Dr Patricia Lohr is the Medical Director at bpas and set up the successful Reproductive Health Externship.  

Legalisation of abortion is a necessary pre-requisite to reductions in death and serious injury from unsafe abortion, but it is not sufficient to secure access to abortion for the many women who will need to terminate a pregnancy each year. For that, you need a willing and skilled clinician workforce, and according to the British abortion law, that means a ready supply of doctors.

Each of the nearly 200,000 abortions undertaken in England and Wales each year needs two doctors to sign the HSA1 form certifying that the request meets one of the legal grounds. Doctors are also the only type of clinician allowed to perform abortions, whether that means physically undertaking a surgical procedure or signing prescriptions for medical abortions that are then carried out by nurses or midwives. And, while only a relatively small number of women need to have an abortion in the second trimester or in a hospital setting, specialised training is needed to conduct these procedures safely particularly by surgical methods, which are lacking in hospital-based services.

Despite clear evidence that abortion saves lives and that control over when and whether to have children has tremendous personal, educational, and economic benefits for women and society, doctors are not signing up to undertake this work in large numbers and do not complete post-graduate training with the skills to provide comprehensive abortion care, especially at the latest gestations allowed by law.

The reasons for this are likely multifactorial but are influenced by lack of exposure to abortion care during training, few positive role models within training environments which junior doctors can aspire to emulate, the existence of abortion within the criminal code that can leave doctors feeling vulnerable, and few opportunities for career development within traditional employment settings.

These are complex problems, which will require a variety of solutions, but one successful programme to foster more positive attitudes to abortion and commitment to provision, are short externships for medical students in a variety of settings where abortion care is delivered. Developed in 1995 by the international, non-profit, grassroots organisation Medical Students for Choice (MSFC), these Reproductive Health Externships are now offered at 48 locations around the world including, for the past 3 years, at several BPAS clinics.

In their own study of 161 medical students who undertook externships in the United States, MSFC found that following participation students were significantly more knowledgeable about unintended pregnancy and able to counsel women about abortion, as well as significantly more supportive of abortion provision, and significantly more inclined to provide abortions in the future. Our experience has been equally positive and is best reflected in the comments provided to us from the students themselves:

“It was so eye opening to see the many different walks of life who availed of the service and comforting to see the great help they received for something, which I found from my experience, that every women found to be a challenging experience in their own way. I feel it will stand to me in the future when I am counselling my patients about their options. If it is still not legalised in my country (Ireland) when I am practising then I feel patients will appreciate the knowledge that I have had first hand experience of abortion services, that I have met many women who have gone through similar experiences to the ones they are facing and that I am there to help them no matter what their decision with no judgement but simply advice and support and to let them know that not everywhere is there a stigma or taboo attached to abortion.”

“Overall the experience was hugely positive. I have always considered a career around obstetrics and gynaecology and this placement has reinforced my interest in the area. At first I was unsure how I would feel/react to the placement but the professionalism of the staff and the realisation of the positive influence that the service BPAS offers on the women it serves was brilliant. I was worried that I would be put off a potential career in this service but I am now more likely to pursue a career in this area.”

“One of the most memorable high points of my clinical observations was when I was able to assist in an early gestation surgical abortion. This moment was a turning point for me in that it made me feel much more involved in this patient’s life. For those few minutes, I felt like I was doing my part to help this individual. She voluntarily visited this clinic looking to terminate her pregnancy, and I was able to help change her life.”

Finding new and innovative ways to engage and train doctors in abortion care is essential to fulfilling the promise of the Abortion Act in Britain. By bringing medical students into our clinics and giving them exposure to compassionate services delivered by competent and inspiring clinicians early in their careers, I feel BPAS is making a positive contribution that will benefit women for years to come.

Dilys Cossey was the Abortion Law Reform Association Secretary from 1964-68 and was a leading campaigner for abortion, birth control and reproductive rights through her further involvement with IPPF, FPA, Brook and IPAS. 

Why call for decriminalisation of abortion? Surely abortion is legal? Yes, of course it is, but it is not generally realised that the 1967 Abortion Act per se only legalises abortion in certain circumstances as exceptions to the provisions of sections 58 and 59 of the 1861 Offences Against the Person Act (OAPA) which make abortion a criminal offence.

The 1967 Abortion Act was groundbreaking legislation. This 1960s reform, in which I was privileged to be involved as Secretary of the Abortion Law Reform Association (ALRA) campaigning team, reflected the social mores of that time and has served women and their families well. However, much has changed since then, not least the advent of medical abortion which has significantly transformed the abortion scene both for women and their healthcare providers.

Today the accumulated experience of nearly half a century points, among other things, to the need for clarification of the role of clinicians, for positive recognition of abortion services as an integral part of health care, for giving women autonomy in abortion choice, and for acknowledgement of contemporary social and sexual behaviour in Britain. The underlying nineteenth-century legislation is a block, exercising a ‘chilling effect’ with the threat of criminal proceedings for alleged infringements of the Abortion Act.

So, the question is: in today’s context is the Abortion Act fit for purpose? Certainly the 1861 Offences Against the Person Act is not. As the Law Commission stated in a recent scoping exercise, inviting views on whether selected sections of the OAPA should be reformed, ‘The Offences Against the Person Act 1861 is widely recognised as being outdated’. Unfortunately, the Law Commission is not intending to review the sections of this ‘outdated’ law that relate to abortion.

BPAS has already set the ball rolling in the decriminalisation debate at its meeting in the House of Commons, hosted by Kate Green MP on 16 October 2014, which included a contribution on the Canadian situation, where abortion has been decriminalised since 1988. I am pleased to support the call to regulate abortion in Britain according to the standards of the best clinical care, and invite all those who share these beliefs to join in the campaign for the decriminalisation of abortion.