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17 June 2015

Abortion: Trusting women to decide, and doctors to practise

This new BPAS publication lays out the case for why we need to re-think Britain's abortion law.

Executive summary

• Britain’s abortion law will be 50 years old in 2017. While it has served women well, its provisions are increasingly out of touch with the reality of women’s lives, and with best practice in abortion care.

• Abortion in Britain today is a normal fact of life. There are around 200,000 abortions a year. One in three women will have an abortion in her lifetime. Sexual health policy supports the provision of abortion, and 98% of abortions are funded by the National Health Service.

• Developments in services, pregnancy testing, and medical abortion, mean that an increasingly large proportion of abortions take place under 10 weeks’ gestation. Early procedures are safer, more straightforward, and better for women. This also creates a significant role for nurses and midwives. First trimester abortions increasingly use the medical method (the abortion pill).

• A small proportion of women (8%) will continue to need access to abortion in the second trimester of pregnancy, for many reasons. These may be very young women who hid their pregnancy, or perimenopausal women who did not suspect they were pregnant. They may be women whose contraception failed without their knowledge. Abortions may be requested when a relationship has broken down, an existing child has become seriously ill, or a fetal anomaly has been detected. Women may need time following a later diagnosis to make the decision that is right for them. It is crucial that the abortion service continues to provide care for these women.

• Less than 0.1% of all abortions take place after 24 weeks’ gestation, mainly for reasons of fetal anomaly. This reflects the fact that anomalies cannot always be detected until later in pregnancy, and that women need time to make what is often a very difficult decision to end a much-wanted pregnancy.

• The expectation that safe, legal abortion care can be accessed when needed underpins significant social and cultural changes with regard to women’s equality. Without the ability to control their fertility, women would have not achieved the level of educational and workplace equality that younger generations can rightly take for granted. Abortion cannot solve all the problems of gender inequality; but without the ability to exercise reproductive choice, all problems of inequality are made worse.

• Given the role played by abortion in mainstream healthcare today, the fact that it remains situated within the criminal law is an anomaly. Under the 1861 Offences Against the Person Act (OAPA), having or performing an abortion is a criminal offence that carries a lengthy jail sentence. This Victorian piece of legislation fossilises values well out of step with those cherished today.

• The 1967 Abortion Act provides a therapeutic exemption to the offences under the OAPA, and makes abortion legal provided that women and doctors meet certain requirements. But the 1967 Act is also the product of a very different era to now. The legislation was crafted to regulate different clinical techniques, in a climate where the biggest threat to women’s health from abortion came from illegal, backstreet abortions.

• The 1967 Act was also developed in a context where public opinion was far more ambivalent about abortion than it is today. Two thirds of people today say that abortion should be allowed according to a woman’s choice, compared to 37% in 1983.

The very provisions of the Abortion Act that sought to protect women’s health are today preventing the provision of modern, evidence-based clinical care. These provisions include:

- The arcane requirement that two doctors must authorise each abortion;
- The fact that women are prevented from taking the ‘abortion pill’ (early medical abortion) at home;
- The way that nurses and midwives are prevented from playing a full role in the straightforward abortion cases.

• Under the 1967 Abortion Act, a woman cannot decide for herself to have an abortion: this decision has to be made on her behalf, by two doctors. This paternalistic approach sits at odds with other clinical procedures, and with the equal status accorded to women in most other areas of life.

• One of the aims of the Abortion Act was to protect doctors from prosecution when performing legal abortions. But the discordance between the law and best standards of clinical practice has exposed doctors to the ‘chilling effect’ of smear campaigns and legal misinterpretations imposed by opponents of abortion.

• Other jurisdictions, in Australia and Canada, have successfully removed abortion from the criminal statute, in order to regulate it with laws more appropriate to a mainstream healthcare procedure. This has not caused an increase in numbers or rates of abortion, and has provided a more constructive platform to consider how abortion can best be provided.

• In addition to the criminal law. abortion in Britain is tightly regulated as a healthcare procedure. Clinics are inspected by the Care Quality Commission (CQC), and healthcare workers are bound by their professional bodies, the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC). Healthcare teams work to detailed evidence-based guidance produced by the eminent Royal College of Obstetricians and Gynaecologists (RCOG).

• The word ‘decriminalisation’ immediately implies that there is something wrong with abortion; that maybe it should be criminal. Our aim here is to present a positive case for why we need regulation that meets women’s needs. We believe that the time has come to remove abortion from the criminal law, and to regulate the service according to standards of best clinical care.

Download the full publication for free here.