After 50 years of legal abortion in Great Britain, calls grow for further liberalisationBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5278 (Published 23 November 2017) Cite this as: BMJ 2017;359:j5278
Last month saw the 50 year anniversary of the passing of the 1967 Abortion Act, which legalised termination of pregnancy by registered practitioners in Great Britain provided certain conditions were met.
In the intervening half century British social attitudes towards abortion and British women’s reproductive choices have shifted significantly. In 2016 some 72% of Britons supported a woman’s “right to choose” whether to have an abortion,1 up from 37% in 1983. Women today have fewer children and do so later,2 with little fear of stigmatisation if these children are born out of wedlock.
Abortion procedure has also altered beyond recognition with the use, into the ninth week of pregnancy, of the drugs mifepristone and misoprostol, whose effects do not need to be monitored in a clinical setting.
“Social” abortions are illegal
Despite these shifts and many countries having moved to liberal models of social “abortion on demand,”3 the 1967 Act remains largely unchanged. An increasingly vocal lobby of medical practitioners and campaigners, including the BMA, the Royal College of Obstetricians and Gynaecologists (RCOG), and the Royal College of Midwives (RCM), say that the act is outdated: it excludes social abortions; it restricts abortions to registered medical premises but not primary care settings; and, perhaps most controversially, it does not extend to Northern Ireland.
Some campaigners also complain that the act does not legalise abortion but merely outlines exceptions to the 1861 Offences Against the Person Act, which makes abortion a criminal offence, punishable by life imprisonment.
Last month, at a conference of medical professionals to mark the 50th anniversary of the 1967 Act convened by the University of Bristol at the RCOG in London, Katherine O’Brien, of the reproductive health charity and leading abortion provider the British Pregnancy Advisory Service (BPAS), called for reform of a law that makes criminals of the women and doctors its provisions exclude.
“In 2017 it’s ridiculous that a young woman who takes abortion pills bought online could be sent to prison for 12 years . . . or that a doctor who provides safe abortion care to a woman who requests it without the approval of his or her colleague could be sent to prison for 12 years,” O’Brien said, adding that BPAS wants complete decriminalisation of abortion with no time limit in criminal law. Instead, professional and regulatory standards would apply, as would all other law pertaining to healthcare.
The Abortion Act 1967
The 1967 Act provided that abortion was lawful when conducted by a registered medical practitioner and when two medical practitioners are of the opinion, formed in good faith, that the pregnancy would involve a risk to the physical or mental health of the pregnant woman or any existing children of her family; that the pregnancy involves risk to the life of the pregnant woman; or that there is a substantial risk that if the child were born it would have such physical or mental abnormalities as to be seriously handicapped.4
In 1990 the act was amended by the Human Fertilisation and Embryology Act so that abortion was no longer legal after 24 weeks except in cases where this was necessary to save the woman’s life, where there was evidence of extreme fetal abnormality, or where there was a grave risk of physical or mental injury to the woman. The original act had provided until the 28th week of gestation.5
The terrible toll of backstreet abortions
Denis Pereira Gray was a member of the 1974 Lane Committee, set up to inquire into the workings of the 1967 Act.6 He explained to last month’s RCOG conference, “Then, as now, there was little use talking to male ministers about women’s rights. The act was designed to address the terrible toll of backstreet abortions, particularly for those who could not afford other options.”
Before the 1967 Act an estimated 10 000 women a year sought illegal (“informal”) abortions in the United Kingdom.7 Rich women could visit Harley Street surgeries in secret, where abortions were conducted in sterile conditions under anaesthetic. But most women resorted to backstreet methods, ranging from orally administered lead to sharp implements inserted through the cervix.7
Before the 1967 Act an estimated 10 000 women a year sought illegal (“informal”) abortions in the UK
The 1967 Act has ensured that backstreet abortions are a thing of the past. The NHS now funds 95% of abortions in England and Wales (two thirds of these are carried out by charities such as BPAS and Marie Stopes) and funds 98% of those carried out in Scotland.
