectic mix of progressive, neutral, and regressive policies. Finally, we call on all governments to recognize abortion as essential healthcare and act to ensure that the law does not continue to interfere with providers' ability to adapt to circumstances and to guarantee safe and appropriate care not only during the pandemic, but permanently.