In defence of abortion on a woman’s request, including on grounds of fetal sex

Ach, what a furore. The Daily Telegraph is in its element and having a ball printing nasty allegations about doctors doing abortions illegally on grounds of sex selection. Let’s look at the issues a bit more dispassionately. First, is it actually illegal? Yes and no. The 1967 Abortion Act does not permit abortion on grounds of sex selection per se, it is true, and the law is framed so that anything that cannot be defended as coming under one or more of the named legal grounds is technically illegal. However, the question remains whether abortion on grounds of sex selection can be defended under the existing legal ground for abortions. I believe the answer is yes.

Sex selective abortion, like late second trimester abortion, lends itself to easy condemnation and stigma, and many otherwise pro-choice people are opposed to it. In India and China, where the laws on abortion are otherwise very liberal, sex selective abortion is subject to several laws banning it, all of which are totally ignored  ̶ both because women are under great pressure to have boys, especially women whose first child was a girl and who have only one or two chances, and because those doing the ultrasound scans are making a lot of money from them.

This isn’t a question of designer babies, though it is always the case that where something is possible technically, and is available for a range of reasons, e.g. determining whether there is a risk of sex-specific genetic anomalies, it will also be used in other ways. In this sense, finding out fetal sex during an ultrasound scan is inevitable and justified. This information belongs to the parents and should not be withheld. The baby is theirs after all. Preferring a baby of one sex over the other is nothing new, but has become more of an issue, according to the literature on sex selection in Asia, precisely because people are having so few children. But this is not just a cultural or ethnic issue. I watched my next-door neighbour treat her second child, a boy, badly throughout his childhood because she had wanted a second girl. She never forgave him for being born, at a time when there was no ultrasound for finding out fetal sex. Is this so uncommon?

I believe doctors faced with a request for abortion from women whose cultures practise discrimination against women and girls can justify it under the existing abortion law on the following grounds: taking the woman’s social situation into account, and because the woman’s physical and mental health and well-being may be at risk, and also her existing children. The potential for abuse of a woman by her husband and family, and poor treatment of and even purposeful neglect of girl children (leading to poor development and even death), are common outcomes in Asian cultures that demand that women produce boys. Women can be rejected and their lives made miserable. No one that I am aware of has ever investigated the existence or extent of such abuse and neglect in the UK among families from these cultures, but perhaps it’s time someone did. Moreover, it is also the case that a woman may not want another baby anyway, for other valid reasons, and fetal sex may be the only acceptable excuse she can give in her family situation for seeking an abortion.

Lastly, if anyone thinks that incrimination, condemnation and prosecution of pro-choice doctors is going to make this situation go away, they need to think again. Women will simply say they have a different reason and doctors will duly record it.

I believe health professionals and everyone who is pro-choice on abortion should support pro-choice doctors and women seeking abortions, whatever their reasons, even when sex selection may be involved.

The Daily Telegraph’s stories and the cowards who remain unidentified who went under false pretences to abortion providers and doctors who authorise abortions with the intention of incriminating them, should be condemned. Their aim is not to stop sex selection, which will not go away until discrimination against women and girls becomes history. Their aim is to stigmatise abortion and women who have abortions, to frighten women and abortion providers that they are breaking the law, and to seek to restrict the law on abortion. Their behaviour is unethical and under-handed, and constitutes harassment, which should be rejected and even subject to prosecution for wasting the Health Department’s and police time.

The UK needs to make abortion available legally on the request of the woman, and to decriminalise abortion altogether. This is an idea whose time would have come long ago if misogyny and harassment of women were illegal ̶ and prosecuted ̶ instead.

Hormonal contraception and risk of HIV: new studies, the issues, and the response of the World Health Organization

Many feminists, including me, actively opposed the hormonal injectable contraceptive Depo Provera (DMPA) three decades ago  ̶  it was at a time when certain women weren’t being given a choice of method or any information about possible side effects, and before long-term post-marketing studies began to be done to monitor long-term safety. Here in the UK, we demanded that all women be given information about side effects and a choice of methods, and we called for long-term safety studies. The research was duly done, and it found that the side effects were within the range of what experts consider to be safe and acceptable. Once these were known and women began to be given a choice of method, there was nothing more to oppose.

Injectable contraception has distinct advantages  ̶  it is highly effective, the woman and her partner need do nothing more in between injections to gain protection from unwanted pregnancy, and women can use it without partner consent or knowledge if they need to. However, like all hormonal methods, female sterilisation and IUDs, injectables do not provide protection against sexually transmitted infections, including HIV. For that, people need to use condoms or other forms of safe sex, or always have sex with only one partner (who is negative) who also always has sex only with them (also negative).

