Triumphs and trials with the UK abortion law: The power of collaboration in abortion reform

The UK is usually viewed as having liberal abortion regulations, providing good access to abortion care within a publicly funded health service. However, the underlying laws are authoritarian, dating from an era when public executions drew large crowds and 67 years before women were able to vote. Abortion is only legal when two doctors certify it meets the permitted grounds, and the penalty for self‐managed abortion is up to life imprisonment for both the woman and any accomplice. These laws had prevented the use of mifepristone and misoprostol at home. Changes to the regulations for misoprostol in 2018 and mifepristone in 2020 permitted home use, but the government announced they were rescinding the approval for mifepristone in 2022. This article discusses how, despite the opposition of government, significant progressive changes to the abortion laws were achieved. Early medical abortion at home is now protected in law, and safe access zones protect patients and staff from harassment and intimidation from protesters. Despite this progress, increasing numbers of women are facing criminal investigation and face long prison sentences if convicted. The need for decriminalization and for abortion care to be regulated like all other health care is the next pressing issue.

which commands a large majority. 2Prominent cabinet ministers, including the government's longest-serving Secretary of State for Health (the government cabinet minister in charge of health and social care in England), have expressed antiabortion views, 3 and both the current junior minister in charge of abortion care in England and the minister for women have voted against buffer zones and home use of mifepristone in EMAs.
How has it been possible to achieve the first liberalization in abortion laws in England and Wales since 1967, despite a relatively hostile political environment?The key factor has been collaboration-varied groups, including those who would normally be political adversaries, have united and learnt how it is possible to achieve genuine reform for the benefit of women, girls, and pregnant people.
Pro-choice views have always been the majority in the UK, 4,5 but what has changed is that a broad coalition of authorities, groups, and individuals are now willing to stand up and publicly support abortion care.

| UK ABORTI ON L AWS AND ACCE SS
Although the UK is usually thought to have liberal abortion regulations, there is a mismatch between how restrictive the laws are on paper, and how they can be more liberally interpreted by doctors in practice. 6The primary legislation remains from a law from 1861 (Offenses Against the Person Act)-the year the American civil war started-in an era when England was still transporting criminals to its colonies, when public executions drew large crowds, and 67 years before women were able to vote in the UK.This made abortion illegal both for the woman and for whoever procured it, with the only subsequent change being in 1948 when the additional penalties of "hard labor" and "solitary confinement" were removed from the maximum sentence, which remained "penal servitude for life." Another law was introduced in 1929 to cover "child destruction" of the unborn infant with much the same effect and the same penalty.
In 1967 the Abortion Act was introduced, which provides grounds for defense against prosecution under these earlier laws.The most common ground, accounting for 98% of abortions in England and Wales, 7 requires two doctors to certify that the woman is under 24 weeks of gestation and that the continuation of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman.
Abortion is permissible to term where there is a threat to the life or of grave physical injury to the mother, or where there is a "substantial risk of serious handicap" in the child.
In practice this means that the UK allows abortion on broad social grounds, but unlike most EU countries there is no legal right for abortion on the request of the pregnant woman. 8All cases require third-party authorization from two doctors, and doctors can refuse to provide care on grounds of conscience.There is broad consensus among healthcare practitioners that this is hypocritical and anachronistic, 9 rooting abortion care in an era when a woman would need to have the permission of her husband to obtain oral contraception, when medical paternalism was the norm, and before the evolution of modern concepts of patient autonomy, choice, and informed consent.It has also prevented best practice; for example, both the World Health Organization (WHO) 10 and the UK's own guidelines from the National Institute for Health and Care Excellence (NICE) 11 recommend maximizing the role of nurses and midwives in abortion care, yet it remains illegal for them to prescribe abortion medication or to perform an abortion autonomously.It would also be difficult for a general practitioner (GP) to get the approval to be able to offer abortion care to their patients at their local GP surgery. 12men still experience many problems accessing abortion in Britain, but these are largely caused by problems in the organization and funding of services rather than from the law itself. 6,13,14Access in Northern Ireland has been especially problematic despite abortion being decriminalized in 2019 and new regulations subsequently brought in, with women still having to travel out of the country or pursue self-managed care. 15However, the spark that finally led to real change was access to EMA medication to take at home, opening up the possibility not just of a woman being able to take the medication at home, but also for full, remote, telemedical care.

