Parliament voted to make telemedicine for early medical abortion permanent: but consider the details

13/05/2022 Comments Off on Parliament voted to make telemedicine for early medical abortion permanent: but consider the details

A commentary, revised 15 May 2022

This commentary is about the vote in Parliament on 30 March 2022 to retain telemedical abortion or end its use at the end of August 2022, treating that date as also representing the end of the Covid-19 pandemic in the UK.[1] A great deal of good lobbying and organising took place behind the scenes to achieve this outcome. I did not participate and I hope others will record and share their description of these efforts. Following the vote, members of Voice for Choice expressed their delight at the outcome. I too am very glad about this outcome, but what I do not understand is what happened to deliver it, as it is a very unusual story and I want to try and unravel it a bit.

According to the first paragraph of the Parliamentary webpage that records votes, the vote was 215 for retaining telemedical abortion and 188 against, with 250 MPs not voting.[2] Here is the breakdown of the votes by party:

To get a breakdown of the parties and how their members voted, I counted them manually here, as follows:

This is an unusual breakdown in votes, and leads to the immediate question of why so many MPs did not vote, particularly Tories, but also Labour. There are only two obvious reasons why some MPs didn’t vote: if Scotland had already made the decision to retain telemedical abortion independently, the 45 SNP MPs may have decided not to vote on the question for everyone else.[3] If they hadn’t already decided, they would equally feel they could not decide for the rest of the country either. On the other hand, the Welsh Government had definitely announced on 24 February 2022 that their temporary telemedical arrangements would be made permanent,[4] yet Plaid Cymru’s 3 MPs did vote and said yes.

As regards the Tory members, I am told that they had a “conflict”, in that the Government had written to and directed all the members of the Tory Party to vote NO. When such a “command” is given, it is quite difficult for MPs to ignore, as everyone knows. On the other hand, for those who follow the rules – because this was about abortion – everyone should have been given a free vote, which was acknowledged by Edward Argar for the government when the debate on this matter opened.[5] In the event, 184 out of 359 Tories (51%) did not vote NO.[6] It would be interesting to know their reasons.

The reasons why so many Labour MPs did not vote, including Keir Starmer, are also unclear, and from my point of view (as a member of the Labour Party), their reasons would be hard to justify. It is hard to swallow the thought that there may be more Tory MPs who didn’t vote because they are pro-choice while so many Labour MPs didn’t vote because they are not pro-choice. But this is speculation.

The bottom line, however, is that whatever the 112 MPs’ reasons for not voting were, the outcome could easily have been different. Yet the views of the non-voters are unknown and completely opaque.

Under temporary rules introduced by the Government during and because of the risks of transmitting Covid-19, the two kinds of pills used for an early medical abortion (up to 10 weeks’ gestation) can be used at home, following a telephone or video consultation with a qualified nurse, midwife or doctor. [Please note that before the pandemic, the mifepristone was taken in front of the doctor and the misoprostol was used at home, where the abortion occurred). In England, the Department of Health and Social Care announced in February 2022 that the temporary approval had been extended to 29 August 2022, at which point it would end because the pandemic would be over (sic).

The World Health Organization (WHO) has for some time supported self-care with medical abortion pills up to 12 weeks of pregnancy.[7] Not surprisingly, the Faculty of Sexual & Reproductive Health, the Royal College of Obstetricians and Gynaecologists and many others expressed their concern about the Government’s decision, because it flew in the face of solid clinical evidence and survey data showing that telemedicine for early medical abortion is safe and effective and that a large majority of women were satisfied with using the pills at home or even preferred it, especially when a 24/7 phone support line was open if they needed information or help. Two major changes took place when access to the pills became possible in this way: first and most importantly from women’s perspective, abortions overall could and did take place more than a week earlier than previously. Unnecessary routine examinations, particularly an ultrasound scan and routine blood tests, were finally dropped as clinically unnecessary.

Secondly, the organisation of abortion service delivery by the two main independent providers of NHS-funded abortion care – BPAS and MSI – changed substantially. To reverse that after two years, back to a system that was more costly and is now effectively out of date, would have been difficult and costly.  

