When I was 30 years old, I found out that I was pregnant for the first time. It was an odd experience for someone who was sure with every fibre of their being that they would like to be a mother one day, in whatever form that takes. I say 'odd' because almost immediately upon reading the result on the pregnancy test, I knew that I wasn’t going to be able to continue the pregnancy; not because I wasn’t physically capable, but because emotionally, I wouldn’t be able to.
Trying to navigate the complex decision-making involved with terminating a pregnancy, I felt completely at sea. While many people in my orbit were having babies and taking leaps forward into their adult lives, I was stuck. I knew I could no longer carry the pregnancy, but I was naive as to what to expect when terminating it, and what this process would involve. With a basic knowledge of physiology, though, I had assumed that the process would be similar to that of a friend who had experienced a miscarriage, and was surprised to find out that they are dealt with very differently at a medical level, despite the fact that the majority of the physical and psychological implications are similar.
Most women who opt to terminate a pregnancy in England, Wales and Scotland are referred by the NHS to an abortion service. There are three of these, including the British Pregnancy Advice Service (BPAS); Marie Stopes UK; and the National Unplanned Pregnancy Advisory Service (NUPAS). From then on, the process is managed by the abortion service, and this can vary depending on their own internal processes, but in all instances, women are given the option of deciding between a medical or a surgical procedure, depending on the maturity of the pregnancy.
A surgical procedure, which is considered more invasive by some, involves a minor procedure with either a local or general anaesthetic. A medical procedure, which was opted for by 9 out of 10 women terminating pregnancies in 2018, involves the use of two different pills, mifepristone and misoprostol, which are taken orally and vaginally. Recent successful campaigning by the British Pregnancy Advisory Service (BPAS) led to the successful passing of legislation to allow women to take the second pill at home, in order that they have some control over how and when the process is initiated. Because of the fact that abortion services are managed and delivered by different organisations, though, the relevant processes can vary from case to case, making it difficult to be able to advise women with real clarity on what to expect.
Decriminalisation would mean that abortion and miscarriage could become standardised procedures
Miscarriages, on the other hand, are overseen by a centralised NHS service. In the case of a miscarriage, depending on the maturity of the pregnancy, women can opt for either a medical or a surgical procedure, or what is known as 'expectant management', which involves waiting for the pregnancy to pass on its own, with no intervention. Although these procedures are (with the exception of expectant management) medically identical to what women go through during an abortion, the experience is overseen within the NHS and can therefore vary in terms of how patients are informed of what to expect, and the administration of the processes involved.
When Gemma_,_ a teacher from Yorkshire, was 29, she had a medical abortion at a clinic in London. 'The most shocking part for me, was that the nurse made me insert the misoprostol pills myself rather than doing this for me,' she says. 'It’s hard to explain, but there was an added layer of guilt attached to initiating the process myself, which was already extremely emotionally complex.' This echoes the experience of Jen, who has had both a medical abortion and a medically managed miscarriage, and was surprised when, during the latter, she had two consultants present for the procedure, and that the misopristol was inserted for her by a medical professional. 'It seemed so inconsistent, so I asked the doctor why this was, and they said that if the pills aren’t inserted properly, then the procedure is much less likely to work, which I found so shocking.'
According to Clare Murphy, executive director of external affairs at BPAS, there is no medical evidence to suggest that this is true. However, she does believe that any inconsistency in the delivery of abortions is the product of the fact that the legislation around abortion in the UK is outdated and restrictive. 'Until we have a situation in the UK where abortion is completely decriminalised,' she says, 'a patient-centric model of abortion care and service will be impossible'.
The original legislation, written in 1861, known as the Offences Against the Person Act (OAPA) stated that having or providing an abortion was a crime, which carried a potential life sentence. The 1967 Abortion Act neither decriminalised abortion nor removed the OAPA, but merely allowed for physicians and patients in England, Wales and Scotland to terminate a pregnancy if they met certain requirements. This means that an abortion remains the decision of the medical practitioner, and not the woman in question. Two doctors must sign off on an abortion in order for it to be legal, and failure to meet these requirements could technically result in prosecution. This makes abortion the only routine medical procedure that requires legal authorisation in addition to the patient’s consent. This has informed how the entire system is built and operates, and affects everything from consistency in the delivery of care to how women are advised when facing this difficult experience.
'It is important to recognise that different women want different things,' says Murphy, 'and we need to provide a system that allows for this. Decriminalisation would mean that abortion and miscarriage could become standardised procedures, allowing for the NHS to build a more patient-centric model that allows for women to have greater control over their experience.'
Ultimately, as a society we need to address why women’s health is so under-researched and misunderstood. But decriminalisation of abortion would have a huge positive cultural impact for women’s rights, bringing legislation in line with moral thinking around the issues. The statistics tell us time and time again that creating barriers to abortion in any country doesn’t reduce their prevalence, it just places the lives of women seeking to end a pregnancy for whatever reason at risk. Decriminalisation is the only logical step, and would go some way to normalising a distressing life experience which, according to BPAS, one in three women will experience in their lifetime. The stakes could hardly be higher.