Abortion in the 21st Century: Home Administration of Misoprostol in Early Medical Abortion

29 April 2018

What is early medical abortion?

Early medical abortion (EMA) is the most common type of abortion procedure in England and Wales. It is carried out up to 9 weeks’ gestation and involves taking two medications: mifepristone and misoprostol. Mifepristone ends the pregnancy by blocking the hormone progesterone, and misoprostol induces contractions in order to expel the pregnancy. Although these two medications can be administered simultaneously, they are more effective, and the side effects are reduced, if misoprostol is administered 24–72 hours after mifepristone. This means that women often need to attend a clinic twice for their EMA treatment.

Following the administration of misoprostol, women are usually given the option of either staying in the clinic until they have passed the pregnancy, or travelling home. The majority of women choose to leave, so that they can pass the pregnancy in the comfort and privacy of their own homes. Before leaving, they are given a supply of pain relief, prophylactic antibiotics, detailed information about what to expect, and the number of a 24/7 telephone line which they can call with any questions or concerns.

The current legal framework surrounding the administration of abortion drugs

The circumstances under which abortion drugs can be administered in England and Wales are governed by the Abortion Act 1967, which provides that:

“…any treatment for the termination of pregnancy must be carried out in a hospital…or in a place approved for the purposes of this section by the Secretary of State [for Health]”.                                                                                                                              Section 1(3), Abortion Act 1967

When the Abortion Act was initially passed in 1967, the treatment that Parliament had in mind was purely surgical. Given the risks inherent in any surgical operation, it was perfectly reasonable to require that the procedure should be carried out in a hospital or clinic. However, over the next few decades a non-invasive method of termination, known as ‘medical abortion’, was developed.

In 1990, anticipating the introduction of this safer method of abortion, Parliament decided to insert a new clause into the Abortion Act 1967. Section 1(3A) gives the Secretary of State the power “to approve a class of places” for “the use of such medicines as may be specified”. When proposing the insertion of this clause to the House of Commons, Kenneth Clarke, the Health Secretary at the time, explained that:

“As the law stands, if no power such as that contained in the amendment is provided, it will continue to be necessary for the patient to have the drug administered in a hospital or other approved place. There is no medical reason for that.”                              HC Deb 21 June 1990, Vol. 174, Col. 1201

Why should women be allowed to self-administer misoprostol at home for EMA?

The cramps and bleeding triggered by misoprostol usually start about 1–2 hours after administration, however they may start sooner. This means that some women begin to expel the pregnancy, or completely expel the pregnancy, whilst travelling home. This is undoubtedly a distressing experience, and one that does not need to occur given the proven safety of administering misoprostol at home. It is also logistically difficult for many women to attend a clinic on two separate occasions. This particularly applies to women who live in rural locations, those with work and childcare commitments, and those in controlling family environments.

Home administration of misoprostol for EMA is standard practice in countries around the world, such as France, Sweden and the USA. Many studies have been conducted to assess the safety, efficacy and acceptability of this regimen, and the evidence in this area has been so conclusive that the World Health Organization states in its guidance:

“Allowing home use of misoprostol following provision of mifepristone at the health-care facility can further improve the privacy, convenience and acceptability of services, without compromising on safety.”               Safe Abortion: Technical and Policy Guidance for Health Systems (2012), p.44

Although British researchers have largely been hindered from carrying out work in this area by the legal restrictions placed on them, guidelines have been updated in accordance with the findings of studies carried out abroad. The Royal College of Obstetricians & Gynaecologists states in their guidance that:

“…published data do not suggest any clinical reason why women should remain in hospital during their abortion, and demonstrate that it is safe for women to administer misoprostol at home.”                                        The Care of Women Requesting Induced Abortion (2011), p.72

Crucially, the accepted safety of home administration of misoprostol is demonstrated by the fact that it is legal in England and Wales for women who are diagnosed with an incomplete miscarriage to self-administer misoprostol at home. The treatment for incomplete miscarriage and EMA is the same; however, it has to be delivered in a completely different manner due to Section 1(3) of the Abortion Act 1967. This double standard makes the process unnecessarily more distressing for women undergoing EMA.

Support for changing the law

In 2011, the British Pregnancy Advisory Service (BPAS) brought a legal challenge against the Department of Health in an attempt to change the law to allow for home administration of misoprostol in EMA. Unfortunately, they were unsuccessful; however, the High Court judgment reiterated that Section 1(3A) of the Abortion Act 1967 gives the Secretary of State:

“the power to approve a wider range of place [for the administration of abortion medications], including potentially the home”.                                                                                                    British Pregnancy Advisory Service v Secretary of State for Health [2011] EWHC 235 (Admin) [32]

Last year, the Scottish Parliament (to whom power over abortion law was devolved in 2016), took the decision to allow home administration of misoprostol in EMA. The Public Health Minister, Aileen Campbell, said that:

“Scotland is now the only part of the UK to offer women the opportunity to take misoprostol at home when this is clinically appropriate, a decision that allows women to be in control of their treatment and as comfortable as possible during this procedure”.

As part of its current campaign to decriminalise abortion – We Trust Women – BPAS continues to work towards changing the law in England and Wales to allow for home administration of misoprostol in EMA. BPAS is supported by the Women’s Equality Party, which published an open letter on 29 March 2018 to the Secretaries of State for Health in England and Wales, calling for a change in the law. The letter was written by a woman called Claudia, who underwent EMA and endured a distressing taxi journey home from the clinic following the administration of misoprostol.

Progress finally seems to be on the horizon in Wales, where Vaughan Gething, the Secretary of State for Health, confirmed on 17 April 2018 that his officials are looking into how the law can be amended to allow for home administration of misoprostol in EMA. At the time of publication, Jeremy Hunt, the Secretary of State for Health in England, remains notably silent on this issue.

Andrea Adams, MA, Registered Nurse, and Non-practising Solicitor; andrea.adams7@gmail.com