Regulating abortion in Britain: Evidence from the SACHA study

In this month’s eFeature, we hear about the ‘Shaping Abortion for Change’ (SACHA) study from Professor Kaye Wellings, on behalf of the SACHA study team, its findings, and how they could help shape abortion regulation.

Abortion has scarcely been out of the news of late, following a series of high-profile prosecutions under current abortion law. The most recent of these, the case of the 44-year-old mother of three who was convicted and jailed for taking medication to induce abortion at 32 weeks gestation, prompted MPs on both sides of the House to call for abortion law to be overhauled. Stella Creasey, Labour MP for Walthamstow commenting on the BBC’s Newsnight, declared the legislation on which the case was brought ‘unfit for purpose’, while Caroline Nokes MP, chair of the House of Commons Women and Equalities Select Committee, described it as "out of date".

Pressure has been building for some time for abortion to be decriminalised in Britain. Many of the relevant bodies in Britain, including the British Medical Association; Royal College of Nursing; Royal College of Obstetricians and Gynaecologists; Royal College of General Practitioners; Royal College of Midwives; and the FSRH have issued position statements supporting the move. Internationally, the World Health Organization and the United Nations have called for abortion to be treated like any other healthcare procedure and not as a legal matter. The case for taking abortion out of the law has been strengthened by recent therapeutic and technological trends; the striking increase in the prevalence of medical abortion, for example, which can be safely managed by women at home, and the innovative telemedicine interventions enabling them to do so. The COVID-19 pandemic further transformed abortion provision in Britain, permanently allowing home management of both abortion medications, and allowing a woman’s home to be included among approved premises for abortion. Medical abortion now accounts for over nine in ten abortions in Britain.

These developments have prompted re-examination of issues such as the role of non-specialist health professionals in abortion provision, the appropriate location for abortion, and how abortion is best regulated. The changes have clear benefits, making it possible to access abortion earlier, allowing patients more control over their abortion and reducing stigma. For the benefits to be realised, health systems and services needed to be adequately prepared and fit for purpose.

What is the SACHA study?

The National Institute for Health and Care Research (NIHR)-funded SACHA study, ‘Shaping Abortion for Change’ was set up in recognition of the need for a robust body of evidence to help health services respond to the changes. An international team of more than 20 colleagues led by myself and Dr Rebecca French at the London School of Hygiene & Tropical Medicine (LSHTM) designed a multi-component study aimed at underpinning decisions on how maximum benefit and minimum harm might be obtained from current trends.

The study has drawn on published evidence; case studies from countries that have partially or completely decriminalised abortion (Canada, Sweden and Australia), quantitative and qualitative data from a dedicated survey of the views and experience of 771 healthcare professionals including doctors, nurses, pharmacists and midwives; in-depth interviews with 48 women with recent experience of abortion, and a consultation with 15 key stakeholders prominent in the field of abortion on what is feasible and appropriate in the British context. Begun in 2020, the study is now beginning to report its findings.

What does the study tell us about knowledge of the law?

Firstly, and perhaps surprisingly, a significant minority of patients and practitioners did not know that two doctors’ signatures vouching that the legally permitted grounds have been met are needed before an abortion can be performed. A third of all male health professionals, a third of all those aged under 30, and a third of GPs were unaware of this legal requirement. One in three patients interviewed were also unaware that the law requires two doctors to authorise their abortion.

Would there be support for a change in the law from patients and practitioners?

Yes, according to data from the SACHA study. Nine out of ten healthcare professionals surveyed believe that abortion should be a woman’s choice. Patients interviewed held similarly strong views, that the outcome of pregnancy was for them to decide, and was not a matter for the law. Comments from health professionals and patients alike revealed resistance to the need for two doctors’ signatures authorising abortion.

Comments from health professionals concurred with the idea that the current law was outdated (“continuing to make it illegal without a doctor’s approval is unfair in the 21st century”). The views of patients on the need for abortion to be authorised by a medical practitioner were universally negative (”bizarre”; “absolute disgrace’’; “it’s woman’s body and it should be her choice, no one else’s”).

How might a change in the law affect where abortion can be provided?

Currently, legally permitted premises are restricted to NHS hospitals and independent specialist abortion services licensed by the government and, since 2020, in the homes of women managing medical abortion. A change in the law would, in principle, allow abortion to be integrated into routine health care. In the SACHA survey, there was not a great deal of enthusiasm for abortion to be incorporated into general practice, on the grounds of resources, time, and workload. By contrast, the majority of health professionals working in sexual and reproductive health services embraced the idea of providing abortion in their specialty, seeing it as an opportunity to provide more holistic care.  

Which healthcare professionals would be willing to provide abortion under a change in the law?

Under the current law, only medical practitioners (generally construed as doctors) are permitted to authorise and provide abortion, yet nurses, and to a lesser extent midwives, emerged from the SACHA study as the mainstay of abortion provision. There was strong support for this to continue.

Nearly half of nurses themselves embraced the idea of routinely providing abortion and the majority saw it as likely to increase job satisfaction, though there was less willingness to extend roles to surgical abortion. By contrast, most doctors saw abortion as out of scope for their service, and as burdensome.

Health professionals saw as time-wasting the requirement that they should pass the patients’ paperwork to doctors to sign off and many, especially nurses, felt that they should be able to prescribe abortion medication and carry out vacuum aspiration (in which they have proven competence in the management of miscarriage). For their part, patients were generally unconcerned about the role of the health professional they consulted with. What mattered to them was that they were skilled, non-judgmental, and supportive.

The policy relevance of the SACHA study

Whether or not Britain joins the growing list of countries which have decriminalised abortion in the last five years, including the Republic of Ireland, Northern Ireland, Colombia, Mozambique, Chile, New Zealand and Australia (Southern Territory being the last and latest jurisdiction to do so), these and other findings from the SACHA study will have important implications for abortion policy and practice. The SACHA country case studies showed that decriminalisation does not address all the challenges of abortion provision. Stakeholders in all three countries described clear benefits for access, quality of care, funding, and the morale of providers, but cautioned that decriminalisation has not removed all barriers to abortion care. They advised that decriminalisation alone had not removed all barriers to abortion care, and that both resources and political will are needed for countries to realise its full benefits.  

The SACHA study has produced a wealth of data drawing on a wide range of sources which will hopefully shape current and future provision of abortion care and support. A first and necessary step in making this happen is to ensure that the findings inform national and local action plans and strategic documents. Policy documents on women’s health and sexual and reproductive health in Britain are currently being drafted. In Scotland, the Women’s Health Plan for 2021-24 outlines a specific action plan for abortion care. In Wales, the November 2022 Foundations for a Woman’s Health Plan includes abortion, but no specific action plan to date. In England, the August 2022 Women’s Health Strategy reported that plans for sexual and reproductive health were forthcoming. There is, therefore, a valuable opportunity for abortion policy and practice to be guided not by political but by scientific considerations.

Read more about the SACHA study here.

Published in June 2023 edition of the Sexual Health, Reproductive Health and HIV Policy eBulletin.  The content of all eFeatures represents the views and opinions of the authors. FSRH and coalition partners do not necessarily share or endorse the views expressed within them.