BMJ, by Maria Lewandowska, 2023;382(5 July),1517
“Two recent cases in Poland and England have sparked widespread concern about abortion laws and the role of healthcare professionals in implementing them.
“The past weeks have seen a number of tragic events surrounding abortion in Europe. In Poland, yet another pregnant woman has died of sepsis having been denied a life-saving termination. In Britain, a woman was sentenced to 28 months, half of which are to be spent in prison, for taking abortion pills beyond the gestational age limit.
“In Poland, abortion laws were relatively liberal during Communism. When democracy was restored in the 1990s, a new, restrictive law was imposed allowing abortion in three narrowly defined cases: when pregnancy carried a risk to the life or health of the mother; when it was a result of a crime; or in the case of severe fetal anomaly. This last condition, accounting for the overwhelming majority of the few abortions carried out by the Polish health system (97% of the total 1,110 in 2019), was ruled to be unconstitutional by Poland’s Supreme Court in 2020. This caused a 10-fold drop in the number of lawful abortions per year from around 1,000 to 100. The decision sparked some of the largest protests in Polish history. Cities were covered in pro-abortion graffiti and posters, and opinion polls showed an increase in public support for abortion on request from 53% to 66% of those surveyed.
“Activists’ campaigns that followed the ban led to a substantial improvement in the public’s knowledge about medical abortion. Between 2021 and 2022, an estimated 40 000 women in Poland terminated their pregnancies by pills obtained online, outside of the legal system, from providers such as Women Help Women, or Women on Web, and some 2,000 more travelled abroad for surgical termination. They travelled to Germany, Austria, the Netherlands, or indeed to England. Almost half of the latter revealed that they were seeking care on the grounds of fetal anomaly—a medical service denied to them by the recent change in law. But within the healthcare system, there are still those who seek, but do not receive, emergency obstetric care and lawful, life-saving terminations. That was the case of “Izabela” from Pszczyna, who died of sepsis in 2021 after doctors failed to terminate her non-viable pregnancy. Last week, after the death of Dorota Lalik, the patients’ rights ombudsman in Poland ruled that her rights had been violated. Information about her health condition was withheld from her, and she was denied lawful treatment.
“An additional consequence of the near-total lack of abortion provision within the Polish healthcare system is inferior obstetric care, which fails to follow the latest scientific evidence. Mifepristone… is not available. Manual vacuum aspiration is not routinely used. Sharp curettage (D&C), a practice deemed by the World Health Organization as incompatible with human rights and causing suffering and pain, is still in common use. Doctors are not trained in modern methods of pregnancy termination, nor are they prepared for how they should provide it.
“Meanwhile, in Britain, although abortion is widely available, the provision is still based on an archaic law from 1861—before women had the right to vote. The 19th century Offence Against the Person Act stated that “procuring a miscarriage” was punishable by “penal servitude for life,” a penalty applying to both the pregnant woman and the abortion provider. It was only the 1967 Abortion Act that legalised abortion under specific conditions… Most of the public do not understand the current abortion law in Britain. In a poll in 2017, only 15% correctly answered the question about the current legal status of abortion. But it is not only the public who are unaware of the intricacies of the current law. A sizeable minority of the 48 of patients with recent experience of abortion and 771 healthcare professionals who participated in the SACHA: Shaping Abortion for Change Study were not aware of the requirement for two doctors’ signatures for an abortion to be lawful in Britain.
“An important difference between the law in Poland and the law in Britain is that under the Polish law women cannot be prosecuted for ending their own pregnancy before the 22nd week, and only people providing or aiding abortion can be held accountable. Meanwhile, in Britain, women are at risk of prosecution if they do not follow the strict measures imposed by the law, at any gestation.
“Even though thousands of women are able to access legal abortion services in Britain every year, it remains the case that some are prosecuted for self-managing an abortion outside of the health system. Last week, a woman in England was given a 28-month sentence, including 12 months in prison, for ending her own pregnancy beyond the legal gestational age limit. She accessed emergency services after the procedure, and the police were called to her bedside by the hospital staff. This judgment serves no one: not the woman, not her three children, and not the community. There is extensive evidence that in most cases women who are given short prison sentences have acute unmet needs that criminalisation exacerbates; and that the children of women given custodial sentences suffer severe mental and social impacts. The current abortion law highlights the issue of health inequity, as women seeking care outside of the official health system, as well as those who seek it later in their pregnancy, are more likely to be those marginalised, raising children alone, struggling with mental health or addiction, or experiencing domestic violence.
“What these two recent cases in Poland and England highlight is the role of doctors and other health professionals in caring for pregnant women. In Poland, the protest chant of “not one more” has now changed to “stop killing us”— directed not only at lawmakers, but also at doctors who, through conscientious objection, fear, interpretations of the law in ways that are least favourable to patients, and through a lack of knowledge and skills, have allowed another preventable death to happen. The chilling effect of abortion laws on doctors is a known phenomenon, but in Poland no doctor has been sentenced for providing abortion care since the 1993 abortion restrictions were introduced.
“In England, following the recent sentencing, Elizabeth Barker, a member of the House of Lords stressed during a parliamentary debate that there is no legal obligation for any health professionals to report women suspected of “illegal abortion” to the police. The General Medical Council advises that disclosures should occur for the protection of patients and others; that the potential harm to the patient must be considered; and so must the potential benefit to an individual or to society—which, in this case, are difficult to perceive.
“Abortion laws must change. The law should allow for delivery of best medical practice, and to ensure that no woman has to die rather than be provided with an abortion. Women should not be criminalised for seeking to end a pregnancy. But until that happens, the harm done to trust in doctors and the healthcare profession must be tackled. Doctors should serve as allies and guardians to their patients—ensuring their life-saving care is delivered and supporting their physical, mental, and social wellbeing. Do no harm—has to serve as credo for all health professionals. The opposite is true when women are denied life-saving healthcare, or when they are reported to the police for making decisions about their body.”