| EMA AT HOME
Since 2002 the proportion of abortions using EMA has increased every year in England and Wales. 16From 2014 EMA has accounted for over half of all abortions in England and Wales, rising to 87% by 2021. 7National and international guidelines have recommended EMA at home for more than a decade, but a judicial review of the Abortion Act had found that neither mifepristone nor misoprostol could be lawfully administered anywhere other than a hospital or abortion clinic approved under the Act. 17This meant that women choosing an EMA at home had to attend in person at least twice or accept a higher failure rate from a simultaneous regimen, 18 and needed to travel while enduring worsening cramps and bleeding from misoprostol administered in a remote clinic. 19r some time, clinicians thought that nothing could be done unless there was a change in the law; however, a legal expert at the British Society of Abortion Care Providers (BSACP) annual conference in 2017 made it clear that the Secretary of State had discretion to permit home use without requiring any change in the legislation.
In Scotland, which has different laws, the government had been persuaded to act on the evidence and agreed to permit home-use misoprostol from October 2017.Wales announced they would follow in 2018.The government in England was reluctant to act, but by now campaign and advocacy groups were becoming more vocal.
An editorial outlined the issues in June 2018, 20 and its publication was planned alongside a press campaign.Individual patients were brave enough to speak publicly about their distressing experiences in aborting while traveling on public transport, and abortion clinics permitted filming and interviews with their staff, and as a result the issue received significant mainstream media coverage.This coincided with a rare bit of luck-the previous Secretary of State, who was not sympathetic to abortion, 21 was promoted in a government reshuffle 22 and, as a result, the new incumbent inherited the media storm in their first few weeks in office. 23Agreement was reached that England would follow the lead of Scotland and Wales and approval was granted on December 27, 2018, alongside updated clinical guidelines. 24The coordination that led to this success was more fortuitous than preplanned, with some alliances beginning while meeting for the first time at media studios.However, there was no longer any doubt about how effective a coalition of like-minded groups could be, and how valuable it was to bring together the skills and experiences of academics, clinicians, and campaigners from various disciplines; but most importantly, how powerful the narrative is from individual patients willing to share their story.

| P OLITI C S AND ABORTI ON C ARE
While the harrowing stories from patients forced to take misoprostol and then travel home had been addressed, the ongoing legal necessity to swallow mifepristone-a drug with few adverse effects and a long-established safety record-within the boundaries of a hospital or clinic demonstrated how the law was simply not fit for purpose.
It demonstrated that legislation only served to interfere with clinical discretion and prevented the implementation of best practice and patient-centered service development. 25In the UK this was further highlighted by publication, in September 2019, of NICE guidelines on abortion care, which recommended EMA at home and the use of remote consultation. 11anges to the regulations require the engagement of politicians.In all other areas of medicine, the weight of evidence, especially when supported by NICE guidance, would invariably guarantee implementation, especially given how cost-effective EMA at home is compared with the alternatives and how obviously preferable it is for many patients.Abortion is of course subject to different prejudices and bound by a law that preceded the availability of mifepristone by over 20 years.In UK politics, any vote on abortion is by tradition not led by government but through a free vote of members of Parliament (MPs).Government, who control the business of Parliament, will not provide the time necessary to debate and pass new laws unless they are sponsored by them, making it very hard to secure any Parliamentary time to debate abortion.The ability to change the law, or to convince politicians to permit home use of a drug they had probably never heard of, seemed remote.But then the COVID-19 pandemic arrived.

| COVID -19 AND MAINTAINING ABORTION C ARE
As it became clear that the global pandemic would have a significant impact on the ability of health services to function, abortion providers, government, and the Royal College of Obstetricians and Gynecologists (RCOG)-responsible for standards and advocating quality in women's health-met to discuss how to ensure continuity of access to abortion care.Given how access to inpatient facilities and theaters was likely to become compromised, it was agreed to draw up clinical guidelines in the expectation that EMA at home would be approved by Ministers.Events moved fast-the initial invitation from the government was on March 6, 2020, and key stakeholders met 4 days later.After less than a week the first draft of new clinical guidelines for fully remote access was produced and submitted for peer review.On March 19, 2020, the Minister for Health agreed an approval order be granted to permit home use of mifepristone, and 2 days later the clinical guidelines were published. 26 March 23, 2020, the approval order was signed and uploaded to the government website; however, a few hours later it was withdrawn amid confusion, with the Secretary of State announcing to Parliament the next day that this had been a mistake and that there would be no change to abortion procedures.Given that a national lockdown had just begun, with the underlying legislation passed on March 25, 2020, there was alarm as to how services could continue to function with the government blocking measures to protect abortion care.The straightforward message from our political leaders to the public was the repeated advice to stay at home and protect the National Health Service (NHS).
On March 28, 2020, a group of 55 public health specialists and academics wrote an open letter calling on the government to approve telemedical abortion services immediately in order to protect public health.The letter stated: the impact of failing to implement this service on both individuals and the wider population will be grave, and services are currently at the brink of collapse … We urge you to act immediately to protect the health of individuals, the wider population, and our healthcare workers. 27ven how urgent the need for action was, a group of abortion care advocates, clinicians, and representatives worked with a major national newspaper who covered the crisis on their front page.Just before this went to press on March 29, 2020, the government announced that it would permit home use of mifepristone after all, with the legal order published the following day.Providers began offering telemedical abortion care the next week, and by the end of the year over 72 000 women had undergone an EMA entirely at home, with the new pathway representing 50% of all abortions through the rest of the year. 28Abortion opponents launched a judicial review of the approval process, but both this and subsequent appeals were dismissed.