What the government actually appeared to prefer, given that the Secretary of State for Health and Social Care (Sajid Javid) and the Public Health Minister (Maggie Throup) are according to the media both apparently anti-abortion, was that the issue would not come to a vote in Parliament at all. There had been a so-called public consultation on the subject earlier in the year, in which all the members of the anti-abortion group Right to Life apparently sent in individual letters opposing telemedical abortion, which added up to somewhat more (numbers wise though) than the number of supportive letters from a wide range of NGOs, health professional associations and many other organisations and individuals. Ms Throup declared that the “vote” against was greater than the “vote” for, as if the value of the vote of the individuals (especially since most were from one group) equated to that of e.g. a medical association. She therefore announced that telemedical abortion would be stopped. The total lack of understanding on her part of how to manage and interpret a public consultation and how to measure the views expressed was astounding.

So, our side got busy. In March, the House of Lords voted through an amendment tabled by Baroness Sugg to the Health and Social Care Bill (among some 120 other amendments the Lords tabled to that atrocious bill). It would make the telemedical abortion provision in England permanent. The government was thus forced to accept that a vote in the Commons would be necessary. On 30 March, the House of Commons began consideration of the 120+ amendments to the whole bill, and after a debate on telemedical abortion, lasting over two hours, they voted not in support of the Lords’ amendment but in support of a Government amendment to the Lords amendment – reversing the Government’s previous decision but also probably changing the outcome as, in a way, it opened a door for Tory MPs to support it.

The debate opened with a Labour MP suggesting that since Scotland and Wales had both made telemedical abortion permanent, England should follow suit.[8] The Minister immediately rejected this without apparently considering the consequences. The question of what might have happened in a devolved situation, had the vote gone the other way, is worth giving some thought to, however. One imagines women in England wanting to contact e.g. Welsh abortion providers, for example, in order to be able to use the pills at home… would that be illegal, I wonder?

The Minister then tried to argue that the Secretary of State could have ruled on this question without Parliament being involved. He described telemedical provision as “a detail” that did not deserve insertion into primary legislation. Why? Because allowing “that sort of thing” would serve to prevent the Secretary of State from reacting quickly to something, e.g. during a pandemic (a silly argument). He also claimed that “it would create legal uncertainty for women and medical professionals by including wording on the statute book that does not, in fact, change the law in the way it appears to” (meaning unclear) and he therefore proposed an amendment to the amendment. But he had to allow the vote nonetheless. Dr Rosena Allin-Khan for Labour’s health team strongly supported the Lords’ amendment, closing by saying: … “please do not ignore clinical best practice and the expert opinions of organisations and royal colleges”.

Barry Gardiner, Labour MP, said: “I too believe that it is a woman’s right to choose. One of the features of a physical consultation was that it gave the woman an opportunity to do so in a free environment. Does my hon. Friend share the concern that I know exists among many of our constituents that if the consultation is done by telephone, it is possible that a woman who is being coerced will not be understood to be being coerced by the consultant who is dealing with her? It is important that, in preserving the right to choose for the woman, we do not allow a situation in which that woman could be coerced, by a coercive partner, into making a choice that is not her own.” I was listening to the debate live, and I immediately wrote Barry Gardiner an email saying there was no evidence that I am aware of indicating this as a concern. I don’t know if he read the message but in the vote, he supported the amendment. I brought this up in the European Safe Abortion Networking Group a few days later. Unexpectedly, a Swedish colleague in the group said this concern had been raised in the Swedish parliament too. It makes me wonder whether this was one of several anti-abortion “false news” claims, circulated internationally, aimed at making people think that a perfectly acceptable means of having an abortion has dangers.

