Does access to abortion vary across the UK?

The recent reversal of Roe v. Wade in the United States has highlighted the fragility of abortion rights. In the UK, abortion rates and access are unequal across the constituent countries, within regions and between different income groups.

The decision by the US Supreme Court to overturn Roe v. Wade – and return decisions on whether to allow abortion to individual states – has shone a spotlight on abortion rights around the world.

While there is no imminent threat of legal restrictions on abortion in the UK, access already varies across the constituent countries. For example, despite abortion being decriminalised in Northern Ireland in October 2019 and regulations coming into effect in March 2020, access remains limited, forcing hundreds of women either to travel to other countries or to continue their pregnancy.

Abortion rates also differ within regions in the UK. They are higher for women living in deprived areas, indicating that abortion is an economic issue as well as a legal one.

What is the legal status of abortion in the UK?

Women in the UK are legally entitled to an abortion through the 1967 Abortion Act (for England, Scotland and Wales) and the Abortion (No. 2) Regulations 2020 (in Northern Ireland).

The conditions under which women can access abortion according to these two pieces of legislation are broadly similar. They include risk to the life of the mother, to the physical or mental health of the mother or any existing children in her family, or risk that if the child were to be born, they would suffer from severe physical or mental abnormalities.

In the light of the US Supreme Court decision, Labour MP Stella Creasy has warned that abortion rights in the UK are ‘more fragile than people realise’. In particular, in England, Scotland and Wales, abortions are still deemed a criminal act and doctors who do not comply with the terms of the 1967 legislation can face punishment.

As such, Creasy intends to table an amendment to the Bill of Rights to protect and enshrine women’s access to abortion into law.

How accessible are abortions in the UK?

The abortion rate has increased in England, Wales and Scotland over the last 40 years (see Figure 1).

In 2021, the abortion rate for England and Wales reached its highest ever rate of 19.2 per 1,000 women residents. In Scotland, the rate has been consistently lower – at 13.4 per 1,000 in 2020 (GOV.UK, 2022; Public Health Scotland, 2021). This figure is even lower than that of the United States – 14.4 per 1,000 women in 2020 (Guttmacher Institute, 2022).

Figure 1: Abortion rate per 1,000 women residents of England and Wales and Scotland, aged 15-44

Source: GOV.UK, 2022; Public Health Scotland, 2021

How do abortion access and abortion rates differ across the UK?

England and Wales

The number of abortions performed in England and Wales reached their highest levels in 2021. A total of 214,256 were carried out, of which 206,664 occurred in England (GOV.UK, 2022). One possible reason for the high rate is the increased availability of early abortion pills (mifepristone and misoprostol).

These were introduced in the 1990s for abortions up to ten weeks of pregnancy. They were initially both required to be taken at a clinic but from December 2018, mifepristone was allowed to be taken at home. Then, in 2020, taking both pills at home was temporarily approved under the 1967 Act as a response to the Covid-19 pandemic (Calkin and Berny, 2021). This change has now been made permanent in England and Wales.

The overwhelming majority (around 98%) of abortions were carried out on grounds of risk of mental harm for the woman. This provision leads to what has been described as a system of de facto ‘abortion on demand’.

Nevertheless, one study suggests that the requirement of two doctors’ approval may cause undue stigma among abortion-seekers, and delays in rural settings where there tend to be lower availability of doctors (Calkin and Berny, 2021).

Further, research finds that women living in rural areas also face greater barriers to abortion than those in urban areas due to longer travel distances and lack of abortion services (Caird et al, 2016; Heller et al, 2016).

Longer travel distances can also impose financial barriers and necessitate unwanted disclosure of information, making it harder for women to maintain privacy. One study reports that more time away from home requires many women to turn to their family or ex-partners for childcare, which often requires an explanation (Heller et al, 2016).

Scotland

The abortion rate in Scotland is lower than in England and Wales (see Figure 1). Since 1980, the rate has risen from 7.3 to 13.5 per 1,000 women, reaching a record of 13,896 abortions in 2020 (Public Health Scotland, 2022). An additional barrier in Scotland is that abortion is not provided up to 24 weeks of pregnancy, as it is in England and Wales.

One report suggests that it is even difficult for women to access abortion services in Scotland after 18 weeks of pregnancy, although the legal maximum for England, Scotland and Wales is currently at 24 weeks under most circumstances (Sexual Health Scotland, 2021).

