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An opportunity for abortion policy reform is on the horizon for the Isle of Man, a self-governing British Crown dependency situated in the Irish Sea between Great Britain and Ireland. After almost 150 years of severe restrictions, the island’s Parliament, Tynwald, will shortly debate a new bill to allow Manx women widespread access to abortion services through the island’s healthcare system. In January 2017, Dr Alex Allinson, a general practitioner and a member of the lower branch of Tynwald, the House of Keys, was granted leave to introduce a private member’s bill on abortion. The bill would allow abortion on request up to 14 weeks gestation, or in the case of serious health concerns, serious social grounds, or severe fetal anomaly, up to 24 weeks gestation.1 The draft bill has undergone public consultation and is due to be considered by Tynwald in early 2018.1 The Isle of Man Minister for Health and Social Care, Kate Beecroft, called for any new legislation to be based on evidence.2 In light of this call, we consider how data on the demographics, circumstances and needs of Manx of women who seek abortions under the current law can inform the policy debate.
Current abortion policy on the Isle of Man
As a self-governing British Crown dependency, UK legislation does not automatically extend to the Isle of Man, although many of the island’s laws are similar to those in Great Britain. However, the 1967 Abortion Act, which legalised abortion in a wide range of circumstances, but did not decriminalise it, is a major exception. Until 1995, abortion on the Isle of Man was governed solely by a law dating from Victorian times: the 1872 Criminal Code, which rendered abortion illegal.3
Under the 1995 Termination of Pregnancy Act, abortion is allowed only in limited circumstances under a gestational age framework.4 Abortion is legal up to 12 weeks gestation only, in the case of rape, incest or sexual assault that is reported to the police and attested to in an affidavit. Up to 24 weeks, abortion is legal when doctors consider it likely that the fetus will not survive birth, will die shortly after birth, or will suffer a serious handicap. Abortion is legal without a gestational limit if the doctor who will carry out the procedure and an independent doctor agree that continuing the pregnancy involves serious risk to the woman’s life or "grave permanent injury" to her physical or mental health. If the abortion is performed after 24 weeks, the doctor must undertake the procedure in the manner most likely to ensure that the fetus is born alive. Abortion outside of these specific circumstances remains punishable under the Criminal Code by a maximum sentence of 2 years in prison3 and abortion law on the Isle of Man therefore remains among the most restrictive in Europe.
Pathways to abortion for Manx women
Consistent with provision of legal abortion only in very limited circumstances, the most recent estimates suggest that fewer than 10 abortions take place in hospitals on the Isle of Man each year.5 Yet the island has a population of 17 647 women aged 15–49 years.6 Women who do not meet the narrow eligibility criteria to obtain an abortion through the island’s healthcare system have two main pathways to access: 1) travel abroad to a clinic or hospital for either a surgical or medical abortion or 2) self-source and self-direct their own medication abortion at home using online telemedicine.
Under the first pathway, travelling to England or Wales is the most common option, although women may also travel to clinics in mainland Europe, including Belgium and the Netherlands. Over the last 10 years, no women with an Isle of Man address have accessed abortion services in Scotland.7 Travelling is not necessarily an easy or straightforward process. Women face all the potential challenges of accessing care described by women in other settings, including logistical difficulties, finding childcare, taking time off work, and maintaining confidentiality from family, friends or employers.8 Moreover, Manx women must also cover the costs of travel and of the abortion procedure themselves, despite the fact that Isle of Man residents may access other types of healthcare free of charge in Great Britain under the National Health Service.5
Under the second pathway, women obtain the abortion medications mifepristone and misoprostol through an online telemedicine service and take them at home. The non-profit organisation Women on Web (WoW) began providing early medication abortion through online telemedicine in settings where safe abortion is not legally available in 2006.9 In the WoW model, women request abortion medications using an online consultation form that is screened by a doctor who then prescribes the medications. Women receive the medications by mail and conduct their abortion at home with instructions, information and support provided by WoW’s online helpdesk.9
At the time of their initial contact with WoW, women consent to the anonymised use of their data for research purposes, so it is known that the service is widely used in other nearby settings where abortion is unavailable, including Ireland and Northern Ireland, where it has been demonstrated to be effective, safe and highly acceptable to women.10 11 However, seeking abortion by this route falls outside the remit of the existing Isle of Man abortion law and thus carries legal risk. In response to a Freedom of Information request, Isle of Man customs have recently reported seizing packages containing abortion medications, thus interfering with the reliability of services providing abortion medications by mail.12
Who accesses abortion from the Isle of Man and what are their needs?
