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The Impact of Northern Ireland's Abortion Laws on Women's Abortion Decision-Making and Experiences

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The Impact of Northern Ireland's Abortion Laws on Women's Abortion Decision-Making and Experiences Downloaded from http://srh.bmj.com on January 16, 2019 - Published by group.bmj.com Research The impact of Northern Ireland’s abortion laws on women’s abortion decision-making and experiences Abigail R A Aiken,1,2 Elisa Padron,3 Kathleen Broussard,2,4 Dana Johnson1 1LBJ School of Public Affairs, ABSTRACT University of Texas at Austin, Key messages Background In Northern Ireland, abortion is Austin, Texas, USA 2 Population Research Center, illegal except in very limited circumstances to ► Women in Northern Ireland still University of Texas at Austin, preserve a woman’s life or to prevent permanent experience multiple barriers to travelling Austin, Texas, USA or long-term injury to her physical or mental 3College of Natural Sciences, to access abortion care even though University of Texas at Austin, health. Abortions conducted outside the law are abortions are now provided free in Great Austin, Texas, USA a criminal offence punishable by imprisonment. Britain. 4Department of Sociology, We assessed the impacts of Northern Ireland’s ► Self-managed medication abortion using University of Texas at Austin, Austin, Texas, USA abortion laws on women's decision-making and online telemedicine may be preferred experiences in accessing abortion. over travel due its convenience and Correspondence to Methods Between April 2017 and February safety, but the experience is dominated Dr Abigail R A Aiken, LBJ School 2018 we interviewed 30 women living in by fear and isolation due to the risk of of Public Affairs, University Northern Ireland who had sought abortion prosecution. of Texas at Austin, Austin, TX 78713, USA; araa2@ utexas. edu by travelling to a clinic in Great Britain or by ► Lack of clarity surrounding Northern using online telemedicine to self-manage a Irish abortion laws delays access to care Received 31 July 2018 medication abortion at home. We interviewed and fuels mistrust of the healthcare Revised 5 October 2018 Accepted 5 October 2018 women both before and after a policy change system. Published Online First that allowed women from Northern Ireland 19 October 2018 access to free abortion services in Great Britain. We used a semi-structured in-depth INTRODUCTION approach and analysed the interviews using Northern Ireland, a part of the United grounded theory methodology to identify key Kingdom (UK), has some of the world’s themes. strictest abortion laws. Abortion is Results Four key findings emerged from our permitted only to preserve a pregnant woman’s life or to prevent permanent analysis: (1) women experience multiple barriers 1 to travelling for abortion services, even when damage to physical or mental health. Abortion following rape or incest, or abortion is provided without charge; (2) self- following the diagnosis of fetal anomaly, management is often preferred over travel, but is not permitted. In the UK, conducting its criminalisation engenders fear and isolation; an abortion outside the law is a criminal (3) obstruction of import of abortion medications offence under the 1861 Offences Against by Northern Ireland Customs contributes to Person Act and carries a maximum penalty stress, anxiety, a higher risk of complications, of life imprisonment.2The UK’s 1967 and trial of ineffective or unsafe methods; and Abortion Act, which made legal abortion (4) lack of clarity surrounding the obligations widely available in England, Scotland of healthcare professionals in Northern Ireland and Wales, was not adopted in Northern causes mistrust of the healthcare system. Ireland.2 Conclusions Northern Ireland’s abortion laws Despite these laws, women in Northern © Author(s) (or their negatively affect the quality and safety of Ireland do have abortions. For those who employer(s)) 2019. No women’s healthcare and can have serious commercial re-use. See rights do not meet one of the few legal excep- and permissions. Published by implications for women’s physical and emotional tions, there are two main pathways to BMJ. health. Our findings offer new perspectives for obtaining care: (1) travelling to countries To cite: Aiken ARA, Padron E, the current policy debate over Northern Ireland's where abortion is legal, most commonly Broussard K, et al. BMJ Sex abortion laws and suggest a public health England, to access services in a clinic; or Reprod Health 2019;45:3–9. rationale for decriminalising abortion. (2) using online telemedicine to access Aiken ARA, et al. BMJ Sex Reprod Health 2019;45:3–9. doi:10.1136/bmjsrh-2018-200198 3 Downloaded from http://srh.bmj.com on January 16, 2019 - Published by group.bmj.com Research mifepristone and misoprostol, which are mailed to and travel have been available options); (3) lived in women’s homes, allowing them to self-manage a medi- Northern Ireland at the time of their abortion; and cation abortion at home with instructions and support (4) sought abortion either by travelling or by online provided by the