That became more probable when Fiona Bruce MP, long-time anti-abortion advocate, spoke next and said the all-party anti-abortion group were concerned about that too and 60 of them had written to the Health Secretary to express their many concerns. They claimed that taking the pills at home “without direct medical supervision had led to a number of deeply concerning, unacceptable health and safety risks to women and girls in this country. These included a lack of basic checks by abortion providers before sending abortion pills, and the occurrence of severe complications and later-term abortions due to the lack of in-person assessment.” This is almost all false, however. There are rare cases of women being more pregnant than they thought, but they are so rare that claiming that they invalidate this practice is a mistake. It would be like saying that if another medication causes a bad reaction in a handful of people, it must be removed from the market. In that case, we would have o medications. Bruce went on to press a further point: “…[S]everal women who have needed hospital treatment after taking an at-home abortion pill were clearly many weeks over that limit.” MP Alec Sherbrooke interrupted her at this point to ask: “Can she give data referring to the examples she is giving? I have been struck by the fact that in this debate, I have heard a lot of anecdotal evidence that has not been backed up by any reference to data, and I think that data is important for this debate.” Her reply was that her group, Right to Life, had indeed gathered data, which showed that “…one in 17 women taking abortion pills requires hospital treatment. That means that more than 14,000 women have been treated in hospital following the approval of pills-by-post abortion.”[9] This is pure fantasy, however, as was everything else she said about women being vulnerable, being distressed about having an abortion at home, the large numbers of doctors who are concerned, etc.

Jess Phillips MP spoke passionately in support of telemedical abortion on the grounds that women are adults and capable of making decisions that are safe for them. Like Dr Maria Miller MP she pointed out that the World Health Organization (WHO) says telemedical abortion is safe. She also noted that everyone seems to think telemedicine for all sorts of health care consultation is safe, so why just not for abortion. Try getting to see a GP in person, she suggested, zero chance.

The next speaker, Dr Caroline Johnson, expressed concern about lack of safeguards in giving adolescents under the age of 18 the pills to use at home. She was also worried that not everyone knows how pregnant they are, and may be much later in pregnancy than 10 weeks. She went on to say: “One can only imagine the distress felt by these women and children when they take an abortion pill to deliver what they believe to be a foetus of less than 10 weeks and out comes a baby of up to 30 weeks’ gestation who may at that point have been alive.” While it is true that there have been a few cases in this country of abortions at home beyond 12 weeks (but none at 30 weeks nor with a live fetus with a telemedical consultation), it is also the case that abortions with pills after 10 weeks are safe. The WHO supports telemedical abortion up to 12 weeks, for example. Moreover, abortion with pills is safe throughout the second trimester. In Sweden, for example, it is the main second trimester method used, though always in an outpatient clinic, not at home.

Dr Johnson then raised the issue of not being able to ascertain who actually uses the pills if they are sent by post. Her responses are all anti-abortion, while pretending not to be, using her role as a doctor to make unsubstantiated claims and raise unsubstantiated fears.

Have you ever heard an anti-abortion person acknowledge that women die from complications of illegal, unsafe abortions? I haven’t, not in 40 years. So much for caring about women. Instead, women are ignorant, women are liars, women don’t know how pregnant they are, women are coerced, women don’t know what they want – it’s incredible they don’t just lock us all up for our own protection from ourselves.

The next speaker, Jim Shannon, took the line of “both lives matter”, which for him, he said, means he supports women too… That stance was put to bed when Savita Halappanavar was allowed to die in Ireland a decade ago, and it is unacceptable to use it to justify keeping abortion illegal. He too was concerned about a woman “unexpectedly passing a mature baby at home”. He also questioned data on complications, and said that “the Government and the Minister’s Department say that “data on complications is incomplete”. Then he claimed there was a “well-known link between abortion and domestic violence”. Well, one in four women on average globally will have an abortion in her lifetime and a whole lot of women are subjected to domestic violence – but how are these connected? The connection is that there is coerced unprotected sex, if anything, leading to the request for an abortion. This MP at least said he questioned telemedical consultations with GPs as well, as a lot of his constituents were unhappy about them. This raises a lot of questions about quality of care and the lack of training to do telemedical consultations, but not only in relation to abortion particularly.

Then another doctor,[10] Ben Spencer, spoke and asked: “I have to say that I am unclear about whether we really have positive data to support saying that telemedicine abortions are safe. Is it not more a case of the absence of negative data?” No, it isn’t actually. This doctor clearly hasn’t even read the clinical literature, let alone what the World Health Organization has to say. But then he said he would like to see the government propose new legislation on abortion altogether. Perish the thought!

