Mifepristone at homeBMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o819 (Published 29 March 2022) Cite this as: BMJ 2022;376:o819
- Sharon Cameron, professor of sexual and reproductive health12,
- John Reynolds-Wright, community sexual and reproductive health specialty trainee1
- 1Chalmers Centre, Edinburgh, UK
- 2MRC Centre for Reproductive Health, Queen’s Medical Research Institute, Edinburgh, UK
- Correspondence to: S Cameron
The World Health Organization’s new guidelines on abortion care recommend that medical abortion in the first 12 weeks of pregnancy can safely be delivered by telemedicine and that women can self-administer both mifepristone and misoprostol at home.1
Yet on 24 February 2022, the Department of Health for England announced that its temporary approval of home use of mifepristone, made during the covid-19 pandemic, would cease in August 2022.2 The following day, the Welsh government announced that home use of mifepristone would become permanent, citing the safety and benefits for those accessing abortion services, as well as for the NHS.3 The Scottish government has yet to decide whether home use of mifepristone will become permanent. Home use of mifepristone was never introduced in Northern Ireland. Why has England taken a decision in opposition to WHO guidance, and why have the UK governments taken different approaches?
Around 80% of all abortions in Scotland, England, and Wales are medical, using mifepristone and misoprostol. Around 80% occur in the first 10 weeks of pregnancy, with the pregnancy ending at home.4 Scotland introduced legislation permitting women to self-administer misoprostol at home in 2017, followed in 2018 by England and Wales, but legal restrictions meant that women had to take the first dose of mifepristone at a licensed clinical site. This legal requirement was clinically unnecessary and resulted in extra visits for women and extra costs to the NHS.
In recognition of the need to limit transmission of covid-19 from in-person attendances, the governments of England, Wales, and Scotland introduced temporary approvals in March 2020 to allow administration of mifepristone at home.567 This was the only change made to the law surrounding abortion care and meant that women could collect medication packs to use at home or receive them by post.
Evidence based clinical guidance from the Royal College of Obstetricians and Gynaecologists, Faculty of Sexual and Reproductive Healthcare UK, and British Society of Abortion Care Providers emphasises the use of telemedicine and assessment of gestation using last certain menstrual period, with ultrasound conducted only where clinically indicated.8
UK guidance has never mandated routine ultrasound scanning to assess gestation or location of pregnancy before abortion, and pre-pandemic guidance from the National Institute of Health and Care Excellence (NICE) already encouraged telemedicine.9
Registry data for England and Wales show that the new model for delivery of abortion care introduced during the pandemic—a telemedicine consultation, ultrasound only when indicated, and both mifepristone and misoprostol at home—was associated with an increased proportion of abortions being conducted medically and at earlier gestations. This suggests better access to abortion.4
Treatment at earlier gestations is less painful and causes less bleeding. Published evidence from England, Wales, and Scotland shows that the new model of care is as safe and effective as former models of in-person consultation and administration of mifepristone on clinical premises.1011 Studies also show that women are able to take mifepristone at home correctly12 and appreciate the option and privacy of consultation by telephone.13 Women support continuation of home use of mifepristone for reasons of privacy, convenience, and autonomy.14 Research among providers suggests they consider the new model more patient centred.15 An economic evaluation estimates that the telemedicine model saved the NHS at least £3m (€3.6m; $4m) a year.16
The English government’s decision to act against substantial clinical evidence, expert advice, and pleas from royal colleges17 serves only to punish and infantilise women. At a time when reproductive rights in the US and parts of Europe are being attacked,1819 our governments should not be bowing to pressure from anti-abortion extremism. Restrictions to abortion do not prevent abortion; they simply result in later abortion.1
Telemedicine delivery of abortion care in England will remain, in line with clinical guidelines, and medical abortion at home will continue (as before covid-19), but in England, women will be forced to take one of their pills in clinic rather than at home like their Welsh and Scottish counterparts. This means less flexibility of care in England, less patient centred care, more travel, more time off work for appointments, delays to care, an increase in gestation at abortion, and greater costs to the NHS in England.
Abortion is an essential part of healthcare, and delivery of care should be led by evidence. Governments should act in accordance with the best evidence available for improving public health. This includes following national and international evidence showing that taking mifepristone at home is safe. Sadly, for the English government, home use of mifepristone seems to be the bitterest pill to swallow.
Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.