Many studies have been done on whether hormonal contraceptives increase HIV risk or not, and the findings have sometimes shown an increased risk and sometimes not. This variation is because there are a lot of confounding factors and risks involved that are extremely difficult to control for. On PubMed, for example, a study on this subject at the very top of the page using the keywords “Depo Provera and HIV risk” today reached the following conclusion: “In this study conducted among [5,567] South African women, hormonal contraception did not significantly increase the risk of HIV acquisition. However, the effect estimate does not rule out a moderate increase in HIV risk associated with DMPA use found in some other recent studies.”[i]

Several other recent studies, however, have found an increased risk of HIV acquisition among Depo Provera users. As a result the Department of Reproductive Health and Research/Human Reproduction Programme at the World Health Organization held an expert consultation several weeks ago to consider the latest evidence and decide whether it warranted a change in their current guidance, dating from 2009, on this subject. They decided not to change their current advice. Below is the press release they sent out a few days ago, explaining this. The fact remains, it’s the lack of safe sex/condom use and sex with more than one partner, or with a partner who has more than one partner, that really puts women and men at risk of HIV. That hasn’t changed since the HIV epidemic began.

WHO Press Release (a different version of this release is available on the WHO site):

WHO upholds guidance on hormonal contraceptive use and HIV

Geneva, 16 February 2012. Following new findings from recently published epidemiological studies, HRP convened a technical consultation (from 31 January to 1 February 2012) regarding hormonal contraception and HIV acquisition, progression and transmission. It was recognized that this issue was likely to be of particular concern in countries where women have a high lifetime risk of acquiring HIV, where hormonal contraceptives (especially progestogen-only injectable methods) constitute a large proportion of all modern methods used and where maternal mortality rates remain high. The meeting was held in Geneva between 31 January and 1 February 2012, and involved 75 individuals representing a wide range of stakeholders. Specifically, the group considered whether the guideline Medical eligibility criteria for contraceptive use, Fourth edition 2009 (MEC) should be changed in light of the accumulating evidence.

After detailed, prolonged deliberation, informed by systematic reviews of the available evidence and presentations on biological and animal data, GRADE profile summaries on the strength of the epidemiological evidence, and analysis of risks and benefits to country programmes, the group concluded that the World Health Organization should continue to recommend that there are no restrictions (MEC Category 1) on the use of any hormonal contraceptive method for women living with HIV or at high risk of HIV. However, the group recommended that a new clarification (under category 1) be added to the MEC for women using progestogen-only injectable contraception at high risk of HIV as follows:

Some studies suggest that women using progestogen-only injectable contraception may be at increased risk of HIV acquisition, other studies do not demonstrate this association. A WHO expert group reviewed all the available evidence and agreed that the data were not sufficiently conclusive to change current guidance. However, because of the inconclusive nature of the body of evidence on possible increased risk of HIV acquisition, women using progestogen-only injectable contraception should be strongly advised to also always use condoms, male and female, and other preventive measures. Expansion of contraceptive method mix and further research on the relationship between hormonal contraception and HIV infection is essential. These recommendations will be continually reviewed in the light of new evidence.

The group further wished to draw the attention of policy-makers and programme managers to the potential seriousness of the issue and the complex balance of risks and benefits. The group noted the importance of hormonal contraceptives and of HIV prevention for public health and emphasized the need for individuals living with or at risk of HIV to also always use condoms, male and female, as hormonal contraceptives are not protective against HIV transmission or acquisition.[ii]

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[i] Morrison CS et al. Hormonal contraception and the risk of HIV acquisition among women in South Africa. AIDS 2012;26(4):497-504.

[ii] Technical statement: Hormonal contraception and HIV and background documentation.

http://www.who.int/reproductivehealth/topics/family_planning/hc_hiv/en/index.html

An open letter to Shirley Williams

Dear Baroness Williams,

I have greatly appreciated your continuing efforts during the debate on the NHS Bill in the House of Lords until recently and that you took the time to send out the group emails that have kept those of us on the outside informed.

I am writing now, however, to say how disheartened I was to learn earlier this week that you have called for the Bill to be amended and passed, as if the entire Bill were not about competition, intended to open the door wide to privatisation and atomisation of the NHS, which is the Government’s strategy not only with the Health Service but with home and social care, with education and indeed almost everything else.

Your Party, as part of the Coalition, is certainly in an untenable position, as you are the ones who will make the passage of the Bill possible. I would not want to be in your shoes with the public when the true nature of the betrayal of the Health Service emerges if the Bill goes forward. Simon Hughes misguidedly believes that removing Andrew Lansley after you pass the Bill will save the situation, but it will not, though indeed Andrew Lansley should go precisely because he tried to sign away responsibility for his own position. But he must go along with the Bill, not after it or instead of it.