telemedicine service.3 Between 2010 telemedicine. Participants were invited through three and 2016, the number of women who travelled to organisations that have frequent contact with women abortion clinics in England and Wales and who gave in Northern Ireland who are seeking abortion: (1) the Irish and Northern Irish addresses declined from 5503 Abortion Support Network (ASN), which provides to 3992.4 5 Over the same time period, the number information and financial assistance to women who of women living in Ireland and Northern Ireland who travel from Northern Ireland to access abortion and requested medication abortion via the online telemedi- which sent invitations to their mailing list; (2) WoW, cine service Women on Web (WoW) more than tripled, which sent invitations to women who had used their from 548 to 1748.3 online telemedicine service; and (3) Alliance For In 2017, however, the number of women giving Choice, a Northern Irish organisation that provides specifically Northern Ireland addresses at abortion information and support to those seeking abortion, clinics in England and Wales increased for the first and which shared the invitation via social media. time since 2002.6 This increase coincided with a policy Eligible women contacted the research team to set up change by the UK government at the end of July 2017, an interview. The study was reviewed and approved allowing free abortion care in England and Wales by the Institutional Review Board of the University of under the National Health Service (NHS) for women Texas at Austin. from Northern Ireland.7 Abortion services were also Trained research team members conducted the inter- made free by the Scottish NHS for women travelling views by phone. All participants gave their informed from Northern Ireland to Scotland, but no data on the consent to participate and for the interview to be number travelling will be available until 2019.8 Prior audio recorded. Audio recordings were stored on an to this change, Northern Irish women had to pay for SSL-protected server and no records of personal infor- abortions in Great Britain, despite being eligible for mation were included in the recordings or retained free NHS care when travelling there for other medical by the research team. Participants were not asked to procedures. Yet an increase in travel to England and share their real names and were provided with pseud- Wales does not neatly translate into a decrease in the onyms. Interviews lasted between 35 and 75 min and use of online telemedicine. Analysis of the number of were conducted in English. Participants were offered women living in Northern Ireland who received abor- £80/€90 in appreciation for their time. tion medications from WoW in the year prior to the The interviews followed a guide developed using policy change compared with the year after indicates insights from existing literature on Northern Irish only a 3% decrease.9 abortion laws,10–12 the options available to women,3 13 The recent repeal of the constitutional amendment and the theoretical context of the AAAQ (Availability, prohibiting abortion in the Republic of Ireland, along Accessibility, Acceptability, Quality) framework, which with the passage of a bill to legalise abortion in the Isle is used by the WHO to ensure the highest standard of Man, has brought Northern Irish abortion law into of healthcare services.14 We asked women about their the international spotlight. Although possible legal circumstances at the time of their pregnancy, their deci- reform is a subject of intense debate among politicians, sion-making when choosing a pathway to abortion, healthcare professionals, and the general public, no and their experiences with that pathway. The change scientific studies have examined Northern Ireland’s in UK policy to offer free abortion services in Great laws from the perspective of the women who seek abor- Britain for women travelling from Northern Ireland tion services. Our objective was to assess the impacts took place during our data collection phase, so we of Northern Ireland’s abortion laws on women’s deci- were able to interview women who sought abortion sion-making around how to obtain abortion and on both before and after NHS coverage was available. their subsequent experiences accessing care. We used Because the interviews were semi-structured, partici- in-depth interviews with women in Northern Ireland pants were also able to explore whatever they consid- who sought abortion either by travelling overseas or ered important about their experience. We obtained by using online telemedicine, both before and after the very limited demographic information in the interests policy change to offer free NHS abortion care in Great of protecting anonymity. Four pilot interviews were Britain. conducted to test the interview guide. Our analysis followed the principles of grounded METHODS theory.15 Interviewers made field notes immedi- Between April 2017 and February 2018, we conducted ately after completing each interview and engaged anonymous in-depth interviews with 30 women living in constant comparison between data and notes to in Northern Ireland.
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