Background

A moment when the world′s most powerful country has just elected one of its most anti-abortion presidents might seem an odd time for UK abortion care providers to be seeking the liberalisation of Britain′s abortion law. But 50 years on from the passing of the 1967 Abortion Act, abortion care in the UK is heading towards a crisis, and practitioners are undeterred by the political climate. This is reflected in the founding of a new support organisation for service providers, the British Society for Abortion Care Providers (BSACP),1 a new campaign for legal reform by the UK′s largest service provider, the British Pregnancy Advisory Service (BPAS),2 active consultation processes on abortion care quality and legal reform within the Royal College of Obstetricians and Gynaecologists (RCOG) and the Faculty of Sexual & Reproductive Healthcare (FSRH), and a constant stream of material submitted to this journal.3–13

Challenges

Among many challenges women seeking abortion face, inequitable access, inadequate numbers of appropriately trained staff, stigmatisation, and a culture of exceptionalism, or ghettoisation, have often been highlighted.14 ,15 Much abortion care in the UK is provided outside the National Health Service in specialist organisations, excluding students and trainees, among them the potential service providers of the future. As well as reinforcing stigma, this deprives trainees of valuable learning opportunities. It is noteworthy that while the RCOG has offered an Advanced Training Skills Module in abortion care since 2007, fewer than 1% of trainees completing such modules have taken it (RCOG, personal communication, November 2016).

Opportunities

For practitioners not excluded by conscientious objection – a right which within limits must be upheld and respected16 – abortion care offers an important learning environment. Here, we encounter the same women whose babies we may also deliver at other times, but at a different stage in their reproductive life-course. We gain confidence and skill in early pregnancy examination and safe uterine intervention, and see medical and surgical care in a complex ethical, legal and biopsychosocial context. This teaches high-level, transferrable consulting skills. All practitioners need to be able to facilitate ethically complex, patient-centred decision making with interest, confidence and self-reflection.

Abortion law

Problems of access and stigma, familiar worldwide, are compounded in the UK by an abortion law that is now widely seen as not fit for purpose. Framed as a medically sanctioned defence against a piece of criminal law passed in 1861,17 UK law is out of step with technical advances in safe medical abortion, the trend away from paternalism towards patient-centred and nurse-led services, and current UK social values.18 Hence, while many women now attend our services in early pregnancy believing they have a right to make their own choice, as they would in most of Europe19 – British law still requires the identification of serious physical or mental health risk by two doctors not necessarily qualified in psychological disciplines, who may not know the woman personally. There is broad consensus among practitioners that this is hypocritical and anachronistic.

Reflection

But if the law is to be reformed as BPAS, the Royal College of Nursing, the Royal College of Midwives, and other women's health organisations propose, space must first be made for reflective debate. That debate needs to place women's wellbeing centre stage, but also acknowledge ethical complexity. Agreeing how far a woman's autonomy can be extended, and what processes can best safeguard this core value while also acknowledging its ethical context, will require a degree of mutual respect which has been lacking. We need to move beyond the kind of violent communication that sees a minority of so-called ‘pro-life’ campaigners bullying women seeking abortion, and a minority of so-called ‘pro-choice’ campaigners refusing to acknowledge moral complexity. Achieving social consensus will be no less demanding a process than that faced by each individual woman forced to weigh serious and conflicting concerns in considering whether to end her pregnancy.

Acknowledging complexity

In joining this debate, we must not as practitioners fall into the trap of focusing narrowly on clinical concerns and conceding the moral debate to extremists – an argument made cogently in a new book reviewed in this issue.9 ,11 For many women seeking abortion, acknowledging it as a sad and serious event seems an essential part of reaching a decision that they can live with and learn from. For others, the decision is more straightforward, and individual difference needs to be respected. But where ambivalence, guilt, regret or other ‘difficult' feelings do exist, we should not, in our eagerness to avoid ‘abortion-negativity', suppress these. Abortion care must not be an obstacle course, but neither should it be a conveyor belt.

What is in this journal issue?

One casualty of exceptionalism and factionalism is good evidence to inform care quality. While two articles in this journal issue highlight specific areas in which UK abortion care could improve – cervical preparation before,10 and contraceptive provision after,8 abortion – a systematic review highlights a much broader problem with agreement over care quality indicators.3 A linked commentary calls for valid quality criteria to be set in the UK.4 Looking at an Australian experience of abortion law reform, a mixed methods study of practitioners' views cautions that despite empowering women and increasing clarity and safety for practitioners, it failed to address stigma, access and workforce sustainability.5

Other contributions remind us that apparently neutral language can reinforce stigma,7 and of the ‘inverse care law’, which compounds disadvantage for poor women, wherever services are poorly accessible.12

So your contributions on abortion keep flooding in, because abortion care remains a high-volume, under-researched and under-integrated area of women’s healthcare. And 2017 is an excellent time for practitioners to be challenging hypocrisy and exceptionalism in UK abortion care, and leading respectful debate centred on women's needs, with complexity acknowledged.