Leanne Morgan1 and Ralph Roberts2*
Received:September 17, 2021Published: October 4, 2021
Corresponding author:Ralph Roberts, Consultant Obstetrician and Gynaecologist, South-eastern Health and Social Care Trust, UK
Recent legal changes restricting abortion in Texas have focused attention on the continuing issue of a lack of reproductive freedom for women. This affects women in many countries throughout the world including Northern Ireland. The 1967 Abortion Act, which established legal access to abortion in the rest of the United Kingdom (UK), never applied in Northern Ireland (NI). Prior to a recent change in the law, abortion was illegal in NI with the exception of very limited circumstances. The options for women were either to continue with the pregnancy, travel to services in Great Britain or to access abortion pills from the internet. The choices available to NI women have increased since the decriminalization of abortion on 22 October 2020, following the passing of the Northern Ireland (Executive Formation etc.) Act 2019. However, despite this liberalization of the legislation, abortion services are yet to be commissioned. It is for this reason that the Northern Ireland Abortion and Contraception Task group (NIACT) continues to lobby politicians, policymakers, and commissioners on the issue of commissioning.
NIACT is a multidisciplinary, multisector group which was set up by health professionals seeking to influence abortion policy following decriminalization. It includes Obstetricians and Gynecologists, Sexual and Reproductive Health (SRH) doctors, a GP, nurses working in SRH, the Chair of the Northern Ireland Committee of the Royal College of Obstetricians and Gynecologists, the current and past Directors of the Royal College of Midwives in Northern Ireland, the NI chair of the Faculty of Sexual and Reproductive Healthcare, representatives from Informing Choices NI and Common Youth, and academics with a research and policy interest in abortion. Within this membership, there is representation from each of the five NI Health and Social Care (HSC) Trusts . At the point of formation, NIACT’s purpose was to provide input into the commissioning, implementation and development of local services. However, it soon found itself directly establishing services without any funding or support from the Department of Health (DoH).
The Abortion (Northern Ireland) (No. 2) Regulations 2020
came into effect on 31 March 2020 just after UK travel restrictions
were imposed in response to the COVID-19 pandemic . For the
first time since implementation of the 1967 Abortion Act, women
were unable to travel to England to access abortion care. Despite
abortion being recognized as an essential service by the World
Health Organization (WHO), Royal College of Obstetricians and
Gynecologists (RCOG) and Faculty of Sexual and Reproductive
Healthcare (FSRH), accessing services posed significant challenges
for women from NI. The only option for travel at the height of the
first wave was an eight-hour freight ferry, with no accommodation
at the other side, and the very clear risk of COVID transmission. The
grave human rights and patient safety implications soon became
apparent when two women faced with these options attempted to
take their own lives. NIACT convened an emergency meeting on the 30th of March 2020. It was determined that an interim Early Medical
Abortion (EMA) service could be established within existing NHS
Sexual and Reproductive Health services across the five HSC Trusts
until a comprehensive abortion service could be commissioned.
Implementing emergency services was deemed to be feasible
due to a downturn in clinical activity because of the pandemic.
Senior Management support in two HSC Trusts had been secured
and services were ready to commence on the 2nd of April 2020.
However, Health and Social Care (HSC) Trusts were instructed by
the Department of Health to cease and desist as the health minister
wished to take the matter to the NI Executive. Following a week of
intense media and political lobbying, the Chief Medical Officer gave
the go ahead for services to commence on the 9th of April 2020.
Most of the clinicians working within services had previously provided abortion care outside of NI; online training resources were also utilized. Clinic protocols, policies and patient information leaflets were quickly produced in line with the RCOG/National Institute for Health and Care Excellence (NICE) guideline on abortion care. Templates for telephone consultations and treatment were designed for the online system, Lilie. A referral pathway was established in partnership with Informing Choices NI (ICNI), a charity that agreed to be the Central Access Point facilitating selfreferral, initial assessment and safeguarding. This enabled easy access to services and also offered optional pregnancy choices and post-abortion counselling. Commencing in three HSC Trusts initially, services were quickly rolled out to all five. However, the limitations of such non-commissioned services soon became apparent with temporary cessations of provision at different times within three Trusts due to the absence of funding.
Since April 2020, data has been collected on the number of women self-referring to ICNI, accessibility to Trust services, waiting times, patient outcomes, contraceptive uptake, and service user feedback. In the first twelve months 2,182 women referred themselves to the central access point and just over 80% of these proceeded to EMA treatment. A more detailed analysis was performed in the first 3 months of the service in the Belfast Trust. During this period, the Belfast HSC Trust received the largest number of referrals (252; 48.0%). Of these, 212 (84%) received EMA treatment. The mean waiting time was 1.58 days and the average time between consultation and treatment was 0.81 days. The mean age of the women was 28.9 years. Some 126 (59.4%) women were parous and 86 (40.6%) were nulliparous. Eighty-six (40.6%) had a dating ultrasound scan, most commonly for conception while on hormonal contraception (30; 34.9%) or uncertain last menstrual period (LMP) (23; 26.7%). In line with the regulations, all patients received mifepristone at the clinic and misoprostol at home. All were less than 10 weeks gestation. Sixtyfour (30.2%) were less than 6 weeks gestation (VEMA). Half of the women (108; 50.9%) opted for LARC either by subdermal implant (57; 26.9%) or intrauterine contraception (51; 24.0%)
EMA is currently available in four Trusts; the temporary suspension of the service in one Trust due to a lack of staff has now extended to over 6 months. In the absence of commissioning, permanent staffing has not been put in place, and the service has relied heavily on the good will of conscientiously committed clinicians. Demand remains high with over 40 women per week selfreferring to ICNI. Uptake of long-acting reversible contraception is high and service user feedback is excellent. Mifepristone is not permitted for home use in NI, necessitating a clinic visit. Due to the temporary cessation of three Trust services, and the absence of surgical services or treatment beyond 10 weeks gestation, many women have still needed to travel to England during the pandemic. Nonetheless, the NI experience of NHS integrated SRH services to date, provides a solid foundation for the commissioning of services going forward.
On 30th March 2021, NIACT published a report providing an evidence-base and setting out a forward-thinking strategy to inform the funding and commissioning of integrated sexual and reproductive healthcare, including abortion, for the population of Northern Ireland. Unfortunately, political obstacles have so far prevented this commissioning from taking place despite recent interventions by the Secretary of State for Northern Ireland. Not only does this threaten the sustainability of the individual EMA services, but also the Central Access Point provided by ICNI on which the EMA services depend. A further challenge is the protests outside EMA clinics by anti-abortion pressure groups, some of which are directly funded from the USA. Whilst the actions of these protestors have not been as extreme as those witnessed at some US clinics, they do deter women from attending, and make the experience of attending unpleasant for many of those do choose to avail of the services provided.
In Northern Ireland the journey to abortion reform began through grass-roots activism, and service implementation has been no different. Legal liberalization and the initiative of service providers has resulted in a high quality, local EMA service. However, obstruction by religiously conservative politicians has led to a continued lack of commissioning, and this threatens to negate many of the gains that have been made. As in the USA, achieving reproductive freedom for women in Northern Ireland continues to be an ongoing battle.
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