Half a century after abortion was made legal in England, Scotland and Wales, outsourcing of NHS services and a subsequent lack of specialist doctors mean that hundreds of women each year are prevented from having an abortion, sometimes seriously threatening their health, according to leading medics.
“The system is broken. It’s in crisis. Not fit for purpose,” says professor Lesley Regan, the president of the Royal College of Obstetricians and Gynaecologists (RCOG).
Abortion is the most common medical or surgical procedure in the UK: more than 200,000 women have one each year. It is still illegal in Northern Ireland but this week the government revealed plans to provide free abortion services in England for women from Northern Ireland. Women can have either a medical abortion, which involves taking two pills usually 24 to 48 hours apart to induce a miscarriage, or they can have a surgical abortion. Around 80% occur at under 10 weeks gestation. Only in exceptional cases, if there is a grave risk to the woman’s life or severe foetal abnormality, are abortions legal beyond 24 weeks.
But one major provider of abortion services says women needing late abortions (between 19-24 weeks) are not always able to get them. The British Pregnancy Advisory Service (BPAS), along with Marie Stopes International (MSI), is one of the two main providers of abortion services for the NHS. Clare Murphy, BPAS’s director of external affairs, says: “We think there are probably hundreds of women a year prevented from having an abortion, due to long waiting times and the distance to a hospital providing an abortion – or because it is simply not equipped to carry out a termination late in the pregnancy.”
BPAS says that last year 158 women who had been referred for an NHS hospital termination due to complexities, gave up on their decision to have an abortion because they had been confronted with long distances to travel to a hospital that could carry out the procedure, and lengthy waiting times. A further 20 women diagnosed with multiple health problems who wanted an abortion could not be allocated a place in hospital – and had to continue with their pregnancies and give birth, despite the threat to their health.
“Unless this situation is addressed urgently, more and more women will have to continue with pregnancies they don’t want – and which may pose a serious risk to their health,” warns Murphy.
These women’s stories are harrowing and desperate. Because they went on to have a child after being denied an abortion, and are few in number, they are understandably wary of being identified. But there are recurring themes to their predicaments: pregnancy not detected until late on, then made difficult because of high blood pressure, heart conditions, obesity, or unexplained seizures. Some had abusive partners, others had existing children who were unwell. One woman became so ill that the baby was delivered at 26 weeks; another’s condition deteriorated so badly she qualified for a post-24-week abortion.
One of the problems is the growing number of young women seeking an abortion who are obese, diabetic or have hypertension. Increasing obesity among women of all ages makes operations more complex, and the later a termination, the more skilful the surgeon has to be. At 19 weeks there are just four hospitals offering medical terminations across the whole of England and Wales, and three offering surgical procedures. From 21 weeks, only Imperial College Healthcare NHS trust and King’s College Hospital NHS foundation trust, both in London, have one doctor able to undertake late procedures. At 15 weeks’ pregnancy, 18 hospitals across England and Wales can provide a medical abortion, 11 a surgical one.
The Department of Health (DoH) says there are 524 more obstetricians and gynaecologists now than there were in May 2010, but not all of those will work in abortion care. Regan says the attrition rate is high and some junior doctors are choosing not to specialise in abortion services because of vilification from anti-abortionists, and sometimes even criticism from medical colleagues. But another factor is that opportunities to train within the NHS have disappeared. Although figures are not held centrally on numbers of acute hospitals training in abortion care, as an indication of declining numbers, the RCOG advanced training skills module in abortion – a core part of training – has not been completed yet this year in Kent, Surrey, Sussex, Thames Valley or the West Midlands. Only one has been completed in Wales, Wessex and south west England.
“When my generation goes, there will be very few people who have any experience, ,” says Regan. “Less than a handful” of consultants in England are doing late surgical abortions.”
The way in which commissioning has developed since the 1980s accounts for the lack of training. In 1981, abortion services were split almost evenly between the NHS and the private sector, such as Harley Street clinics. The NHS-funded independent sector – effectively the BPAS and Marie Stopes – played a tiny role. But it has grown steadily, often as a result of commissioners searching for less expensive contracts. Now the BPAS and Marie Stopes have 70 clinics each, accounting for two-thirds of NHS-funded services. The problem is, neither organisation is contracted to train doctors in abortion care, or to terminate pregnancies if there are complications because the patient has multiple health problems, leaving a dwindling number of acute teaching hospitals to train medics and provide more specialist care.
