First published by The Pool on 12 November 2016
If I found myself pregnant under circumstances that were dangerous, ill-advised or unhappy, I would have no moral objection to seeking an abortion. 185,824 women in England and Wales made that decision last year and yet the procedure is still a taboo-enough topic that I can count on the fingers of one hand the friends who’ve told me about theirs. Nobody really talks about abortion – so perhaps it’s no surprise then that, when we think of it, we tend to picture only surgical procedures and legs in stirrups. The truth is that for the majority of women going through this in the UK today, the chosen method is far less invasive and far more discreet: the abortion pill.
We often refer to it in the singular, but getting a medical abortion actually involves two drugs, taken 24 to 48 hours apart: Mifepristone and Misoprostol. Mifepristone is taken first; it reduces pregnancy hormones and softens the neck of the womb, encouraging the foetus to detach. Misoprostol then causes the womb to contract and these contractions expel the contents of the uterus, but also stop the bleeding.
The medication has been available on the NHS for 25 years, though it’s taken a long time to become a common choice. “Mifepristone received its licence in the UK in 1991 – we were one of the early countries to get approval for it,” says Dr Sam Rowlands, secretary and founding member of the British Society of Abortion Care Providers (BSACP). “To begin with, people weren’t familiar with it, so it took some time to become more widely used. In 2005, the proportion of abortions done medically was 24 per cent. 2014 was the first year where there were more medical abortions than surgical abortions and, in 2015, it had gone up to 55 per cent of them being done medically.”
In the UK, terminations can be carried out in three main ways: under general anaesthetic, under local anaesthetic or by medication. Many women would rather avoid a general anaesthetic; the NHS would probably rather avoid it too, where appropriate, because the cost of using an operating theatre and an anaesthetist makes the procedure more expensive than the alternatives. For most women, the more appealing choice is between the other two options – a walk-in, walk-out procedure under local anaesthetic, or a medical abortion – but the former is not always available. “Performing surgery is obviously a lot easier if the patient can’t move around, so it’s slightly more complicated to offer abortion under local anaesthetic,” says Rowlands. With this method often not within reach, the abortion pill is in many cases the best solution.
Abortion in the UK, regardless of method, is considered extremely safe. “It’s vanishingly rare to have very serious complications,” says Rowlands. The most common problem with the abortion pill is that it can fail to end the pregnancy, which Marie Stopes estimates at a risk of between 1 and 14 in 1,000 – women are advised to follow up with a test. Most risks of the pill, though, are similar to those of an ordinary miscarriage: infection, pregnancy tissue retained in the womb and bleeding. “The chance of having very heavy bleeding, heavy enough to go to hospital, is one in 1,000.”
For most women, the process of taking the pill is unpleasant, but manageable. Mia, who lives in Cornwall, was only offered one possible date for a surgical abortion and couldn’t get leave from work – so she opted for the drugs. “It wasn’t nice, obviously,” she says. “But, for me, the pain was quite minimal – it was like a heavy period. You can feel yourself passing larger things; it kind of feels like big blood clots.” Laura, a Belfast-based teacher who bought the pill online, recalls vomiting some time after she took the Misoprostol. “I was really quite violently sick – but, once that passed, it was OK; it was just like a period. Instantly, I knew I wasn’t pregnant any more.”
Laura is one of an increasing number of women in Northern Ireland and the Republic of Ireland who have tapped into another of the pill’s advantages: it makes it easier for women to access abortion secretly and safely in countries where it’s not legal. The charity Women On Waves estimates that 25 per cent of the world’s population lives in countries with highly restrictive abortion laws. Most of these countries are in Latin America, Africa and Asia. And yet abortion access has been seriously reduced in the USA in recent years (in Texas, 82 clinics have been closed since 2011; Donald Trump has also threatened to defund Planned Parenthood); and there is a small, sad minority of European countries where abortion is almost impossible: Poland, Malta, the Republic of Ireland and Northern Ireland.
