Month: April 2020

It was a relief to many last week when the Scottish Chief Medical Officer wrote to NHS Health Boards to advise that mifepristone can now legally be taken at home by women seeking early abortions. Mifepristone and misoprostol are the two drugs used in medical abortions in the first 10-12 weeks of pregnancy and, in 2018, home use of misoprostol became legal in Scotland (and shortly after in Wales and England).

However, until last week, women were still required to visit clinics to be given mifepristone, despite evidence that this is safe for home use. Given the current COVID-19 pandemic, and ‘lockdown’ conditions in the UK, this put women seeking abortion and health professionals providing care at unnecessary risk, and directly contradicted government advice against all but essential travel. This is indicative of an exceptionalism with which abortion is often marked in health services, with it also being, for example, the only routine gynaecological treatment that requires permission from two doctors for women to undergo. Conversely, the normalisation of abortion, and some of the ways in which it might be achieved, is the subject of two recent papers from the SASS project (Purcell et al 2020; Maxwell et al 2020).

Our research from 2017 found that women in Scotland were happy to have the option to return home to complete the early abortion process in the privacy and comfort of their own home, and more recent research has been exploring the shift to home self-administration of misoprostol (Harden, Boydell, et al forthcoming).

Safe self-managed abortion has long been offered to women in countries where access is restricted, by organisations such as Women on Web. For many women in Scotland, abortion care via telemedicine (phone or online consultation) and having the necessary medication posted to them will be a welcome option at this time. In particular this would improve access for women living in remote and rural areas, for whom attending a clinic is particularly difficult. It is also crucial to note that, for some women, home is not a safe or appropriate space for them to undergo an abortion, for example in cases of domestic abuse. Hence, alternatives to home self-management must continue to be provided.

Similarly, the letter from the CMO advocates that in the current context of COVID-19, women should be provided with later abortion care as close to home as possible. At present, women requiring abortion after around 18-20 weeks have to travel to clinics in England for treatment, and no later abortion service is provided north of the border, except in the case of fetal anomaly (and even then, only if the woman is willing to undergo early induction of labour). This seems in part to be down to a difficulty or lack of will to establish a service in any one NHS Health Board area, and the reluctance of some individual health professionals to be involved in abortion care as a pregnancy progresses and the fetus becomes more developed. It also relates to the different surgical techniques required (dilation and evacuation rather that the vacuum aspiration used at earlier stages, or medical induction), as well as the need for an injection to stop the fetal heartbeat prior to these.

But what will happen when the pandemic subsides and normal life begins to return (whatever that may look like)? Will the option of safe home self-management of abortion be withdrawn? Or can there be some hope that this small amendment to abortion regulation in Scotland might remain, relieving pressure on over-stretched sexual and reproductive health services, and potentially offering women more control over ending a pregnancy which they do not feel able or want to continue? It is likewise too early to speculate whether the current shift might enable a shift toward longer-term provision of later abortions in Scotland, regardless of the reason the procedure is needed. However, it could certainly set a precedent that this provision is possible for the small proportion of women who present later in pregnancy, often for complex reasons outwith their control. In doing so, it would remove the additional stress and stigma, and in some cases cost, created by the need for travel (Purcell et al 2014).

As they relate to both early and later abortion, the changes brought about by the COVID-19 pandemic will be worth monitoring for their longer-term implications for the equitable provision of abortion care in Scotland.

As we all have had to dramatically change our professional and personal practices in the last few weeks – changes which will last for weeks, if not months or longer – what are the implications for cross-sector collaborative research in sexual and reproductive health and rights (SRHR) and social justice? While our research may be stopped, temporarily paused, or shifted to virtual methods to accommodate new material conditions, much more than our methodologies will be affected by COVID-19. We have already witnessed significant disruption to health care practices and services, where existing services have been temporarily suspended, moved online or continue in extremely challenging circumstances; and we are now faced with the immediate impact of physical distancing, increased ill-health within communities and radical transformations of livelihoods on the social, sexual and health practices of communities.

The demands of SRHR and social justice do not stop during a global pandemic. This public health crisis presents a complex set of challenges, implications, and – potentially – innovations – for sexual and reproductive health, and research should play a key role in documenting, understanding and supporting these changes. Below, we pose a number of questions that are intended as a starting point for a collaborative SRHR and social justice agenda. That is, we aim to start conversations, encourage dialogue between and across research, community, clinical and policy partners and to support our much-needed collaborative efforts in the midst of the current crisis.

What are the immediate responses to current public health measures (including but not limited to physical distancing), and how can SRHR and social justice be safeguarded and supported in this context?
As services and practitioners respond in uncertain times, we need to ensure that existing SRHR and community support services are safe, that ongoing access is facilitated, and that these transitions to new modes of delivery and models of service do not exacerbate already existing inequalities. Where some services have significantly restricted or stopped entirely (e.g. Gender Identity Clinics, in-clinic STI testing), others have moved to telemedicine and online support (e.g. abortion services, private home testing, intimate partner violence services). How will these transitions affect not only the experience and effectiveness of these services, but the disproportionate burden of ill health, inequalities and injustices for those in already precarious positions? Beyond access to services, what are the material implications – and strategies for support – for those communities who rely on physical outreach support (e.g. people who live in remote and rural locations with limited/no internet connection or phone reception, people who are not digitally literate, and/or support for harm reduction amongst people who use drugs and/or who may be homeless) or who rely on income and/or provisions that necessitates physical contact (e.g. people who engage in sex work)?

How will increased and long-term delays to already over-stretched services and care affect existing socio-economic and socio-cultural inequalities and how can these be mitigated?
Even before COVID-19, support for sexual and reproductive health was already operating in a challenging environment; budget cuts, increased complexity of sexual health interventions, and the realities of structural barriers to health provided significant challenges and long waiting lists. What, then, will large-scale disruption to, and pausing of, services mean for the ongoing health and wellbeing? What does the absence of state provision mean for community care practices? Will this gap be filled by individual and/or more privatised health practices (e.g. self-sourcing of PrEP or gender-supporting hormones) and how might this affect more marginalized communities as well as government commitment to state services?

What role for community voice, involvement and rights?
Public patient involvement (PPI), and the meaningful engagement and participation of communities is recognized as an essential component of effective and sustainable SRH services. At times of crisis, how can the lived experiences and concerns of affected communities continue to be included in multi-sectoral responses? How can communities play a key role in the design of responses to COVID-19 and the re-organisation of services in the short, medium and potentially long-term? And how can we support the meaningful and ethical involvement of diverse communities at a time when physical contact is minimised and when ongoing inequalities and socio-economic disparities are heightened?

What are the longer-term implications of this crisis for SRH?
We know that testing and access to medications will be affected by COVID-19 as supply chains, physical mobility and staff capacity are disrupted. We also know that socially complex SRHR issues will feel the effects of this crisis for months and likely years to come. How resilient are communities, practitioners and even researchers, and how can they best be supported? What creative and generous responses will emerge from community need and how might these affect relationships with healthcare provision? What will the longer-term economic implications of this crisis be on funding for health services and organisations (third sector, community research) and how might this affect both how we work together and on what we prioritize?

These questions and concerns are by no means the only questions we need to consider. We would welcome further thoughts on the immediate, and longer-term implications of COVID-19 on sexual and reproductive health, rights and social justice.