UK reproductive healthcare could benefit from implementing practices from low- and middle-income countries

New research from the British Pregnancy Advisory Service (BPAS) and the School of Public Health at Imperial College London has found that innovative abortion care delivery models in low- and middle-income countries (LMICs) could improve accessibility in Britain, without compromising on qualityInnovations from LMICs are often discounted or given shorter shrift, with clinicians more likely to favour research from high-income settings.The 1967 Abortion Act prevents these novel service models from being introduced in the UK, despite their potential to benefit patients.The evidence from LMICs demonstrates that providing early medical abortions in GP surgeries, for example, could enable more women to access safe abortions locally in their own community. Under the 1967 Act, this is not permitted.Researchers conclude that that the UK has much to learn from service provision in low- and middle-income countries – places typically and incorrectly thought of as passive recipients of wisdom from the Global NorthNew research published today from the British Pregnancy Advisory Service (BPAS) and the School of Public Health at Imperial College London has found that innovative abortion care delivery models implemented in low- and middle-income countries (LMICs) could improve access to abortion services in Britain, without compromising on quality.A new review published today in the journal Globalization and Healthexplored the quality of early abortion services provided in LMIC primary care settings, and the potential benefits of extending their application to the UK. The authors showed that providing early medical abortions in primary care settings is safe and feasible, and “task-shifting” to mid-level providers such as nurses and midwives can effectively replace doctors in providing abortion. They conclude that implementing similar innovations in the UK would improve accessibility without reducing quality or safety. Providing early medical abortions in GP surgeries, for example, could enable more women to access safe abortions locally in their own community.The paper challenges the assumed unidirectional flow of medical knowledge and wisdom from the Global North to the Global South. In LMICs, resource constraints motivate policymakers to rethink existing processes, make decisions that are cost effective and leverage regulatory gaps to adopt “frugal innovations”. These “frugal innovations” are implemented under different legal systems that permit service modernisation. The authors found that the UK has much to learn from novel service models developed in these settings, and that their application in the UK could improve patient access while maintaining safety standards.Innovations from LMICs are often discounted or given shorter shrift, and studies have found that unconscious bias plays a role in the interpretation of research abstracts based on their country of origin, with clinicians more likely to favour research from high-income settings.However, these innovative service models cannot be introduced in the UK, despite their potential to benefit patients. Under the 1967 Abortion Act, abortions may only be provided by two doctors on specifically licensed premises – prohibiting the full participation of nurses and midwives and the provision of early medical abortions in GP surgeries. In recent years medical bodies including the Royal College of Midwives, the British Medical Association and the Royal College of Obstetricians and Gynaecologists have called for abortion to be decriminalised to permit the modernisation of services. MPs have voted twice in favour of this change, but currently the criminal law remains in force.The recent introduction of a “pills by post” service for early abortions in Britain was driven by necessity due to the COVID-19 pandemic and permitted in law by Health Secretary Matt Hancock on a temporary basis. Statistics published this month showed that telemedical abortion services have enabled women to access care at significantly lower gestations, with shorter waiting times. The study authors conclude that removing abortion from the criminal law could permit new service delivery models in Britain, including providing the pills by post service on a permanent basis, and complementing it with early abortion provision in GP surgeries.Rebecca Blaylock, study co-author and Research and Engagement Lead at BPAS, said:“The design of this study was motivated by two key frustrations. The first is the constraints on innovation in abortion care services caused by the archaic Abortion Act, which has also been exported to previously colonised countries. Our study shows that if we removed the legal barriers associated with the Abortion Act we could provide abortion services in a more person-centred way.We also wanted to challenge long-standing assumptions within medicine in general, and reproductive medicine in particular, about where high-quality services are delivered and who creates innovative knowledge. In this paper we demonstrate that the UK and other high-income countries have much to learn from service provision in low- and middle-income countries – places typically and incorrectly thought of as passive recipients of wisdom from the Global North.”Matthew Harris, study co-author and Clinical Senior Lecturer in Public Health at Imperial College London, said:“Innovation in the delivery of abortion care is just one of many examples of frugal healthcare innovations from low-income countries that the UK needs to look at and adopt. Improving access is a cornerstone of the NHS and learning from low-income countries will need to be part of that moving forward.”Dr Annabel Sowemimo, Founder and Director of Decolonising Contraception, said:“Whilst the term ‘reverse innovation’ is problematic as it suggests innovations in less resourced countries are not innovative in themselves; this study highlights that much can be learnt about abortion service delivery in countries where people and resources may be more limited. It is imperative that we start to understand that lower- and middle-income countries have much to contribute in our understanding on how to improve abortion services – the learning process cannot be one way. More money does not always make for the most effective healthcare system.”Clare Murphy, Deputy CEO of BPAS, said:“This review demonstrates clearly what we already know: that the current law in Britain is stifling service improvements. It is incredibly frustrating that efficient, innovative models that have been successfully implemented elsewhere are unavailable to us due to our criminal framework. Ensuring the best possible access to health services is fundamental to the NHS’s ethos, and no other area of healthcare is prevented from introducing improvements by a piece of criminal legislation from the nineteenth century. We would like to see abortion removed from the criminal law and governed in the same way as all other medical procedures, so that we can provide patient-centred care fit for the 21st century.”

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