Lived experience under the act
Case study: Asma
Asma, now 28, had an abortion at age 23 after her oral contraceptive failed. After “scaring [herself] half to death” researching the permitted conditions for abortion under the act, she spent several days rehearsing a story for her GP. “I thought the GP might turn me away if my circumstances were not dire enough,” says Asma. “I spoke to her about my history of depression, and I told her that having a child at this moment in time would put my mental health at risk, a factor I knew was listed in the Abortion Act.”
Healthcare professionals as well as patients feel frustrated about the act’s administrative burden. An obstetrician requesting anonymity told The BMJ, “For vulnerable patients, the prospect of convincing two doctors often seems immense,” adding that she had heard of similarly frustrated practitioners being summoned before the General Medical Council for having signed multiple secondary permissions “out of kindness,” without seeing the patients.
Medical practitioners, the church, and politicians have often sought local restrictions—making access to abortion uneven geographically. For much of the 1970s Birmingham had no abortion services, and many Scottish women had to travel to Liverpool to access its BPAS clinic. Indeed, Scottish women still have to travel to England for surgical abortions in the second trimester.8
Case study: Tara
Tara, aged 30 and from Glasgow, was struggling to escape an abusive relationship when she discovered that she was 19 weeks pregnant. “Having to travel to England from Glasgow made a difficult situation simply awful,” she recalls. “At the time I was on Jobseeker’s Allowance, so the additional costs of getting around in London and paying for a private prescription [were] a real burden.”
The 1967 Act does not apply in Northern Ireland: abortion remains unlawful under the 1861 Offences Against the Person Act, qualified by the 1945 Criminal Justice (Northern Ireland) Act, which permits the abortion of a “child capable of being born alive” only where the mother’s life would otherwise be at risk.9 (An average of 37 abortions a year are carried out in Northern Ireland under these provisions.)
Today an estimated 10 000 women a year from Northern Ireland travel to England for an abortion,10 and unknown numbers of Northern Irish women order the abortion pill illegally online. Since devolution, legislation on most domestic issues has succeeded to Northern Ireland; however, the UK Supreme Court is currently hearing a claim that preventing sexual crime victims and women carrying fetuses with fatal abnormalities from accessing terminations in Northern Ireland breaches human rights.
In October 2017 the UK government announced that it would cover the medical costs of abortions for women from Northern Ireland who travel to England for an abortion, including means tested assistance with travel and accommodation for women on low incomes.11
Public opinion in Northern Ireland is also moving towards decriminalisation, as 71% of respondents to a Northern Ireland Life and Times Survey agreed that “abortion should be a matter for medical regulation and not criminal law.”12
Case study: Ashleigh
Ashleigh, aged 27, fell pregnant within a year of marriage. At the 12 week scan she learnt that the fetus had a lethal developmental dysplasia that was likely to be fatal within days of birth. “All I could hear was the word ‘fatal,’” she says, “as we listened to the doctor telling us that termination of pregnancy was illegal in Northern Ireland and that we would have to continue with the pregnancy to term.” Eventually the baby’s heart stopped in utero, and Ashleigh’s waters broke at 34 weeks, at which point her relief mixed with anger. “Being forced to continue this pregnancy added to the tragedy and stopped us from being able to grieve for our daughter,” she says.
Calls for decriminalisation
In 2016 the RCM published a position statement calling for “abortion to be regulated in the same way as all other procedures relating to women’s healthcare.”13 Delegates at the BMA’s 2017 annual representative meeting voted in favour of decriminalisation of health professionals and of women who procure or administer their own abortion. In September 2017 the RCOG’s council voted in favour of abortion on demand with no criminal sanctions.
Clare Murphy of BPAS, which in 2016 launched the We Trust Women campaign for decriminalisation supported by the RCM, argues that the current law is paternalistic, conflicts with fundamental legal principles of bodily autonomy, and impedes best clinical practice.