No one, from David Cameron on down, can ignore the increasingly articulated views of most health professionals as well as the public, which have grown in strength over the past few months as more and more people come to understand what is at stake. If democracy still means anything, then both Houses of Parliament must bow to the strength of public opinion and withdraw this Bill before it can do any further damage.

If all the Conservatives could find to say in defence of the Bill, e.g. on Question Time, is that the BMA didn’t support the NHS in 1948 either (a misreading of history), and that because it is already being implemented it is too late to turn back, then they (and you) have well and truly lost the argument.

Indeed, I would ask you whether the extent of implementation of the Bill – even before it has been debated fully, let alone voted upon – is unconstitutional. If it isn’t, then it should be.

I urge you from your position of leadership to convince both parties in the Coalition that this Bill is unsalvageable and should be withdrawn – as the only honourable thing left to do.

 

With kind regards,

Marge Berer

Editor, Reproductive Health Matters

The breast implant fiasco: a scandal of private medicine

First published 17 Jan 2012 on the BMJ Group Blog

So, the silicone’s hit the fan.

The use of industrial-grade silicone intended for mattresses, the possible fraud in hiding information from inspectors at production stage, and the failure in quality control in the regulatory phase, are particularly outrageous. However, the rapidly expanding private sector provision of breast implants for cosmetic reasons, by an “industry” that has been permitted to remain self-regulating in spite of evidence of its shortcomings and the risks involved, was a public health problem waiting to happen.

According to a 2010 review by Melanie Latham, [1] after the Labour government came to power in 1997, Labour MP Ann Clywd raised debates in the House of Commons about the possible risks of silicone from breast implants leaking into the patient’s body. Some efforts to regulate the private cosmetic surgery sector took place: in the Standards Care Act 2000, the Health and Social Care (Community Health and Standards) Act 2003, the National Health Service Act 2006, and the Health and Social Care Act 2008. These acts provided for a system of registration and inspection of private facilities and providers, but left the supervision of these regulations within a system of self-regulation, largely in the hands of private surgeons and clinics themselves. [1] Powers of entry and inspection of premises were handed over to the Care Quality Commission in 2008, a body that has experienced more criticism than one could reasonably expect it to survive. [2]

In the meantime, criticisms arose which have dogged the industry for over a decade: [1] that clinics were not adhering to minimum standards set in 2000, not monitoring quality of care and not recording adverse events. Accusations were levelled that they lacked written guidance on clinic procedures, published misleading advertisements about the potential success of treatments and had informal and undocumented complaints procedures and inadequate registration of surgeons.

Ann Clywd’s calls for an independent umbrella body to govern the cosmetic surgery profession, the most recent in 2008, [3] went unheeded. In 2009, the president of the British Association of Aesthetic Plastic Surgeons said: “In no other area of medicine is there such an unregulated mess. What is worse is that national governments would not allow it to happen in other areas of medicine. Imagine a ‘2-for-1′ advert for general surgery? That way lies madness!” [4]

Little did he know that Health Secretary Andrew Lansley, by opening the door to privatisation of health care on a wide scale, would make it even more likely that such problems might occur. The Health and Social Care bill is scheduled for report stage—where MPs discuss possible amendments—on 6 February. Lansley’s own response to the current implant fiasco has changed practically by the day and has included a mix of moral outrage on behalf of patients and threats to pursue, through the courts, the cosmetic industry companies that are refusing free removal of the sub-standard implants. [5] Why? Because, as he told the House of Commons, he didn’t think the NHS should foot the bill except for women whose implants were provided on the NHS (almost all of them women who have had breast cancer).

Some of the companies, for their part, are refusing to remove or replace the implants, or refusing to do it free of charge, for fear of bankruptcy. They hold the government responsible for failing to stop the implants coming into the country in the first place. The Medicines and Healthcare Products Regulatory Agency say there is no evidence of cancer risk and that women need not have the devices removed. [6] The bottom line is that in a fiasco, no one wants to take responsibility because of the cost, which reduces women’s health to a political football. Madness? No, these are the consequences of failure to control private medicine.

Is there a risk of cancer if you have mattress material in your tits for the next 5, 10, or 25 years? Who knows! Who wants to wait to find out the hard way? Women who fear the further risks of more surgery in order to have them removed, for a start. How are breasts repaired after they’ve had implants in place, particularly in women who have had breast cancer and may have tissue damage from surgery, radiotherapy, and chemotherapy? This is a serious dilemma, not the sort of “choice” Andrew Lansley goes on about.