Despite current law rendering abortion unavailable in most circumstances, these two pathways – travel and online telemedicine – mean that Manx women do obtain abortions. Figures from the Department of Health & Social Care England indicate that 1076 women travelled from the Isle of Man to access abortion in England and Wales over the decade 2007–2016.13 14 The number travelling has fluctuated over time, but overall shows a decline from 135 in 2007 to 88 in 2016.13 14 (figure 1). Some women may not give an Isle of Man address due to confidentiality concerns or inability to pay for services, and so these figures are likely to be underestimates.5
Between 1 January 2010 (the first year for which data are available) and 9 December 2017, 204 women from the Isle of Man requested early medical abortion from WoW. The number of requests has been increasing steadily over time, and approximately quadrupled between 2010 and 2016, from 12 to 54 requests per year (figure 1). The 204 women requesting medication abortion from WoW over the past 8 years came from all age groups. The majority (140 women, 68.7%) were aged between 20 and 34, 23 (11.3%) were under 20, 25 (12.2%) were aged 35–39, 13 (6.4%) were aged 40–44, and 3 (1.5%) were 45 or older. Most (77%) were under 7 weeks gestation at the time of their request, while 23% were between 7 and 9 weeks gestation. Among the 167 women who provided information on the circumstances of their pregnancies, just over half (54.5%) were using contraception when they became pregnant, 44.3% were not using contraception, and 1.2% were survivors of rape. Data on number of children and reasons for requesting abortion are available from 1 January 2013 onwards. The majority (81.7%) of the 169 women who have contacted the service since 2013 are mothers. Among the 169 women, 284 reasons for requesting an abortion were given, with many women giving two or more reasons. These included not being able to cope with a child or an additional child at this point in their lives (32%), having no money to raise a child (28%), feeling they were too young or wanting to finish school (18%), feeling their family was complete (16%), and being too old or not in adequate health to raise a child (7%).
In table 1 we compare the characteristics of the 88 women who travelled to England and Wales for an abortion in 2016 and gave a home address on the Isle of Man and the 54 Manx women who requested medical abortion through WoW in the same year. These figures indicate that both women who travel and women who request abortion through online telemedicine are diverse with respect to age and number of children. Some 65% of those accessing abortion through WoW and 48% of those travelling were mothers. The vast majority were under 13 weeks gestation when they accessed their abortion and their circumstances overwhelmingly fell under Ground C of the 1967 UK Abortion Act where "the pregnancy has not exceeded its twenty-fourth week and 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". In practice, a wide variety of social and economic reasons – including those cited by women requesting help from WoW – fall into this category.
Although these data capture the majority of abortions to Manx women over the last decade, they cannot guarantee a full picture. Under-reporting of Isle of Man addresses at clinics in England and Wales, abortions taking place in clinics in other European countries, medication for abortions obtained from online sites other than WoW, and abortions using alternative and less safe methods cannot be accounted for. Further, there may be overlap between women who obtained abortions in clinics in England and Wales and women who requested medications through WoW but were not able to carry out their abortion and ended up travelling instead. Some women who requested medical abortion through WoW may also have decided to continue their pregnancy, or may have experienced a spontaneous pregnancy loss while waiting for the medications to arrive.
Conclusions for Isle of Man abortion policy reform
Findings from this analysis of Manx women who access abortion through the two most prominent pathways demonstrate several important facts that are relevant to the upcoming policy debate on abortion law reform.