Apart from lack of training, it has also been suggested that a deficiency of support among medical professionals may be an important factor in explaining lower abortion accessibility in Scotland (Purcell et al, 2014). Research suggests that this may be due to negative attitudes towards late abortion among Scottish abortion providers and senior management, as well as local anti-choice views (Cochrane and Cameron, 2013).

Northern Ireland

Before March 2020, abortion access for women in Northern Ireland was severely restricted. Women in Northern Ireland were only able to access abortion services in other parts of the UK and they were not provided with funding to do so until 2017. On 31 March 2020, regulations came into effect that enabled women to access abortions legally in Northern Ireland (Armitage, 2022).

The number of Northern Irish women who obtained an abortion in England and Wales fell from 1,014 in 2019 to 371 in 2020, a drop of 641. The number of abortions accessed in Northern Ireland increased but only by 41 (from 22 in 2019 to 63 in 2020).

These numbers indicate that approximately 600 abortions that were ‘expected’ to occur in 2020 did not take place. One suggestion is that Northern Irish women in want of abortion services were prevented from travelling to England and Wales (largely because of Covid-19 restrictions). And further that they did not have knowledge of local services that could be accessed, resulting in these abortions not being undertaken (Armitage, 2022).

Access to abortion in Northern Ireland is still limited for many women since the relevant services have not yet been commissioned by the Department of Health and the Northern Ireland Executive. This is in spite of a deadline of the end of March 2022 that was put in place by the secretary of state in July 2021.

Regional differences

The number of non-resident abortions in England and Wales fell from roughly 32,000 in 1980 to 613 in 2021. Out of these, residents of the Republic of Ireland accounted for 33.6%, those from Northern Ireland for 26.3%, Scotland for 24.5% and the rest of the world for the remaining 15.7% (GOV.UK, 2022).

Within regions, there are also differences in the number of women accessing abortions. Those living in the most deprived areas in England are twice as likely to access an abortion compared with women living in the least deprived areas (see Figure 2). Similar patterns apply to Wales and Scotland.

This is also consistent with evidence from the United States, where studies report that nearly 50% of abortion patients live under the federal poverty line (Guttmacher Institute, 2016).

The least deprived women aged 40-44 have the lowest abortion rate at 4.7 per 1,000 women, while the most deprived women aged 20-24 have the highest at 46.4 per 1,000 women. This is almost ten times higher.

For all deprivation levels, women aged 20-24 form the largest group obtaining an abortion in England, Wales and Scotland (29% of all abortions in the UK are sought by women in this age group). The second largest group accessing abortions are women aged 25-29 (GOV.UK, 2022; Public Health Scotland, 2021).

As a result, it appears that abortion services to a great extent concern young and vulnerable women in society, for whom abortion accessibility can be highly critical in shaping their future.

Figure 2: Demographic disparities in abortion rates across the UK

Source: GOV.UK, 2022

Are abortion rights under threat in the UK?

There is strong support for abortion rights in the UK. A recent survey indicates that 90% of UK adults think that women should have access to abortion services (MSI Reproductive Choices UK, 2020). By contrast, in the United States 61% of adults agree that abortion should be legal in all or most circumstances (Pew Research Centre, 2022).

But there is still a worry that the reversal of Roe v. Wade will provide momentum for UK anti-choice organisations and an increase in funding coming from the United States (Oppenheim, 2022).

Jonathan Lord, medical director of MSI Reproductive Choices UK, has pointed out that UK-based anti-abortion campaigners are ‘very small in number, but they are exceptionally well-organised and well-funded. The funding, which all pretty much comes from America as far as we know, will just ramp up [following the rollback of Roe v. Wade]’ (Oppenheim, 2022).

A more direct threat may come from an apparent reversal of previous commitments to women's sexual health and abortion rights by the UK government in recent weeks.

As part of an intergovernmental conference on freedom of religion or belief held in London in July, the government issued a multinational statement that 22 countries signed up to. This included a pledge to repeal any laws that ‘allow harmful practices, or restrict women’s and girls’ […] sexual and reproductive health and rights [and] bodily autonomy’.

But the statement was later amended with references to these rights removed. The new document has been signed by only six countries, including the UK and Malta (where abortion is illegal). Human rights, pro-choice and international aid organisations have urged the immediate reversal of the amendments and a clarification of the reasons for which the deletions were made in the first instance.

This is a reminder that there needs to be appropriate government support for the supply of abortion services. This is especially the case as, despite a common legal framework, access and rates of abortion vary across the UK. Recent events in the United States show that abortion rights cannot be taken for granted.