Is there a greater risk of rupture with mattress material than with approved silicone gel? How can we know when private clinics are not obliged to keep such records and, even if they do, cite “commercial confidentiality” [7] to get out of reporting what data they may have? The so-called Independent Healthcare Advisory Service, which actually represents the major cosmetic surgery companies, claims to have audited all its members about the risk of rupture, and says data showed a rupture rate “within the industry standard of 1-2%.” Who set that “standard?” The industry, of course. Is it acceptable that implants have been found to rupture on average in one to two of every 100 women who have them? Let alone in the 7% reported in a small sample of 100 patients conducted by Transform, one of the biggest cosmetic surgery companies? [8] Acceptable—absolutely not!

Silicone gel being removed from a ruptured implant RHM 2010;18(35):96

But that’s not all. Breast implants cause a lot of problems that we rarely hear about. Last month, for example, the New England Journal of Medicine reported the case of a woman, who had had a mastectomy and later heart surgery, whose breast implant was dislodged during a Pilates breathing exercise. It migrated through the space between her ribs to sit next to a lung and had to be surgically removed and replaced. [9]

The National Research Center for Women and Families, a USA-based, non-profit research and information centre that provides information about breast implants to about 1,000 women annually, reports that all breast implants carry a risk of the following: tightening or hardening of the scar tissue around the implant (which can be painful and disfiguring); rupture of the shell holding the silicone; leaking of silicone following rupture (requiring an MRI to detect accurately and surgery to remove it); autoimmune symptoms in women whose implants have leaked; risks related to removal (this “explanting” is a rare skill even in the USA, the breast implant capital of the world); negative effects on breastfeeding; reduced accuracy of mammograms (serious especially for women who have had cancer); breaking of implants due to pressure during mammography; and the need for subsequent surgery for many of these problems. [10] And let’s not forget the absence of any requirement to provide adequate information to women considering implants in the first place.

Lastly, what does it cost? Breast enlargement at a Transform clinic, according to their website last week, costs £1000 deposit and £224.58 per month payable over one year (a total of £3694.96), or £250 deposit and £88 per month over five years (a total of £5580). This is before we begin to talk about the financial implications for women of having to pay for additional procedures to check for and repair the consequences of a rupture, leaking silicone etc, on top of the implant surgery itself. What caused this fiasco? In the UK, breast implants for purely cosmetic reasons are a highly profitable part of our burgeoning private medicine industry. Welcome to Andrew Lansley’s “new” NHS, American-style.

And now solicitors can get their share too!

Advertisement appearing on a website following the PIP scandal

References
1. Latham M. A poor prognosis for autonomy: self-regulated cosmetic surgery in the UK. Reproductive Health Matters 2010;18(35):47-55.
2. Hawkes N. The Care Quality Commission: unfit for purpose? BMJ 2011;343:d8034.
3. Hansard 6 March 2008, column 1957. Reported in Latham [1].
4. Mercer N. Clinical Risk 2009;15:215-217. Quoted in [1].
5. Boseley S. Breast implant scandal: comestic surgery companies face court action. The Guardian. 11 January 2012.
6. Reported in: Keeley B MP. Breast implants: why a review is welcome [Letter]. The Guardian 3 January 2012.
7. Campbell D. Plastic surgeons facing “significant” rise in legal action. The Guardian. 9 January 2011.
8. Boseley S, Meikle J, Willsher K. Implant firms say rupture rate is within the norm. The Guardian 4 January 2012.
9. Fong TC, Hoffmann B. Disappearance of a breast prosthesis during pilates. N Engl J Med 2011;365:2305.
10. Zuckerman DM. Reasonably safe? Breast implants and informed consent [Commentary]. Reproductive Health Matters 2010;18(35):94-102.
11. At: http://www.transforminglives.co.uk/procedure-prices.html. Accessed 13-1-12.

Jingle pills indeed

This post first appeared on the BMJ Group Blog, 12th December 2011

Many years ago now, when news of female sterilisation first came out, Catholic priests in Puerto Rico and other Catholic countries preached from their pulpits against women being sterilised. As a result many more women learned that sterilisation existed, and many went out from church asking where to get it. In effect, the church gave family planning free advertising space by opposing it. Recently, the Daily Mailand others who rant against emergency contraception and abortion have played a similar role.

The British pregnancy advisory service (Bpas) received widespread coverage for their Christmas morning-after pill campaign, in which they offer to send women who request it free emergency contraception if they phone in and discuss it with a nurse.