“The fact that, unlike any other medical procedure and for no clinical reason whatsoever, two doctors must authorise every request for an abortion inevitably causes needless delays,” says Murphy. “Abortion procedures today are safe and straightforward and do not need to be performed by doctors. However, the law currently denies nurses and midwives a larger role in the provision of care.”
Murphy adds that, while one of the original aims of the 1967 Act was to protect doctors from prosecution when performing legal operations, its restrictions leave doctors exposed to smear campaigns and challenges by opponents of abortion.
In September 2017 the RCOG’s council voted in favour of abortion on demand with no criminal sanctions
Attempts to liberalise abortion laws have long met with resistance. The Abortion Act has withstood 55 parliamentary attempts to make legal abortion harder to access—most recently, Nadine Dorries’ 2007 private member’s bill attempting to bring in mandatory counselling and cooling-off periods for women seeking abortions.14
Many doctors, even those in gynaecology and obstetrics or sexual and reproductive health, have conscientious objections to abortion. The BMA, RCOG, and RCM, in their support for decriminalisation, have met with petitions from their members. The Christian Medical Fellowship has accused the RCOG of having a vested interest in decriminalisation.
Opponents say that decriminalisation will increase the total abortion rate and encourage sex selective abortion, as well as the home use of abortion pills in late stages of pregnancy. At the RCOG conference the “pro-life” campaigner Keith Hindle asked David Baird, a professor at the University of Edinburgh, whether decriminalisation would lead to abortifacient drugs “being taken like sweets, as late as 28 weeks.” Baird countered that aspirin had worse potential side effects than misoprostol if misused, yet few people call for its control. The Daily Mail has warned of “women having terminations up until the birth, for their own convenience.”15
The campaign’s next steps
Will more liberal, and perhaps more honest, legislation follow? In March a former shadow health minister, Diana Johnson, introduced a bill calling for abortion to be decriminalised up to 24 weeks’ gestation.16 The bill won MPs’ support at its first reading and was scheduled for a second reading in May but fell when parliament was dissolved.
Katherine O’Brien of BPAS is optimistic that the bill would have passed, arguing that decriminalisation has bipartisan parliamentary support. “A BPAS poll of MPs found that Conservatives tend to be more anti-choice and Labour more pro-[choice], but that the majority of MPs support women’s right to choose,” she says. O’Brien expects a private member’s bill to be introduced soon.
Countries such as Australia and Canada have successfully removed abortion from the criminal statutes and regulate it with laws more appropriate to a mainstream healthcare procedure—and they could be looked to as legal models, suggests Ann Furedi, also of BPAS. Australia has seen no increase in the number of abortions carried out since decriminalisation in Victoria in 2008, she said. And many European countries allow abortion on request, including France, Germany, Greece, Italy, and Scandinavian countries.17
John Parsons, former director of King’s College Hospital’s termination of pregnancy service, says that he looks forward to a future, after decriminalisation, of slimmed-down services: at-home medical abortions; nurses providing vacuum aspiration abortion procedures up to 14 weeks’ gestation; and fewer doctors, who will perform the later cases by dilatation and evacuation.
It is time, says Parsons, for an end to “meaningless, moralising” legislation. He concludes, “The law as it stands formally—and unfairly—delegates the ambiguity and moral ambivalences of abortion onto the doctors who provide it.”
Abortion in numbers
1 in 3 women in the UK has an abortion in her lifetime.18
1 in 6 pregnancies among women in Britain is unplanned.19
180 000 abortions take place in England and Wales each year.20
78% of women who have had abortions in Great Britain report being “very satisfied” with their clinical treatment.21
56 million abortions are performed worldwide each year, and an estimated 25 million of these are unsafe.22
47 000 women a year die from the complications of unsafe abortion worldwide.23
Competing interests: None declared.
Case studies are provided by the Open University and BPAS. Pseudonyms have been used.
Provenance and peer review: Commissioned; not externally peer reviewed.