The government is currently consulting the public about home use of early medical abortion pills, a policy introduced last March as a temporary measure due to the pandemic. The key question in the consultation is whether allowing abortion providers to prescribe abortion pills over the phone, and then send them to women in the post, should be made permanent.

It is important to spell out that the evidence being put forward by the abortion lobby in favour of home abortion is deeply flawed and highly selective.

In an article typical of those supporting the measure, Kerry Abel of Abortion Rights says, “It is completely unnecessary to have to attend a clinic two days in a row to take a pill.” I expect many people might think such a statment was reasonable, especially during the pandemic. But it is misleading at best. A clinic consultation before an abortion has never been just about taking the pills. Women are clinically assessed to determine if a medical abortion is suitable for them, the gestation of the pregnancy is established by an ultrasound scan (a crucial consideration when the pills can only be used up to a certain gestation), consent is gained, and the woman is seen alone, which could, in theory, help to ensure that she is not being coerced.

The current rules, on the other hand, allow a doctor to send the abortion drugs to a woman without ever having seen or examined her in person. The woman then has to self-manage the abortion, at home, possibly alone, and with little or no medical supervision or follow up care.

It is worth examining some of Kerry Abel’s claims about home use of early medical abortion pills (or, as we prefer to call it, DIY abortion) in detail. She makes many sweeping statements about the safety, efficacy and patient satisfaction of the process, which merit exploration.

Firstly, she links to a series of studies, which she says support her claims. The provenance of these studies is worthy of mention; the most cursory examination reveals that one is authored by Rebecca Blaycock, who works for BPAS, one of Britain’s largest abortion providers and a staunch advocate of DIY abortion. Another involves Rebecca Gomperts, who for many years has made a living posting abortion pills to women, including in countries where it is illegal. So these authors are hardly the most disinterested observers.

But what is wrong with the studies Abel makes use of? She says: “International scientific evidence and studies clearly demonstrate the safety and clinical appropriateness of women taking both of the abortion pills at home time and again.” In fact, she cites just one study, carried out in Kazakhstan (by Gynuity Health Projects, which, according to it’s website, “has been at the forefront of efforts to increase women’s access to medical abortion in settings throughout the world”).  While the study does conclude that “outpatient medical abortion with mifepristone and misoprostol is safe and effective up to 70 days of pregnancy”, what Abel doesn’t mention is what an outlier this study is. The work is out of step with just about any other study on telemedicine abortion – it showed a 99% abortion completion rate, which is almost unheard of, and no adverse events, which is also completely unheard of. In contrast, in the Women on Web (the outfit run by the aforementioned Rebecca Gomperts)  telemedicine abortion study by Endler et al. (2019), it was found that surgical intervention was needed for 12.5% of women with gestational age of less than 9 weeks, and 22.6% for women over 9 weeks.

Other studies show that even with the use of abortion pills in a clinical setting, blood transfusion occurs at up to 0.6%, and infection at about 0.9%.  In a Swedish study by Carlsson et al. (2018), not only was there a doubling in the rate of complications in 2015 compared with 2008 (a period spanning the increasing home use of Misoprostol), but for the year of 2015 itself, for gestations of less than 7 weeks, the rate of complications was 3-fold higher for home use compared with clinic use.^[1]

So Abel is selective with the literature available. She is also selective about which parts of the studies she quotes. She refers to a 2017 study in which a woman tells of her experience of bleeding on the bus home from a clinic appointment. What she doesn’t include is what the same study says about the traumatic nature of medical abortion. In this Scottish study, different women spoke of ‘agony’, ‘such a physical and emotional process’, ‘day was absolutely horrific’, ‘I bled so much … it’s pouring out’, ‘in hindsight I wished I hadn’t looked but I did, and that was probably the most traumatic thing I’ve ever seen or done’, ‘if [friend had] been there and seen me screaming like that …’.^[2] 

Abel is also selective in talking about the plight of women who are victims of domestic abuse. The suggestion that domestic violence may stop a woman accessing abortions services is undercut by research showing that rather than stopping access to abortions, intimate partner violence is related to coercion, violence and women seeking abortion.^[3]

 It is both unbalanced and disrespectful to women that the only reference to domestic violence in this article is to argue in favour of the provision of an unattended secretive abortion, rather than dealing with the reality of coercion and pressure to abort identified in many studies.  Women may  choose to keep their child if they are supported and protected from coercion and violence.^[4]

Even where a victim of domestic abuse is seeking an abortion, is encouraging her to undergo the process with only the abuser present really the best we can do for her? One woman who told her story to the Mail Online said: “The next day I felt really sick, faint and dizzy. I’m still bleeding even now, a few weeks on. Because my partner is here and doesn’t know what I did, I’ve not been able to ring anyone for any advice.”

When she isn’t selectively quoting studies, Abel tries to shut down debate by accusing anyone who raises concerns of hating women. She says: “Any talk of women lying about their gestation times or trying to con doctors into allowing their abortions comes from a deeply misogynistic distrust of women.” This is far easier to say than to actually engage with the fact that women have definitely been taking the pills after the legal cut-off of ten weeks. There are reported cases of babies being born as late as 28 weeks, after their mothers took pills sent in the post. A mystery client investigation found that abortion providers accepted without question women taking part in the exercise changed the date they gave for their last period during the telephone consultation, in order to obtain pills when their fictional pregnancy was later than ten weeks gestation. Even if you argue that no woman in real life would ever lie, it is hardly reassuring that it is so easy to game the system.

However, lying or conning doctors  is not really the issue. What is true is that accurate assessment of the gestational age of the baby (GA) is not straightforward because recall of last missed period (LMP) is not always accurate, failure to use ultrasound, or delaying taking the drugs because of ambivalence or other pressures. 

In a Women on Waves Brazil study of telemedicine abortion, despite the requirement for a GA of  less than 9 weeks, a third of women took the drugs at a GA of 10 weeks or more (Gomperts et al. 2014).  This suggests that self-managed telemedicine abortions could actually lead to later abortions instead of earlier ones, contrary to what Abel claims.

Finally, there are many concerns with telemedicine abortion that Abel just doesn’t engage with at all. What about missing ectopic pregnancies? What about the mental health impact on women from the trauma of going through the abortion at home, and having to dispose of the pregnancy remains? What about the fact that this change came in with no parliamentary scrutiny, and we were explicitly told that it was a temporary measure?

The Government’s consultation asks what should happen to the home abortions approval. Selectively quoting the evidence, ignoring legitimate concerns and trying to brand those who raise them as misogynists can’t hide the fact that the measure is riddled with problems and that women deserve better. Kerry Abel’s “evidence” is no basis upon which to make DIY abortion permanent. It should end immediately.