Should DIY abortion be permitted after 10 weeks?

Independent health consultant Kevin Duffy comments on a proposed amendment to decriminalise abortion, and how it could lead to great physical harm for mothers seeking DIY home abortions

Dame Diana Johnson’s proposed amendment to the Criminal Justice Bill, NC1,[i] seeks to remove women from criminal prosecution if they are found to have self-managed their own abortion.

In England and Wales, it is currently legal for a woman to do so through medical abortion until 9-weeks-6-days of pregnancy have elapsed. The equivalent limit is 11-weeks-6-days for women in Scotland.

The question to be answered is “should women be permitted and enabled to perform their own DIY abortion after the current gestational age (GA) limit?”

In reply, the abortion law says no; best practice guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG) and World Health Organisation (WHO) say no, that it is unsafe; and the independent abortion providers BPAS, MSI-RC, and NUPAS no longer use the medical abortion method after 9-weeks-6-days’ GA.

It is widely expected that Johnson’s proposed amendment will be debated in the House of Commons later this month. In her explanation of this amendment, she states: “This new clause would disapply existing criminal law related to the accessing or procurement of abortion care from women acting in relation to their own pregnancy at any gestation…”

So, how might a woman access or procure her own abortion? The most obvious answer is by exploiting the systemic flaws of the telemedicine pills-by-post process. The lack of an in-person consultation leaves the abortion provider solely reliant on the woman’s claim that her pregnancy is less than the legal limit of 9-weeks-6-days’ gestational age. Legal certification of these at-home abortions relies on two doctors being able to form an opinion in good faith that GA is less than 10 weeks – without an in-person medical consultation it is simply not possible for the doctors to be certain.[ii]

The women most likely to be protected by Johnson’s amendment are those who exploit the pills-by-post process and self-manage their medical abortion at home after ten weeks’ GA. When MPs come to debate this, they need to be aware that these DIY abortions are considered unsafe by the abortion experts and are no longer performed in the UK by the independent abortion providers.

The World Health Organisation defines a safe abortion as: “meaning that they are carried out using a method recommended by WHO, appropriate to the gestational age, and by someone with the necessary skills.” In 2022, the WHO updated its abortion care guideline to include Recommendation 28 stating that it is safe for women to self-manage their medical abortion when their pregnancy is less than 12 weeks’ gestational age. In the same guideline, Recommendation 30 states that medical abortion at 12 weeks or greater should only be managed by doctors in a healthcare setting – in other words a self-managed medical abortion (DIY) from 12 weeks’ GA is deemed to be ‘unsafe’ by the WHO.^[iii]

The Royal College of Obstetricians and Gynaecologists notes in its position statement on self-managed abortion that it “endorses the WHO’s recommendation that self-managed medical abortion up to 12 weeks of pregnancy is a safe and effective abortion method…” This position statement makes no mention of self-management at greater than 12 weeks, and so one can presume that the RCOG also endorses the WHO recommendation against such unsafe practice.^[iv]

The RCOG has an e-learning module for abortion providers called ‘Making abortion safe’. In the related ‘Medical abortion from 12 weeks of pregnancy: Summary sheet’, it lays out some of the risks that providers need to be aware of: [v]

The medical abortion treatment has a ‘failure rate’ of 13%, requiring further intervention to complete the procedure. This is more than twice the risk for women using pills-by-post under the 10-weeks limit, meaning that as many as 1-in-7 who self-manage their medical abortion after 12 weeks will need to seek medical intervention at their local A&E.
Women need to be informed, as part of the consenting process, that she might see the fetus and placenta and may see some reflex movements if she is more than 16-17 weeks pregnant.
From 22-weeks GA, feticide is recommended before using the abortion pills, to avoid the fetus being born with signs of life, which can cause distress for women and their care providers.

The WHO’s Recommendation 29 suggests for medical abortion at 12 weeks, a misoprostol dose of 400 mcg, which is half the dose it suggests for medical abortion at less than 12 weeks, and one-third of the dose typically included in the pills-by-post packages. In its ‘Best practice in abortion care’, updated in 2022, the RCOG echoes the WHO cautionary warning that “The uterus is more sensitive to misoprostol as pregnancy advances, and therefore, in pregnancies over 24 weeks, lower doses of misoprostol should be used and increased intervals between misoprostol doses may be considered, especially for people with uterine scars.” [vi]

Women who are self-managing their abortion will be unable to follow the RCOG best-practice of feticide when the GA is 22 weeks or more and might cause themselves unnecessary harm if using the full 1,200 mcg dose of misoprostol included in the pills-by-post package.

It is worth noting that the three largest independent abortion providers in the UK, BPAS, MSI-RC and NUPAS, no longer provide medical abortion as an in-clinic option after 9-weeks-6-days’ GA. There are no public explanations for this, leaving one to speculate if this is due to a directive from the regulator, perhaps in response to poor clinical outcomes, or based on negative feedback from women undergoing this procedure.

Given the increased risk of abortion failure, the increased risk of uterine rupture, and the risk of a live-birth, it is understandable why both the WHO and the RCOG do not recommend self-managed abortion after 12 weeks of pregnancy, and why the independent providers no longer offer medical abortion after 9-weeks-6-days, and yet, it is a woman’s self-management of medical abortion at these later gestations that would be enabled by Johnson’s proposed amendment, NC1.

Write to your MP urging them to oppose Diana Johnson’s amendment