| HARNE SS ING THE P OWER OF COLL ABOR ATION
The approval order for home use of mifepristone was a temporary one and would expire when COVID-19 regulations were rescinded.
The advantages to patients of the new pathways were obvious and had already been described in the literature and guidelines.However, such an immediate and successful population-level implementation was unprecedented.It was clear that the sector had a duty to publish their outcomes as no previous study had the statistical power to detect rare events.Without definitive data demonstrating that the new pathway was safe, effective, and acceptable to patients, there seemed little chance of persuading the government to maintain the approval for home use of mifepristone.
The three main abortion providers in the UK agreed to collaborate, and through the providers' specialist society, BSACP, secured the help of methodological and statistical expertise from colleagues in the USA.This resulted in the largest ever UK study in abortion care, with the cohort analysis capturing 85% of all abortions in the time studied and analyzing over 52 000 women. 29At the same time a Scottish study, while much smaller, was able to use more robust methodology in following up women and cross-checking that all complications were recorded. 30Both studies reported almost identical outcomes, demonstrating that telemedical pathways are safe, effective, and preferred by patients.
Providers had not previously collaborated on this scale, and three things were apparent.Firstly, that it was feasible to deliver large-scale quality cohort studies which, given the volume of patients treated, were adequately powered to detect rare events.Such collaboration, especially with academic colleagues lending their support, has the potential to significantly improve care.Secondly, that even in the midst of a pandemic and without any funding, the enthusiasm and expertise harnessed from working together could deliver a series of papers that influenced practice both in the UK and internationally.Thirdly, the studies provided compelling and definitive data to support the long-term approval of telemedical EMA pathways.They also demonstrated what could be achieved when services can be delivered on the basis of evidence rather than restrictive legislation.
The governments of England, Scotland, and Wales each held separate public consultations on the home use of abortion pills.This is an unusual approach to adopt when assessing the effectiveness of a healthcare intervention.The process in other areas of medicine would be based on public health and clinical expertise, by asking patients, or by using the established methodology of guideline production.Not surprisingly the consultations were dominated by campaign groups, with 96% of all campaign responses received (46% of total responses) coming from two antiabortion groups with extreme views. 31With concern over the process and that those with strong views and underlying prejudice could have undue influence, a coalition of 28 organizations wrote to the minister in charge of abortion care to express their support for use of mifepristone at home.This was the beginning of larger cross-sector collaboration across multiple organizations, and included Royal Colleges, medical bodies, abortion care providers, women's health organizations, advocacy groups, and charities involved in supporting women's rights and protection from violence.
Six months later the COVID-19 restrictions were being wound down, and rumors began circulating that government was minded to rescind the approval order in England and Wales and make the use of mifepristone at home illegal again.The main medical authorities wrote to the Secretary of State to express concern privately, but it became clear that the political will was to reverse all COVID-19 measures.The Royal College of Obstetricians and Gynecologists began a more public campaign, and the Academy of Medical Royal Colleges (AoMRC)-the coordinating body for the 24 medical Royal Colleges and faculties in the UK and Ireland-also publicly supported the continuation of telemedicine. 32Another 33 organizations, representing a coalition of almost all the major authorities concerned with women's health and welfare, collaborated with several Royal Colleges to write to the Prime Minister expressing their concerns. 33Government published the responses to their public consultation on February 24, 2022, and despite the evidence base and direct and indirect support from almost every medical authority and the multitude of other organizations, issued a statement announcing the end of their approval for mifepristone at home. 34e six key stakeholders responded by issuing a pre-action letter for judicial review against this decision.Thankfully this never needed to progress as the focus switched to the politicians.By this stage the campaign had cross-party support and had developed close relationships with key politicians, but the mechanics of having to change the law without government support required sophisticated tactics to navigate the parliamentary process.An opening was found by inserting an amendment into the Health and Care Bill that was already passing through Parliament, and 2 weeks after government issued their statement, the coalition of 33 organizations issued a parliamentary briefing setting out the evidence, concerns, and recommended solution.The briefing began: We are a group of Medical Royal Colleges, Violence Against Women and Girls groups, and advocates for women's health and rights.Together, we support making telemedical abortion care permanent.We are shocked, saddened, and angered by the government's current plan to make this service illegal, and urge them to listen to us as clinical experts and those supporting women throughout their lives.
As the Bill made its way through Parliament, the main medical bodies issued additional statements to address concerns that were raised. 35Although the government made it clear that they did not support it, 34 they followed parliamentary tradition by keeping it as a free vote.There was considerable media interest, and advocates and medical experts remained available throughout to respond and give briefings and interviews.The amendment was passed after debates in both Houses of Parliament, one of them in the early hours of the morning.The end result considerably strengthens the protection for women as the use of mifepristone and misoprostol at home is now enshrined in primary legislation, whereas previously this could be granted or removed at the whim of a government minister.
The key elements that led to this success were discussed at a subsequent parliamentary reception.The collaboration of the main medical authorities (the Royal Colleges who set standards, and the providers who deliver care) was essential, but it was widening this group to include a range of charities and organizations who support women that really helped to win the argument with politicians.
Having cross-party support in Parliament was essential, and this followed from building relationships and trust with politicians who were united by the common aim of improving women's reproductive health care.Individuals have to be available and responsive to the politicians' need for information and to help with counterarguments to address the concerns of their colleagues.Spokespeople have to be able to respond to media requests for interviews at short notice.
As with many sensitive issues, the outcome tends to rely on just a few individuals who are prepared to co-ordinate, find evidence, draft statements, grasp opportunities, understand the nuances of parliamentary process and have the expertise to brief law makers and journalists.In this campaign, once the momentum commenced, more and more individuals and organizations offered their help and support.