This campaign represents several major advances in support of women who may be having sex without using a regular contraceptive method, but do not want to get pregnant. First, Bpas are making the service available by phone in advance of the “emergency” nature of the need. Thus, just as we keep pain medication in the medicine cabinet in case we get a headache, women are being encouraged to have morning-after pills on hand, in case they need them. Second, they are making the pills free when many chemists charge £25 for one dose, which many young and unemployed women would find prohibitive, and the phoneline will be open when GPs and chemists are closed. Third, they are able to broach regular contraceptive use with the women who phone and encourage them to start regular method use.

The morning-after pill has been available over the counter from chemists without a prescription for over-16s since 2001. So all the palaver about Bpas suddenly making it as easy as dialling for a pizza is silly. In any case, if you’ve had unprotected sex, the morning-after pill will help you far more than pizza. There are people who simply don’t want any form of birth control to be easily accessible and who still claim that emergency contraception (and abortion) promote promiscuity, just as their anti-abortion forbears claimed about the contraceptive pill and female sterilisation in their day. In the end, it’s sex they’re against. Perhaps Nadine Dorries should try putting that on prescription!

A Cochrane review in 2010 found that women who received an advance supply of the morning-after pill had the same chance of becoming pregnant as those who did not have early access to the method. However, these pills do prevent pregnancy when they are used. It seems that many of the women who have unprotected sex and get pregnant without wanting to are not the ones actually obtaining and using the morning-after pill. Perhaps Bpas’ campaign, with the help of all the media who have given it space, will help to change that.

According to the Bpas press office, 1,000 women phoned in the first 48 hours. If many more women find out about this method and start to keep a dose or two at home in case they need it, there is a far better chance they can avoid an unwanted pregnancy.

Andrew Lansley, the Health Secretary who doesn’t want responsibility for the NHS, told the Daily Telegraph that he would prefer there to be face-to-face counselling. Is that actually necessary when only a few questions need answering? And, someone has to seek face-to-face counselling first. For those who don’t, or won’t, this can only be a good thing.

Indeed, helplines for health-related issues are becoming more common and their value is clear. The FPA, for example, has run a helpline for years and has an excellent record of informing and referring for services for family planning and sexual health. The new aspect of Bpas’ campaign, sending the pills through the post, is like ordering something on the internet. Why not?

As for the under-16s, let’s get real. The under-16s who have sex may only do so very irregularly. But if they’re going to have sex, they need access to contraception. The morning-after pill may not be their best option in the long run, but it should be there if they need it.

We need contraception to be in the news more often – it’s good news. I applaud Bpas and all the media who have publicised their campaign. Jingle pills indeed!  Happy holidays!

On 11th January 2012 an update of the situation appeared on Abortion Review.

The cover that got covered

Guest blog by RHM digital editor Cassie Werber

In May 2010, Reproductive Health Matters published a journal on the theme of Cosmetic surgery, body image and sexuality.

Marge Berer, editor of the journal, proposed a cover featuring an artwork which consisted of the vulvas of women – who had volunteered for the project – cast in plaster. Here, Marge Berer describes just some of the reactions and counter-reactions:

The issue featured papers on female genital mutilation (FGM), cosmetic labiaplasty, ‘hymen repair’ and cosmetic surgery as a human right. But among so many controversial topics, what really sparked debate was… the cover.

The cover ultimately featured an artwork bySusan Lyman:

Final cover for RHM35

A different cover had originally been proposed, however, featuring the work of a different artist. Jamie McCarney’s work – the Great Wall of Vagina – comprised plaster casts of the vulvas of 400 women, and it was an image taken from this piece which formed the original cover.

Original cover of RHM35

Alerted by her staff to a possible controversy, Marge asked her editorial board and board of directors for advice. What resulted was a firestorm of comments, opinions and ‘concerns’. “I don’t think anything quite so exciting is going to happen to me, as an editor” says Berer. The months leading up to the May publication date saw an intense, global conversation which brought into play ideas about the female body and its representation; obscenity and indecency; cultural acceptability; freedom and fear; shock; and the law.

Speaking in Brighton in May 2011 – a year after the cover controversy – RHM editor Marge Berer talks about the why she passionately defended the original cover, her disappointment at it being ‘censored’ – and what she did in response.

Other resources:

Watch the full video

Paper titles and abstracts

The Cover Covered editorial

RHM website

World’s 7 billionth baby causes journalistic storm

Last week, an opinion piece in the New York Times in response to the birth of the world’s seven billionth baby put forward family planning as the solution to the problem of the still rapidly rising population of the world.

It took pot shots at UN demographers for not being able to predict precisely when the numbers would reach 7 billion. It claimed that family planning, all by itself, could solve problems such as climate change and the destruction of forests, and blamed the absence of family planning for poverty, civil wars and even terrorism, due to an excess of youth in still growing populations! As if youth, and not old men, started wars.