In England, Wales and Scotland, the 1967 Abortion Act means the procedure is legal up to 24 weeks, if approved by two doctors and carried out by a doctor in licensed premises. In Ireland, it is only legal when the mother’s life is at risk – and even that exception hasn’t always been respected: Savita Halappanavar died of septicaemia in Galway in 2012, having been refused an abortion even though she was having a miscarriage. It’s long been said that Ireland exports its abortions; an Amnesty study last month found that almost 15,500 women travelled to England or Wales for a termination between 2010 and 2012 – an arduous and expensive mission. “We know that the abortion pill has made it much easier for women who live in countries with very restrictive laws to access abortion when they need to,” says Katherine O’Brien, media and public policy manager for the British Pregnancy Advisory Service (BPAS).
However, as with anything on the unregulated mess that is the internet, the market for abortion pills ranges from the reputable to the unsavoury. “There are many, many websites where the products are of dubious quality,” says Rowlands. “They may be nothing, they may be paracetamol, they may even be toxic substances – we don’t know anything about them. So, obviously, extreme caution is needed.”
Laura got the medication through the website Women On Web, a clinician-led, non-profit organisation that has been supplying the abortion pill since 2006. BPAS and the BASCP don’t recommend that women use online abortion pill services (“We would much rather they could access this care at a clinic, with medical support and advice,” says O’Brien), but do confirm that this site and another non-profit, Women Help Women, are highly regarded sources dispensing genuine medication.
According to Women On Web founder Dr Rebecca Gomperts, the organisation is contacted by 10,000 women a month, from all over the world. Those who need the pill start with an online consultation. “They get a questionnaire about their health, about the whole situation, and then a doctor will field the request and prescribe the medicine, and the pharmacy that we work with mails it out. In the meantime, there’s a help desk available to answer questions.” Help is available in 17 languages.
This process is much more affordable than travelling overseas. “We ask women for between 70 and 90 Euros, depending on their economic situation,” says Gomperts. “If they can’t afford it, they get it for free – nobody has ever been refused access to help. You cannot deny a woman a service that she so badly needs because she doesn’t have money.” Women who can afford it often pay more than €90, in order to subsidise others.
For Laura, the main concern was not the expense, but the fact that she was breaking the law. “I was panicking,” she says. “I thought, ‘The police are going to come to my door – they’re going to have caught on.’ It could have been really bad; career-wise, there’s no way I would have been able to keep up the teaching.” She told her husband that if the pill caused complications and he had to take her to the hospital, he mustn’t mention the medication she’d taken. “I remember saying, ‘Promise me you will not do that. Promise me you won’t.’”
If women do experience complications, advises Gomperts, they should seek medical care and simply tell doctors that they’re having a miscarriage. “There’s no way that anybody can tell that they used the medicine,” she explains. Nevertheless, it is frightening to be unable to tell the truth to a doctor. Earlier this year, BPAS launched a helpline for women in Northern Ireland, the Republic of Ireland and the Isle of Man (where abortion is legal but very difficult to obtain), offering medical advice to those who have bought the drug from Women On Web or Women Help Women. “We know that women in these countries might be afraid to seek follow-up medical advice or treatment, for fear of prosecution,” says O’Brien. “So we wanted to provide this helpline to enable them to check that their symptoms were normal, and also just to provide reassurance at what can be a really scary time.”
The fear of prosecution is not unfounded – in April of this year, a young Belfast woman was given a suspended prison sentence for ending a pregnancy with pills bought online. Gomperts believes that she was let down by her lawyer. “I think that if she had had good legal advice, they would have made a totally different court case,” she says. “There have been so many international human-rights agreements protecting the right to have access to a safe abortion that these laws have become obsolete – it’s only that the proper court case hasn’t come up yet. This is why, if women face legal challenges, it’s so important that they have good lawyers.”
It’s true that human-rights organisations have long criticised countries that restrict abortion so severely: in the case of Amanda Mellet, who was denied an abortion in 2011 even though she’d been told her foetus could not survive birth, the UN ruled that Ireland had violated her right to freedom from cruel, inhuman and degrading treatment. In time, these condemnations and the unstoppable wave of abortion medication may bring change. The stakes could not be higher: “You know, women die when abortion is illegal,” says O’Brien. “We have to remember that – the ultimate cost to women is their lives.”