| THE DARK S IDE OF THE UK L AWS
Unfortunately, there are always setbacks and disappointments.
While the future of EMA at home is secure, the underlying law from 1861 remains and that represents a threat to both staff and patients.
Staff have been the victims of politicized campaigns; in one notorious episode in 2012, all abortion clinics were simultaneously raided by inspectors checking for technical breaches of the two-doctor signature rule.This cost the NHS over £1 million and led to the regulator complaining that they were forced to cancel hundreds of planned inspections of NHS hospitals. 368][39] These actions exert a chilling effect on the clinicians directly involved, and more widely on those who work in abortion care and the women who need to use the services. 40st concerning is where the criminal law is used against women who then face prosecution and potentially long jail sentences.In 2023 a woman was jailed having pleaded guilty to the 162-year-old law, despite having considerable mitigating factors including a child with special needs. 41Although the total number of cases recorded as crimes is low (Figure 1), and the number proceeding to prosecution lower still, the trend is definitely increasing and the number of women who are put through the stress and trauma of an initial criminal investigation is likely to be much larger. 42ere are recent reports of women and girls coming under suspicion and being subjected to police investigations after suffering an unexplained later gestation loss. 43These include a young teenager who had her mobile phone confiscated and had to wait months before it became clear she had suffered a natural stillbirth, and a woman who was arrested in hospital and forced to spend 36 h in police custody after presenting with an unexpected later gestation pregnancy loss. 44,45One woman who served a jail term after pleading guilty to taking misoprostol obtained illicitly recently told her story of harrowing abuse and coercion from her partner prior to the abortion. 46In 2023, five women have appeared in court in England. 47Two of these included charges under a niche part of the abortion law (section 60 of the Offenses Against the Person Act) which has its origins in 1623, over 100 years before the last woman was burnt alive at the stake in England.In both these cases bail conditions banned contact with children.The need for decriminalization and for abortion care to be regulated like all other health care is the next pressing issue.

| CON CLUS ION
Compared with many parts of the world, the UK is fortunate in having reasonable access to abortion care that is free to those who need it.However, in this post Roe v Wade era, nobody is complacent that rights previously taken for granted can be relied on.Although in practice the law is applied in a reasonably liberal manner, the underlying statute is not fit for purpose 48 and could be used or easily amended to restrict access.This has recently been highlighted by successive UK governments failing to permit the use of EMA drugs at home, and the current government trying to reverse the approval for mifepristone to be used legally at home.The most disturbing examples are without doubt the criminal investigations and ongoing prosecutions of women who would be treated with compassion in a caring society, but instead have been managed as suspected criminals.
However, there are encouraging signs that progress is being made.Many people can be proud that they played a part in  The key element that enabled the recent successes was the development of coalitions both within the healthcare sector and externally; for example, health professionals collaborating to produce powerful research by sharing their data, and organizations developing links with many other groups with expertise in campaigning for women's health and well-being or offering specialist knowledge such as legal experts.From adversity comes strength and the combination of a hostile government and concerns following Roe v Wade has led to a surge of interest and support from the media, sympathetic politicians, and wider society.We must now harness and retain this support and use the momentum to tackle the ultimate goal of decriminalization, so that abortion care is managed and regulated like all other health care and the threat of prosecution for patients and their clinicians is removed.
first progressive change to the abortion law in 55 years, with recent successes having built on the work of decades of campaigning.Public health colleagues offered great support and, after securing a £1.03 million national research grant, have formed a consortium of 20 researchers from seven countries to drive the evidence base of service provision and regulation in the SACHA studies.49