This article is a real throwback to the old days when all the world’s ills were blamed on overpopulation and contraception was put forward as the only solution. Unfortunately, there has been a rash of such articles, one more erroneous than the next. An article in the Guardian quotes none other than Paul Ehrlich, making the same 1968 claims which, as Prof John MacInnes points out in a letter, have been discredited. Then, he claimed that population growth would lead to widespread famine when in fact drought and inequitable global food distribution policies is what causes famine; now he claims that development, which in regard to agriculture prevented famine, will lead to famine.

As MacInnes accurately explains, it is the rapid fall in mortality over the past 100 years, and not, any longer, increases in total fertility rates, that mainly drives population growth. In the past 4-5 decades, total fertility rates around the world have been falling rapidly, and more and more countries have achieved below-replacement fertility levels, such as almost all eastern and western European countries. Fertility levels (number of babies born per woman) are falling rapidly in most other countries as well. Only the poorest and least developed countries are lagging behind.

Unfortunately, below replacement fertility levels have triggered negative reactions in some countries, Russia being the most egregious recent example. [1] Russia has just passed restrictions on legal abortion and introduced pro-natalist policies in which women are offered financial and other incentives to have more babies. Such policies are supported by rightwing conservative religious forces that are opposed to women having any reproductive rights regardless of population trends. The subject is far more complex than it has been presented as being.

Unlike peer-reviewed journals, newspapers and other media do not have (or rather do not make) the time to have anything they publish peer reviewed. Articles about the seven billionth baby have to be published the day that baby is born or at most the day after. Newspaper editors seem to act on the principle that if an article contains false or distorted or contestable information, oh well, there are letters to the editor to correct it. This is a major mistake. The seventh billionth baby is not the same kind of “news” as Berlusconi stepping down or the US being stupid enough to bomb Iran. Articles such as the ones in the NY Times and the Guardian deserve more thought and research not only because they can contribute to misinformation of the public, who do not all have access to the facts, but also because they tie people who do have access to the facts up in knots writing letters to the editor to correct the errors. These letters must use far fewer words than the original article was given, and are placed at the back of the paper, without a big headline, and with the certainty that far fewer people will see the reply than read the original article.

When it comes to science, medicine and health issues – and in this case global demographic trends and the reasons for them – newspapers and the media could and should try harder to ascertain the truth value of what they publish – before they publish it. And they should avoid “prophet of doom” headlines as well. They could so often be an important source of information for the public of valuable health information and scientific understanding of crucial aspects of our lives. And many times they are. But they are also often responsible for purveying false or only partially true, and ultimately distorted, information. Some journalists are unable to interpret or present information contained in peer-reviewed articles accurately or in a more journalistic form, and some choose to rely for their information on people claiming to be experts whose work is itself inaccurate, and who may also have their own axes to grind.

There were two main wrong claims in the NY Times article. The first was the erroneous assertion that family planning is a solution to “many of the global problems that confront us, from climate change to poverty to civil wars”. On its own, family planning is not a solution to either climate change or poverty, though its greater use by those who have an unmet need for ”family planning” would be beneficial and contribute to the solutions in both instances. As regards civil wars, I would be interested to learn whether there is any evidence whatsoever that the use of family planning reduces civil wars. I doubt such evidence exists. The claim is absurd. Similarly, I doubt there is evidence that “youth bulges”, that is, a high proportion of a country’s population being young, make countries more prone to conflict or terrorism.

The second wrong claim was support, indeed praise, for anyone who supports the use of contraception but at the same time condemns women’s need for safe, legal, induced abortion. Anyone who does so is not a friend to women, anywhere in the world. Abortion is an essential part of family planning, always has been and always will be, whenever contraception fails or people fail to use it, no matter how high contraceptive prevalence may be.

Family planning has had short shrift in recent years in development policy and funding. Yet contraceptive prevalence rates are also as high as they can get in many countries and rising in most others. To support this trend, family planning deserves more attention and more support in every country of the world. Family planning, and in that I include access to and use of both effective contraception and safe, legal abortion, is essential if women and men are to be able to control their fertility and decide the number and spacing of their children, if indeed they wish to have children.

We don’t need family planning to reduce HIV infection; we need safer sex and needle exchange programmes for that. We don’t need family planning to prevent the earth being devastated by climate change. We need environmental policies to be implemented post haste and a serious change in how we spend our riches and use the earth’s resources. There is no need to tout contraception as a cure-all or a panacea for all the world’s ills. It is valuable enough in itself that there should be no need to pretend it is more than it is.

