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On May 25th of 2018, the Republic of Ireland voted to repeal the 8th Amendment to the Irish Constitution, effectively legalizing abortion in a country that previously had some of the world’s strictest abortion regulations. Yet in neighboring Northern Ireland, a part of the United Kingdom, abortion is legal only in the limited circumstances of preserving a women’s life or preventing permanent or long-term injury to her physical or mental health. In 1967 the United Kingdom’s Abortion act made legal abortion available in England, Scotland, and Wales. But that change was not adopted in Northern Ireland, where abortion remains governed solely by the 1861 Offenses Against the Persons Act, with maximum penalty of life imprisonment.
As a result of these uneven changes in law, performing an abortion in Northern Ireland is still considered a criminal offence, even though the rest of the United Kingdom and the bordering Republic of Ireland now provide legal access to abortion care. The 2018 repeal of the 8th Amendment in the Republic of Ireland and the liberalization of abortion in nearby Isle of Man have reinvigorated the debate surrounding legal abortion in Northern Ireland, garnering international attention on the future of this country’s unusually restrictive abortion law. While advocates and politicians in Northern Ireland and the United Kingdom have been working to change the restrictive abortion law, the process has been stalled. The Northern Irish government has been deadlocked due to political division between the country’s two major parties, and their government has not met since March of 2017. In July of this year the U.K. parliament signed into law a bill to maintain public services in Northern Ireland while their government is inactive. Included in the bill was an amendment by Labour M.P.s Stella Creasy and Conor McGinn, stating that the Northern Ireland’s abortion law infringes on the rights of women and effectively decriminalizing abortion in Northern Ireland by October 22nd if Northern Ireland’s government remains inactive.
Complex Legislative Changes and Access to Abortion Care
Despite persistent legal restrictions many Northern Irish women still have abortions. Some women travel abroad to access in-clinic care in countries where abortion is legal, while others access online telemedicine and self-manage their abortion at home. From 2010 to 2016, the number of women who travelled to abortion clinics in England and Wales with Irish and Northern Irish addresses declined from 5503 to 3992. The same period witnessed more than a tripling, from 548 to 1748, in the number of women living in Ireland and Northern Ireland who requested medication abortion via a commonly-used online telemedicine service called Women on Web.
In 2017, however, the number of women giving specifically Northern Ireland addresses at clinics in England and Wales increased for the first time since 2002. This increase corresponded with a July 2017 policy change by the United Kingdom government to allow women coming from Northern Ireland access to free abortion care in England and Wales through the National Health Service. Abortion services were also made free by the Scottish National Health Service for women travelling from Northern Ireland to Scotland, but as yet there are no data available on the numbers who have claimed Scottish services.
The Northern Irish Abortion Experience
Amid change in key pieces of abortion legislation and services, as researchers we sought to inform the debate by assessing the impacts of Northern Ireland’s abortion law on women’s decision-making and access to abortion care. Between April 2017 and February 2018 our research team interviewed 30 Northern Irish women who sought abortion care by traveling to Great Britain or using online telemedicine. During our interviews we asked women about the circumstances of their pregnancy, their decision-making when choosing to travel or self-manage their abortion, and their personal experiences. Through these interviews we identified four major themes in women’s experiences – with travel, self-management, the law, and healthcare professionals.
- Traveling abroad is difficult. Women experience multiple barriers to traveling for abortion care. Travel costs, for instance, are magnified by the need to book flights to go abroad and return within a short time frame. And even when the costs of the abortion are covered under the new policy, women who traveled felt additional stress from public scrutiny, anxiety over leaving work and children, and stress over having to leave for what they considered a foreign country to obtain health care.
- Self-management is a preference for some, the only reality for others. Although some participants in our study dealt with barriers to travel by resorting to self-managed abortions at home, others viewed online telemedicine as a first choice. They saw this kind of care as comfortable, private, and something they could control on their own, autonomously. Prior to discovering the option of ordering pills online, some women who could not afford to travel considered attempting to end their pregnancies through harmful steps such as drinking alcohol or poisonous substances or punching themselves in the stomach.
- The law provokes anxiety. Our interviewees told us that the nature of the law and practices of Northern Irish customs contribute to the stress of self-management medical abortions, causing them anxiety about possibly higher risks for complications. Almost every participant who used online telemedicine reported feeling intense worry that Northern Irish customs would confiscate or delay their packages. Postponed packages pushed some women to carry their fetuses longer, making self-management of their abortions riskier and more difficult. Others became frustrated and worried about delays, and researched other methods to abort, including some that could have been dangerous.
- Lack of information and transparency between women and healthcare professionals causes mistrust. Women’s interactions with the formal healthcare system in Northern Ireland were varied. Many said they were hesitant to attend follow-up care appointments after their abortions. The country’s criminalization of abortion leads to confusion about the kinds of information health care providers can and cannot provide – and also makes patients uncertain about what they can and cannot disclose to providers. This can lead to discontinuities in care and patient-provider communication when women travel abroad for abortions or administer medicines to themselves at home.
Abortion Law Realities in a Modern Public Health and Policy Context
Our research on the Northern Ireland case contributes to a growing body of work about the experiences of women who self-manage abortion care and examine the many kinds of restrictions women face when seeking abortion. It is clear from our findings that despite the significant restrictions on abortion in their country, Northern Irish women are still seeking and receiving abortion care. The criminalization of abortion does not prevent all women from seeking and obtaining abortions. Nevertheless, criminalization causes fear and loneliness among women who need abortion care, as they are forced to be creative in navigating finances, methods, time, and other barriers to access.
With the changing political context of abortion laws in neighboring countries and the evidence of women’s experiences in Northern Ireland, it is critical for policymakers to consider the adverse physical and mental health care implications of abortion restrictions. In practice, women still seek abortion care, but unrealistic restrictive laws impede effective health care and create unnecessary risks for women and their families. The United Kingdom’s decision could effectively end over 150 years of criminalized abortion in Northern Ireland. With this new landscape of decriminalized abortion, it is up to policymakers to determine whether and how women in Northern Ireland will have access to abortion care.
Read more in Abigail Aiken, Elisa Padron, Kathleen Broussard, and Dana Johnson, “The Impact of Northern Ireland’s Abortion Laws on Women’s Abortion Decision-Making and Experiences.” BMJ Sexual & Reproductive Health (online-first article, October 2018).