First, the need for abortion is not limited to any one sector of Manx society. Women accessing abortion are diverse with respect to age, number of children, and circumstances of abortion. Second, there is clear evidence that Manx women need access to abortion in a wide range of circumstances, most of which fall under the ’socioeconomic' category. Very few reported that their pregnancy was the result of rape or that they sought their abortion due to fetal anomaly. Thus, a narrowly construed policy reform to increase access to abortion in only these circumstances would do very little to address the needs of most Manx women who require access to abortion care. Third, the vast majority of Manx women obtain care at gestational ages under 13 weeks. Thus, although the 14-week gestational age limit for abortion on request outlined in the proposed reform bill is reflective of the current situation, the fact that most women are well below this limit also indicates that imposing such a low gestational age limit is highly unlikely to be necessary. Indeed, abortion statistics from women obtaining abortions in England and Wales, where the gestational limit is 24 weeks, and in the USA, where is there is no gestational age limit, indicate that the vast majority of women still obtain care early in pregnancy. Only 8% of abortions in England and Wales in 2016 and 8% in the USA in 2014 took place after 13 weeks gestation, and the majority of those that did occur later were for fetal anomaly or for maternal physical health reasons15 16 Finally, since Manx women are already obtaining abortions on the Isle of Man using online telemedicine, decriminalisation of abortion is an important aspect of legal reform. Decriminalisation would bring such abortions out of the shadows and into the mainstream, and reduce the stigma that criminalisation can engender.17 Since it is also possible that some women are relying on websites that do not provide accurate information and instructions, sell fake medications, or simply cheat women by sending no medications at all, decriminalisation could also play an important role in protecting public health. Moreover, since abortion was originally criminalised in the British Isles at a time when women were not yet recognised as legal persons, decriminalisation also represents an important step towards achieving a more equal and just society.18
The data discussed here demonstrate the urgency and importance of reforming current abortion law in the Isle of Man. While two main safe and effective options are available, both place significant burdens on Manx women and are likely to result in delays in accessing care. Travel requires considerable economic and social resources and may be stigmatising and emotionally traumatic. Abortion through online telemedicine is safe and effective, but is still against current law and carries a risk of criminal prosecution. The situations that Manx women seeking abortion face bear a striking similarity to those faced by women in the Republic of Ireland,19 where abortion law reform is currently under consideration. A recommendation to allow abortion without restriction up to 12 weeks gestation seems likely to be supported by the Irish Parliament, and data on women obtaining abortion medications online played a pivotal role in the decision process.20 The proposed reform on the Isle of Man is a valuable opportunity for evidence-based debate and to design a law that ensures full-spectrum, accessible, affordable and acceptable reproductive healthcare for Manx women.
The authors thank Robert Betts and Mark Dionisio of the Department of Health & Social Care England for assistance with data acquisition.
Contributors ARAA is an assistant professor of public affairs specialising in reproductive health policy. She has extensive experience in abortion policy analysis, most recently presenting evidence to the Oireachtas Committee examining Ireland’s Eighth Constitutional Amendment. RG is founder and director of the Women on Web International Foundation and has extensive expertise in abortion care provision under a wide variety of legal frameworks. AJ is a statistician at the Department of Health & Social Care England with extensive experience working with healthcare data. The data used in the article come from Women on Web (WoW), provided by RG, and from the DH, provided from publicly available reports and through a freedom of information request. All data were provided in fully de-identified format. ARAA devised the idea for the analysis. RG provided the de-identified data from Women on Web. AJ compiled the Department of Health and Social Care data with assistance from his colleagues Robert Betts and Mark Dionisio. ARAA conducted the statistical analyses and prepared the table and figure. All authors contributed to the interpretation of the data. ARAA wrote the first draft of the manuscript and all authors revised the first and subsequent drafts critically for intellectual content, and approved the final manuscript. All authors agree to be accountable for all aspects of the work. ARAA is the manuscript guarantor.
Funding This study was funded by Eunice Kennedy Shriver National Institute of Child Health and Human Development (P2CHD042849).
Competing interests RG is Founder and Director of Women on Web.
Ethics approval University of Texas at Austin IRB.
Provenance and peer review Not commissioned; externally peer reviewed.