This is leading to regional gaps in provision. In Colchester, Essex, for example, the NHS trust would have done some late-stage abortions, but these services have now been transferred to the independent sector, so women have to travel a long way. A spokesman for north-east Essex clinical commissioning group says it awarded the contract for abortion services to Marie Stopes for greater efficiency.
Dr Sarah Prince, 31, a senior registrar in the east of England, is one of the few junior doctors ready to take on abortion work. “It’s part of women’s health and I’m really passionate about that,” she says. “But I might have trouble completing advance study modules because at least three hospitals in my area have stopped providing abortion care, instead contracting it out. I may have to move to live near a hospital over an hour away to complete my studies. The pity is they were really good services – and the staff were really proud of them.”
Prince says she has not encountered animosity because of her work, but she has seen complacency in the profession, such as having only one consultant in a hospital covering the entire abortion workload. When they are away, crucial decisions can come to a standstill. And she’s aware of colleagues who might claim a conscientious objection to abortion, but actually simply don’t want to be involved in contentious work. “It’s terrible seeing women pushed from pillar to post,” says Prince.
Regan, who set up an abortion taskforce two years ago, says: “I don’t want in any way to cast aspersions on BPAS and MSI, they do a fantastic job. I work very closely with them because we’ve got to find a solution together.” But she believes that commissioners of services have often been involved in “a race to the bottom” to find ever cheaper contracts. And fewer hospital chief executives and clinical directors are prepared to get involved in potentially complex cases, particularly when the tariff generated for the hospital is the same as giving a woman two tablets to miscarry. “It’s something people have rather washed their hands of,” she says.
One solution her taskforce will look at is going into the independent sector and making training part of the commissioning – something that BPAS and MSI say they are prepared to consider. The BPAS says regional centres of excellence could be the way forward. “The independent sector must be on hand to help in any way it can, collaborating with the NHS to improve training and provide support for existing NHS services and the doctors and trainees within them,” says Murphy.
At Birmingham Women’s Hospital, doctors have been developing a centre of excellence for abortion services. But Professor Janesh Gupta, head of obstetrics and gynaecology, is facing considerable hurdles. Funding for trainees is under threat and he says “the DoH is putting up further barriers on grounds of cost”. Gupta warns: “The service in England is almost at the point of self-destruction. The health department needs to know that.” He already carries out late-term abortions, but would like the capability to go to 24 weeks when necessary. He thinks a total of up to five such regional centres – at least two in London, and others in Birmingham and Newcastle – would go a long way to providing a service fit for purpose. “We have to provide for the future,” he says.
Part of the recent pressure on services was because Marie Stopes suspended some of its terminations in August 2016 after safety concerns raised by the Care Quality Commission. They have since been reinstated, but CQC inspections are continuing. Caroline Gazet, Marie Stopes UK deputy medical director, says: “The current shortage of surgeons is a sector-wide issue that we would like to see addressed by including abortion as part of the general training for new obstetricians and gynaecologists, as it has been previously.”
Easing demand for later terminations by making earlier abortion more accessible could help: currently two doctors must authorise an abortion and there are growing calls for a relaxation of Britain’s abortion law to allow nurses and midwives to give women the pills that can end an unwanted pregnancy. That would require a free vote in parliament. A survey by the charity Women on Web, published last month, found that among 519 women who had tried to access abortion pills online over a four-month period, running the risk of imprisonment, around 40% said they did so because the barriers they had met trying to obtain an abortion within the NHS – including travel difficulties and a perceived lack of confidentiality – were insurmountable.
Regan would like to bring back experienced clinicians to act as mentors and make training modules more widely available. “This is about changing hearts and minds as opposed to just putting in a workforce that can do the job,” she says. Regan warns: “When you don’t have facilities for safe, high quality abortion care, girls and women die.”
A DoH spokeswoman says: “The late abortions service is high risk and needs to be within the NHS – we are working with the RCOG and NHS England to develop a different approach for this highly specialised area of clinical practice.”