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[1] Russian government seeks to enact laws restricting abortion to increase birthrate. RHM 2011;19(38):219-20

Fighting the English Health and Social Care Bill

I have just written a letter to 16 members of the House of Lords, asking them to intervene and make sure the Health & Social Care Bill is thoroughly examined and if possible rejected to prevent it passing into law as it is.

The letter was designed to support the efforts of those among the Lords already working actively to subject the Health & Social Care bill to the in-depth scrutiny it did not receive in the House of Commons via a special committee, and to urge them at the minimum to find ways to substantively amend it so as to reduce the damage from its worst clauses. Even more, what I really wanted was to convince the House of Lords to reject it altogether. The bill is fatally flawed. If it is passed, even with amendments, it will turn the “NHS” in England into a mere logo.

I believe one of the reasons why the Bill did not fall in the Commons was that the opposition did not attempt to defeat it per se, but rather put forward many amendments without consensus or unity among all those who were seeking to oppose/amend the bill. Cross-party opposition was totally absent on a subject that cries out to be treated in a cross-party manner because it affects us all (though not equally). Moreover, the time for debate was so limited that it made a farce of any serious examination of the bill itself, let alone the many amendments that had been tabled.

Many people who oppose the bill called on both Labour and the LibDems in the Commons to hold a consultation with expert key parties – in the NHS, in health professional associations, civil society health advocacy groups and patients’ groups. We wanted them to draft an alternative bill for which to campaign, as well as table a united set of amendments to this bill. This did not happen, to our great disappointment.

Many people are therefore looking to the Lords to play the role it is justly famous for – stepping into the breach in a crisis and putting things right.

Here are some compelling arguments against the Bill:

My blog, 17 reasons to oppose the bill, which outlines all the forms of privatisation envisaged in the bill, none of which have been ameliorated or cancelled out by amendments in the Commons, why they are a mistake and what to support instead.

 “It’s already happened” by James Meek writing in the London Review of Books is the best description I have seen to date of the negative consequences for hospitals of privatisation of the NHS. It uses the example of what has happened over recent years to the Wrightington Hospital near Wigan and its orthopaedic centre of excellence for hip and other joint replacements.

“An unsuitable case for treatment” by Hackney GP Jonathon Tomlinson describes the serious problems that privatisation and “choice” (highly restricted in reality) have already placed in the way of his treating one of his most vulnerable and ill patients and why he believes he can no longer do what is best for his patient in the face of NHS changes.

A diary by Andrew O’Hagan, also from the London Review of Books, is about Nye Bevan and the history of the NHS, how much the proposed reforms go against the ethos of Bevan to ensure universal access to health care, and a report of his conversations with a GP at the Kentish Town Health Centre in London, who explains what a disaster it will be if GPs have to hold the purse strings locally.

These contain incredibly strong arguments and examples for any debate, and the basis for alternatives to the clauses in this Bill, and to the Bill as a whole.

There are two campaigns being run to try and influence the House of Lords: one by 38 Degrees and the other by the TUC.

Join the fight against the privatisation of the NHS!

Independent abortion counselling? Whose problem?

Published on the BMJ guest blog, 1st September 2011

Nadine Dorries MP is a very skillful politician. She decides there is a problem, for which she has absolutely no evidence. She not only manages to get her problem onto the front pages of the newspapers but also onto the agenda of the House of Commons. Having spoken to her about it, the Department of Health (DoH) agrees to take it up and resolve it without putting it before Parliament. But the DoH have no evidence of a problem either. Nadine Dorries wants to make life harder for the one in three women in this country who will have an abortion in their lifetimes. But what excuse does the DoH have? One can only presume they were trying to stop Dorries from stealing the limelight from Andrew Lansley’s NHS bill next week, which is contentious enough without her. Last week, as reported by the Guardian,[1] Downing Street intervened.

What was going on? Earlier this year, Dorries claimed that Bpas and Marie Stopes, who provide a high proportion of abortions for the NHS and for non-NHS patients, do not give unbiased abortion counselling because they earn money from providing abortions. This is patently untrue. The ethos of non-directive counselling has been central to abortion provision since the 1967 Abortion Act was passed. It is in no one’s interest for abortion clinics and counsellors to do otherwise than give unbiased information and counselling; that is their job. Dorries does not cite claims by any woman that an abortion counsellor or doctor talked her into having an abortion, or encouraged her to do so when she wasn’t sure. She merely said that the process is too fast these days, as if women with an unplanned pregnancy don’t think about it on their own, sometimes for weeks or even months, before approaching an abortion clinic.