Thank heavens for Diana Johnson, who talked about trusting women! She continued: “Such is the strength of the evidence that the Welsh Government recently announced that they will be making telemedicine for abortion permanently available. This sends a clear message that, while women in Wales can be trusted to use a healthcare service in a way that meets their needs, women in England cannot. Not only will there be unequal abortion access between the devolved nations, but this decision will lead to health inequalities within England for the most vulnerable and marginalised. I struggle to see how the decision to bring this service to an end after August is in line with the Government’s commitment to put women at the centre of their own healthcare, as detailed in the vision for the women’s health strategy. / Telemedicine has already enabled an estimated 150,000 women to access abortion care at home. Its removal means that every woman, regardless of her personal circumstances and health needs, will be forced to attend a clinic. Lords amendment 92 would ensure that women can continue to access a consultation with a clinician by telephone. To make it crystal clear to everybody, very importantly, face-to-face consultations will still be available.”

Yes, evidence from 150,000 cases! There’s nothing like facts!! She went on to list the many organisations that support telemedical abortion and then said: “What I find most disappointing is that the Government are going against a wealth of robust and widely accepted peer-reviewed evidence from medical professionals and women’s charities, and appear to give greater weight to anecdote, erroneous opinion and misinformation focused on campaign groups with extreme views who bombarded a consultation. Sadly, that further emphasises that this is not an evidence-based policy decision.” And then she added: “Finally and crucially, women themselves strongly favour keeping telemedicine for early medical abortion. A clear majority want it to continue.

It took this long in the debate for the truth about what women have said even to be raised. One further, strong statement about supporting the amendment because it is based in evidence and is the right thing to do, led to the next speakers moving away from abortion and taking up the subject of tobacco… but only for a few minutes. A Northern Ireland MP, Carla Lockhart, brought it back again, again claiming telemedical abortion “presents huge risks to women’s health and safety”. Then she went into a rant about a 16-year-old who used the pills at home and was taken to hospital when feet appeared from her vagina, and the girl was found to have a 20-21 week pregnancy.

I don’t know whether this particular report was true or not, I would need to see the published evidence. But as I said above, such cases will happen, but they are rare.

At this point, the anti-abortion false news had been repeated far too often, and had begun to get boring. One might ask what the connection is between thinking that embryos are more important than women when a pregnancy is unwanted, and using false claims to support your views. Misogyny comes to mind. I had more respect for the anti-abortion movement in the days when they were simply against abortion. At least one could then say: far enough, then don’t have one.

Ms Lockhart’s rant got several MPs on their feet. Edward Leigh gets the prize for telling the biggest lie of all. First, he claimed that “this is not a debate about abortion” and then that “it is undoubtedly the case that more than 10,000 women who took at least one abortion pill at home provided by the NHS in 2020 needed hospital treatment”.

Thank heavens for MP Matt Warman, who is pro-choice and spoke strongly on that basis, who began by saying: “I rather think that men should enter the debate on abortion with a degree of trepidation and humility…

After another diversion about tobacco, voting on the telemedical abortion amendment began. Quite a few of the amendments to the Health and Social Care Bill that were proposed by the House of Lords were accepted. But many were not, and many others were amended further by different wording from the government. The government amendment that was proposed to revise the amendment by Baroness Sugg formally altered the 1967 Abortion Act, as follows:

Page 127, line 39, at end insert the following new Clause— “Early medical termination of pregnancy (1) Section 1 of the Abortion Act 1967 is amended as follows. (2) In subsection (3), for “subsection” substitute “subsections (3B) to”. (3) In subsection (3A)— (a) the words from “includes” to the end become paragraph (a); (b) after that paragraph insert— “(b) is not limited by subsections (3C) and (3D).” Wednesday 30 March 2022 LORDS AMENDMENTS 5 (4) After subsection (3A) insert— “(3B) Subsections (3C) and (3D) apply where— (a) the treatment referred to in subsection (3) consists of the prescription and administration of medicine, and (b) the registered medical practitioner terminating the pregnancy is of the opinion, formed in good faith, that, if the medicine is administered in accordance with their instructions, the pregnancy will not exceed ten weeks at the time when the medicine is administered (or in the case of a course of medicine, when the first medicine in the course is administered). (3C) If the usual place of residence of the registered medical practitioner terminating the pregnancy is in England or Wales, the medicine may be prescribed from that place by the registered medical practitioner. (3D) If the pregnant woman’s usual place of residence is in England or Wales and she has had a consultation (in person, by telephone or by electronic means) with a registered medical practitioner, registered nurse or registered midwife about the termination of the pregnancy, the medicine may be self-administered by the pregnant woman at that place.

