Intended for healthcare professionals

Editorials

Abortion decriminalised in Northern Ireland

BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6330 (Published 04 November 2019) Cite this as: BMJ 2019;367:l6330
  1. Abigail RA Aiken, assistant professor1,
  2. Fiona Bloomer, lecturer2
  1. 1LBJ School of Public Affairs, University of Texas at Austin, Austin, TX, USA
  2. 2School of Applied Social and Policy Sciences, Ulster University, Shore Road, Newtownabbey BT37 0QB, UK
  1. araa2{at}utexas.edu

People and policy makers must now design a truly patient centred service

On 22 October 2019 abortion was decriminalised in Northern Ireland.1 This historic change followed decades of campaigning, an inquiry by the United Nations Committee on the Elimination of Discrimination against Women,2 an inquiry by the UK parliament’s Women and Equalities Committee,3 and numerous legal cases challenging the restricted access to abortion.

Despite being part of the UK, Northern Ireland previously stood alone in relation to abortion. The liberalising 1967 Abortion Act did not extend to Northern Ireland and attempts to do so over the past 50 years were repeatedly thwarted.45 Legal access to abortion was instead governed by the 1861 Offences Against the Persons Act and case law. This resulted in highly restricted provision, with an average of less than 20 abortions per year within the Northern Irish NHS. In contrast, an average of 800 women per year travelled to England, while hundreds more risked prosecution sourcing abortion medications from online providers.67

Evidence and testimony

Abortion decriminalisation was proposed in July 2019 by Labour MP Stella Creasy as an amendment to a parliamentary bill dealing with governance in Northern Ireland, following the suspension of the Northern Ireland Assembly in January 2017. This move forced the UK government to introduce abortion reform in the absence of the assembly. The final content of the bill reflected recommendations made by the United Nations inquiry, which identified Northern Ireland’s abortion restrictions as a grave and systematic violation of human rights.2 Similar findings were identified by the parliamentary Women and Equalities Committee.3 Scientific evidence89 combined with many women’s lived experiences were at the heart of both inquiries. Advocacy groups including Alliance for Choice, Amnesty International, Informing Choices (formerly the Family Planning Association), and the Northern Ireland Human Rights Commission played a substantial role in challenging stigma, educating, and campaigning for reform.

A new opportunity

After 158 years under the Offences Against the Persons Act 1861, what’s next for abortion access in Northern Ireland? Interim guidelines from the Northern Ireland Office will operate until 31 March 2020 to allow consultation on the shape and regulation of future services.10 No substantial increase in abortions is expected during this period, but the interim guidelines emphasise that all abortions should follow existing recommendations from professional bodies such as the National Institute for Health and Care Excellence and the Royal College of Obstetricians and Gynaecologists.

The consultation is crucial to the future of women’s reproductive rights in Northern Ireland because it will determine how abortion services are regulated and delivered after 31 March 2020. After an abrupt change in the law, people and policy makers now have an important opportunity to design a service that overcomes all the traditional challenges faced by women in need of safe and effective abortion.

Perhaps the most serious of these challenges is stigma. The reported experiences of women who travelled overseas for abortion services and those who used online telemedicine illustrate the shroud of secrecy surrounding abortion in Northern Ireland.8 Attendance at stand alone clinics risks harassment by protestors and potential breaches of confidentiality, particularly in smaller communities. Many women who sought abortion pills online before decriminalisation have said that they would do so again despite a change in the law, citing the privacy afforded by self management.8

Providing services in rural areas will also be a challenge. People living outside the few major cities in Northern Ireland will face additional barriers including longer distances to services, necessitating transport and time away from work and family.

Finally, it’s clear from abortion reform in the Republic of Ireland that misguided policies such as enforced waiting periods are an unnecessary complicating factor that can compel women to seek alternatives to clinic based services. During the nine months since abortion services became available in the Irish Republic, at least one woman per day has requested abortion medications from an online telemedicine service.11 Women in Northern Ireland will also continue to use online services if clinic based abortions remain out of reach.

A patient centred service

Policies guiding the implementation of abortion services in Northern Ireland must be based on the realities of people’s daily lives, as well as scientific evidence on the safety and effectiveness of both medical and surgical abortion.91213 To reduce stigma, medical abortions could be provided in a single visit to a primary care setting, such as integrated family planning and sexual health clinics; surgical abortions could be offered in both community clinics and hospital settings. For stand alone clinics, buffer zones could be put in place to prevent protests directly outside.

In rural communities, and to increase privacy for all, a clinic based telemedicine service could be set up, whereby medical consultation with a clinician takes place remotely and drugs are provided by a pharmacy or even by mail. Good evidence suggests that these services are safe, effective, and acceptable to patients.1415

While the dramatic change in Northern Ireland’s abortion law went into effect overnight, policymaking to guide the roll out of services will be a complex process. But rather than erecting barriers that drive people away from the formal healthcare settings, Northern Ireland must take advantage of this rare opportunity to design a service that is truly based on the needs of its people, and informed by the best evidence.

Footnotes

  • Commissioned, not peer reviewed

  • Competing interests: Abigail Aiken: I have read and understood BMJ policy on declaration of interests and declare that I am on the board of Jane’s Due Process, which helps minors obtain a judicial bypass to access to abortion services, and on the board of the Women on Web International Foundation, which helps people to access safe abortion services worldwide; I have advised Agile Therapeutics on a trial of a contraceptive; I have provided legal testimony to the Irish parliament on matters relating to the abortion referendum; I have provided written testimony to the United Nations Committee on the Elimination of Discrimination against Women on matters relating to abortion policy in Northern Ireland, and I have provided written testimony to the UK parliament’s Women and Equalities Committee on matters relating to abortion policy in Northern Ireland. I have received research support from the HRA Pharma Foundation, which partially funded a study examining people’s experiences accessing abortion in Ireland before the referendum. I have received research support from the European Society of Contraception and Reproductive Health, which partially funded a study examining people’s experiences accessing abortion in Northern Ireland before decriminalisation.

  • Fiona Bloomer: I have read and understood BMJ policy on declaration of interests and declare that I have provided legal testimony to the UK parliament’s Women and Equalities Committee on matters relating to abortion policy in Northern Ireland; I have provided legal testimony to the United Nations Committee on the Elimination of Discrimination against Women on matters relating to abortion policy in Northern Ireland. I have received research support from Unite the Union, which funded a study examining abortion as a workplace issue in Northern Ireland and the Republic of Ireland. I have received research support from the Joseph Rowntree Charitable Trust to conduct research on issues of faith and abortion in Northern Ireland. I have received research support from the Department for the Economy Northern Ireland to explore girls and young women’s reproductive health through a reproductive justice framework in South Africa and the Phillipines.

References

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