The British Pregnancy Advisory Service ([BPAS], 2019a) sees over 80 000 women per year across Britain for reproductive healthcare services including abortion care, pregnancy counselling, miscarriage management, and contraception. Trusting women to make their own decisions is at the heart of everything we do, and we support their choices through both our advocacy work and the provision of non-judgemental, woman-centred services.
Midwives play an inestimable role in this work. As clinicians, our midwives guide clients through the abortion care process, from decision-making to follow up, with skill and compassion. As powerful advocates, they are at the forefront of campaigns for political and legislative reform, ensuring that reproductive choice is safeguarded for generations.
We were proud last year to accept a British Journal of Midwifery Award in recognition of our midwives' passion and commitment, and our contribution to the profession. Now, at a time of momentous change in reproductive rights in the UK, we want to celebrate the care our midwives provide each day to uphold women's choices, and consider how their role may develop as we look to the future.
A new era for choice
Until recently, abortion was a criminal offence in Northern Ireland in all but the most extreme circumstances. Hundreds of women each year with unwanted pregnancies had to make a choice: travel overseas to Britain to access care, or order illegal abortion pills online, risking a maximum sentence of life in prison. We are proud that, during that time, our midwives have cared for Northern Irish women who have travelled, offering them a friendly face at the end of a long journey and a compassionate, high-quality service.
However, on 22 October 2019, the criminal sanctions for abortion fell away and Northern Ireland ushered in a new legislative landscape, where healthcare professionals are now able to develop a woman-centred service—without the threat of prosecution. The government is currently consulting on how a new Northern Irish service might look, and the role that midwives may play.
‘Our midwives have cared for Northern Irish women who have travelled, offering them a friendly face at the end of a long journey’
It is essential that any such service makes room for those healthcare professionals who conscientiously object to providing abortion care. But it must also empower those who conscientiously commit to upholding women's reproductive choices—as our midwives do every day.
Northern Ireland could soon have one of the most progressive care models in Europe, with the potential for a fully midwife-led service. Concurrently, at our clinics in England, Wales and Scotland, we too are looking towards future models of care. There is still so much more our midwives can and want to do.
A woman-centred service
BPAS provides reproductive healthcare services at over 70 clinics across Britain, and midwives are integral at every step of the client-care pathway. Our midwives are particularly involved in the provision of Early Medical Abortions (EMAs), which are administered with tablets up to 10 weeks' gestation.
‘There have been women who I've been lucky enough to do their consultation, I might have seen them during the treatment and maybe they come back for a post-treatment check-up, and that continuity's been lovely. It's been so nice to be able to courier their way through the system and see them so much happier when they leave. And every single one of them is so grateful, because you've offered them this care, because you've given them these choices.’
The vast majority of our abortion care clients receive EMAs, but for those who come to us at later gestations, specialist midwives are on hand to provide support. We maintain close working relationships with midwives in NHS maternity settings to support clients who may need to move between services. Whether one woman has received a heartbreaking diagnosis of a fatal fetal anomaly, or another decides to continue her pregnancy after all, our midwives are there to support them in their decisions.
‘To me, I think it makes perfect sense that I am here providing abortion care because when we started training, we were always taught that midwifery is not about delivering babies, it's about being with women. It's about providing care for women in their pregnancies, and it's about all women who are pregnant. And that makes me proud in my midwifery career that this is where I've gone. I feel like it's a perfect fit for me.’
Supporting women; supporting midwives
In recognition of their invaluable work, BPAS midwives receive the best possible professional support, through access to a Professional Midwifery Advocate (PMA). PMAs (a relatively new role in the NHS) support midwives through a combination of restorative clinical supervision, assistance with revalidation, and extra help for those who have been involved with a clinical incident or are struggling with sickness or stress—all from a midwifery point of view.
BPAS recently became the first non-NHS organisation to introduce a PMA, because we felt strongly that BPAS midwives should have the same level of support as their NHS colleagues.
‘I think the PMA role will benefit BPAS midwives an awful lot. Midwives who are happy at work provide really good quality care—and that is vitally important in this role.’
For trainee midwives, we work hard to ensure development opportunities in abortion care. Alongside the Royal College of Midwives (RCM), we advocate for abortion to be included in the midwifery curriculum so that students can consider this rewarding career path and learn more about a procedure which 1 in 3 women in this country will undergo in their lifetime. We also offer student placements and observational opportunities to trainees from all backgrounds via the Medical Students For Choice externship programme.
A bright future
As Northern Ireland begins to set up its own progressive service, the rest of the UK is knocking at the door of reform. In Britain, abortion is still governed by a criminal law from 1861, which has been a barrier to modernising the service and making evidence-based improvements. But thanks to the recent swell of support, the decriminalisation of abortion up to 24 weeks in Britain seems an increasingly likely prospect.
Decriminalisation will not mean deregulation. Under a decriminalised framework, abortion will still be governed by the same robust medical regulations and standards as all other medical procedures, such as maternity care. Consent and safeguarding procedures are not mentioned in the criminal law and will remain in place after its repeal.
Decriminalisation will, however, allow the development of a fully midwife-led service, as has already become the gold standard of care in maternity and miscarriage management services. Due to our criminal framework, abortion care has been unnecessarily left behind.
There is strong clinical evidence that an early surgical abortion service would be very safe in the hands of midwives, and midwife-led provision is recommended by the World Health Organization (2012). A midwife-led model has already been introduced successfully in Norway, Sweden and France, and its cost-effectiveness has been robustly demonstrated (Sheldon and Fletcher, 2017). There is also evidence that a midwife-led service may be preferred by women themselves, even increasing their uptake of long-acting reversible contraception methods (Sjöström et al, 2016). But to implement these improvements in England, Wales and Scotland, we need a new framework fit for the 21st century, which reflects the role and skills of midwives today.
Midwives leading the way
The historic decriminalisation of abortion in Northern Ireland could not have been achieved without the allyship of midwives. In our advocacy work, midwives are central to our mission to fight for political reform and normalise abortion in society. A midwife's role doesn't end with providing a high-quality clinical service: midwives are skilled and respected advocates, whether caring for individual patients or campaigning for political change.
‘Midwives have never sat back and accepted inequalities in healthcare provision. It is within our gift and our duty as advocates for women to push for change, to say that we trust women to make their own decisions, and that we will support them with the safest, highest quality care available. We will always be there to hold their hand but with the other hand, we must break the glass ceiling.’
In 2016, midwives were the first clinicians to lend their voices decriminalisation, when the RCM joined the ‘We Trust Women’ campaign – led by BPAS – which calls for decriminalisation across the UK. The RCM's decision paved the way for other medical bodies to follow suit. Decriminalisation is now supported by the British Medical Association, the Faculty of Sexual and Reproductive Healthcare, and the Royal Colleges of Nursing, GPs, and Obstetricians and Gynaecologists, alongside a host of other healthcare organisations and charities.
Public support for decriminalisation has surged too, with a recent poll showing that just 14% of the general public agree with the current criminal sanctions for abortion (BPAS, 2019). MPs in the House of Commons have voted twice in favour of decriminalisation, once in 2017 and once in 2019.
We are making progress and midwives are leading the way. The word ‘midwife’ means ‘with woman’ (Oxford Dictionary, 2017), and while the midwifery profession has evolved over the decades, that principle has never faltered. Midwives at BPAS trust women to make their own decisions, and the principle of choice is the cornerstone of their work to care and advocate for women. Under a decriminalised framework, there is so much more we can achieve.