Whew!! Verbose. In short, a registered medical practitioner, registered nurse or registered midwife can conduct a consultation by telemedical means to approve an abortion up to 10 weeks of pregnancy within the context of the 1967 Act, and arrange for the woman/girl to receive the pills by post.

Having listened to the whole debate and read the text of the two amendments afterwards, I’m no longer sure I am entirely happy with the outcome, for a number of reasons. Why? First, because the anti-abortion contributions outnumbered the pro-choice ones in the debate and were all based on fabricated and false information, which some MPs who are not anti-abortion were at least partly convinced by. As usual, those who were anti-abortion did not shift their views one iota due to the evidence they were presented with, but then their inability to accept facts is infamous.

I am very glad of course that in a Parliament in which winning a vote not supported by the government is almost impossible, we won this vote by a comfortable margin. That is, we didn’t lose. But I want to know why so many MPs did not attend and what would have happened if they had.

And now… moving forward

I’m also concerned that because the amendment had to become a new clause in the 1967 Abortion Act, the outcome was to keep control in the hands of doctors. I know this was inevitable as no one was trying to amend the abortion law as such. But it’s a pity. We need to be arguing for women to be able to access these pills not only when they know they are pregnant but also before they need them and in case they need them, with all the autonomy and benefits of very early abortion that would come with such new conditions. This change – which is not in line with the 1967 Abortion Act, would take away the control by doctors of the decision, as represented in the 1967 Act, and move the control of the decision to women. I believe we need a policy in which women can get the pills direct from a pharmacy – that for me could and should have been the outcome of allowing telemedical abortion. That is, the recognition that the use of abortion pills very early in pregnancy and through the first trimester is so safe and simple that medical control can recede into the background unless there are complications, which happen only rarely. But this outcome would have required changing the 1967 Abortion Act. That was not the playbill of the day.

The growing international shift to women obtaining abortion pills from the internet and from women-run hotlines both within countries and via two important international hotlines, or just straight from a pharmacy or drug seller, has perhaps not become a widely known fact or driving vision in the UK – yet. But from an international perspective, the change has been enormous and I believe it represents the future of early abortion.

Would Baroness Sugg’s amendment have passed had the government not tabled its amendment? The 72 Tories who voted yes to the government’s amendment to the Lords’ amendment might well have gone the other way in response to her amendment alone, even though they were not very different. And perhaps the numbers who did not vote at all might also have changed. No one can say. None of this was obvious on the day, at least not to me.

But my conclusion from the whole event is that while I am no less delighted at the outcome than my pro-choice friends, because telemedical abortion was saved, the grip of the medical profession on women’s access to abortion via the requirements of the 1967 Abortion Act, remains in place.

Acknowledgements

Thanks to Jayne Kavanagh, Toni Belfield and a third reviewer, for helpful editing suggestions. Any errors are my own. I have edited this blog twice already to correct a few mistakes and because of helpful comments. Further information on these points that I can share in a new blog would be welcome.


References and Notes

[1] This date was set long in advance. The Johnson government had already declared the pandemic over in April as regards requiring or even recommending that the public protect themselves and each other from the thousands of continuing new cases of infection daily.

[2] There was a discrepancy between the tellers’ count and the numbers recorded by name/party (216/187). In this instance, it doesn’t make much difference (unless you are the MP who was miscounted). In either case, we – the pro-choice movement – won the vote.

[3] That Scotland had already made this decision was stated during the debate at Westminster, but I have since been told it is not the case. If anyone has definitive information on this it would be welcome as Google reports a 2021 consultation in Scotland but not a decision.

[4] Written Statement: Arrangements for Early Medical Abortion at Home, 24 February 2022.

[5] Starting at Column 867 in Hansard

[6] That is, 72 Tories voted YES and 112 did not vote.

[7] WHO. WHO recommendations on self-care interventions Self-management of medical abortion. 2020.

[8] I have learned since then that Scotland has in fact not yet decided, but Wales has.

[9] See Column 871 to 872 in Hansard.

[10] I didn’t know the House of Commons had so many doctors in it. No wonder the NHS doesn’t have enough staff!

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