When Dominic Raab was asked to include the right to an abortion in the forthcoming UK bill of rights last week, he insisted the matter was already "settled in UK law".
But at least 17 women have been investigated over illegal abortions since 2014; abortion pills have been seized on their way to women across the UK; women still have limited access in Northern Ireland; some are being forced to travel hundreds of miles for treatment.
99 MPs voted against decriminalisation in Northern Ireland. And a woman is due to go on trial in Oxford next week for unlawfully procuring her own abortion drugs. None of this appears to support the image of benevolent clarity that Raab seeks to present.
Kaye Wellings has as broad a view of the state of abortion care as anyone: at LSHTM, she runs the SACHA study, the biggest ever UK research project on the subject, with the support of the National Institute for Health and Care Research. She says it's important to start by saying clearly that the overall picture is good for supporters of reproductive rights.
"I've been working in this field for 30 years, and it's striking to me just how satisfactory most services are most of the time," she said. But that doesn't mean there aren't real issues.
What does the law say on abortion?
In the UK, apart from Northern Ireland, the law is … extremely weird. The basis for the provision of abortion is the 1967 Abortion Act – which does not declare that abortion is legal, but instead sets out circumstances under which women and healthcare professionals will not be prosecuted. If an abortion does not meet those criteria, it is a crime.
The language of the act might seem pretty onerous. It says that after 24 weeks, abortion is only legal if there is a grave risk to the health or life of the pregnant woman, or if there is a serious risk of severe fetal abnormalities. Before that point, the standard is a risk to physical or mental health that exceeds the risk of a termination. Two doctors have to sign off on any such decision.
In practice, the law should not stop women getting an abortion if they want one before 24 weeks. (The 2021 statistics show that 90% of abortions take place before 10 weeks, against 1% after 20 weeks and 0.1% after 24 weeks in very unusual circumstances.)
"The criteria are viewed flexibly and leniently," said Wellings. "And taking abortion pills [which now account for 87% of abortions] is safer than childbirth, so the framework is almost redundant."
Meanwhile, though the agreement of two doctors may sound intimidating, it is not required that they see the patient before agreeing, and can rely on information provided by other members of their team.
Are there other obstacles to abortion access?
Yes:
• The fact that abortion remains a taboo in some communities, which is only exacerbated when women hear that it has not been decriminalised. "Women are shocked to think they could be doing something which could be seen as a crime," said Wellings, whose work is heavily informed by interviews with women who have had abortions. "A lot of them were terrified that they wouldn't get through the gatekeeping system."
That fear is sometimes more of an obstacle than the practice. "In general women seeking abortions are of the view that they've been supported, sympathised with, that there's been no frowning or judgmental attitudes," Wellings said.
• The personal views of some doctors. "There are practitioners in this country who don't believe in abortion," said Wellings. "There is a risk that they won't then quickly refer a woman to another GP. But most women are very savvy whatever their educational level. They told us, my GP seemed a bit hesitant so I went online."
• Other doctors feeling that they are unable to provide proper care. "It's not the law that makes them resistant," said Wellings. "The question that seems to worry them is resources – payment for the service – and time."
• The intimidation of anti-abortion protesters outside clinics – although this is much less widespread an issue than in the US, and "buffer zones" around clinics are increasingly common as a way of limiting this effect.
• Living in Northern Ireland, where the law is ahead of the rest of the UK after abortion was fully decriminalised in 2019 – but practice has not caught up. The region's health minister Robin Swann is against abortion, and has refused to publish information about it on the department of health website, the i newspaper recently reported. Some women in Northern Ireland are still being forced to cross the Irish Sea, though many fewer than a few years ago.
Against these concerns, there has been one piece of progress recently: rules brought in during the pandemic allowing both abortion pills to be taken at home have been extended at least until the end of August in England, and indefinitely in Wales. That is good news, Wellings said: "Women we spoke to love having control over their own procedure, and in terms of convenience."
So what needs to change?
While the awkward legal basis for abortion in the UK is far from ideal, there are some risks attached to fixing it, says Wellings, who points to the intensity of the right to life movement in response to a consultation over extending the coronavirus rules: "They got mobilised, they got thousands of signatures. There is a risk in waking sleeping dogs up."
Nonetheless, advocates and MPs pursuing reform are seeking a worthwhile goal, she argues, so long as they are vigilant and ready to make their case. "It would stop abortion being a special case and it would put it on a par with other health issues," Wellings said. "There are many areas of medical practice that cope perfectly well without a law, using the very good systems of medical governance. But a strong theme of our work is that decriminalisation is not enough. There's still a great deal of work to be done."
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