In June, when this hit the news, I wrote to Anne Milton, Parliamentary Under Secretary of State at the Department of Health, to protest at Dorries’ claims, and to ask what the problem was as they saw it. In mid-July, I received two replies from two different civil servants. The first said that women needed to know about “the risks to health (including mental health) posed by the abortion procedure as well as any health risks posed by continuing the pregnancy, to enable [them] to make a decision that would benefit [their] overall health and wellbeing”.

The other, some days later, said: “The Department is drawing up proposals to enable all women who are seeking an abortion to be offered access to independent counselling… provided by appropriately qualified individuals. Independent counselling will focus on enabling a woman to make a decision that would benefit her overall health and wellbeing. Independent counselling will be for those women who choose to have it and will not be mandatory. Full proposals are still being worked up within the Department of Health and it is therefore unable to provide detailed answers while this process takes place.”

Thus, although the Department decided to approach this differently from Dorries, Dorries had still managed to make her problem official – Bpas and Marie Stopes, the accredited independent providers of abortion and abortion counselling, about whose counselling no one save Dorries had complained, were seen as neither appropriate, qualified or independent enough, and were not acting in the interests of women’s health and well-being. Therefore a second tier of counselling should be made available to women – yet it wouldn’t be mandatory! It couldn’t have been more confused.

On 25 July, I wrote to Anne Milton again to ask to see the evidence that the abortion counselling being provided by Bpas and MSI was in some way deficient, and whether she intended to make any such information public or not. I also asked:

• How the Department defined “independent counselling” for women considering or seeking abortion, and if anyone currently provides it.

• If no one currently provided it, did she intend for the Department to set up such counselling centres, and/or

• Did she consider that groups who advertise themselves as willing to help women with unintended pregnancies, but who do not and will not refer women to an abortion provider even if they ask for such a referral, are able to give independent counselling.

I did not receive a further reply.

Health risks? The fact is, induced abortion with a trained provider is among the safest clinical procedures available. As for mental health, recent reviews of the literature by the American Association of Psychologists and by the Royal College of Psychiatrists have shown yet again that unless a woman has mental health problems prior to getting pregnant, abortion does not increase the risk of mental health problems after it. When will that be believed?

Still, what’s that got to do with the need for independent counselling? Does the DoH believe so-called crisis pregnancy centres can do the job instead? A recent study of eight such centres in England found that many of their counsellors lacked basic listening and counselling skills and also lacked practical and accurate information about abortion and other options. Some advised against having an abortion at any cost, for example by giving dramatic misinformation, such as that 100% of women who have abortions will get cancer. Two centres did provide straightforward and impartial advice, but the “added value” of any of these centres was not clear in comparision with counselling by an accredited abortion provider.[2]

But why worry about evidence?

Dorries’ amendments would have provided an inflammatory and unwelcome distraction from the debate on the NHS Bill and the ills that Bill is set to bring us. The Speaker of the House might not have selected the amendments anyway, given that the DoH is (or was) on the case, in pursuit of a problem created out of thin air.

Now, let’s get to the real issue: calling for the withdrawal of the entire NHS Bill.

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[1] Downing Street forces U-turn on Nadine Dorries abortion proposals. At: <http://m.guardian.co.uk/world/2011/aug/31/downing-street-uturn-abortion-proposals?cat=world&type=article>. 1 September 2011.

[2] Education for Choice. Snapshot of Crisis Pregnancy Centres operating in England. 2011. At: <www.efc.org.uk>.

Why is abortion – and particularly repeat abortion – still perceived as a problem?

A study of repeat teenage pregnancies in women under 20 years old presenting for an abortion in England and Wales from 1991-2007 found that the number of women with recorded previous pregnancies had risen steadily from 1991 to 2007, both in absolute numbers and in proportion. The proportion of those who had a repeat abortion also rose.[1]

However, this paper states that “it is difficult to fully ascertain the number of teenagers in the UK who have had more than one pregnancy before the age of 20 years” because figures for children born outside marriage are not recorded by the Registry Office. It was only data collected on abortions that allowed this study to be carried out. Because the number and proportion of abortions has risen, this author concludes that there is a worrying situation here – a conclusion that can only be based on the belief that more abortions are a bigger problem than fewer abortions.

I would suggest that this is not the correct perception. Younger people appear to be starting to have sex earlier than in the past (or perhaps they’ve been asked the question more often). That means that more of them may be at risk of unintended pregnancy. Teenage pregnancy is also perceived as a problem. And it certainly is, among those who cannot cope with a baby after it is born. According to recent research, approximately 50% of teenage conceptions end in abortion, not motherhood.[2] But if more teenage pregnancies are ending in abortion, that should be seen as a good thing, because at least potentially it means fewer young women having children they cannot cope with.

Why then is abortion still perceived as a problem, particularly, though not only, if it happens more than once?

Every new generation of women and men has to learn things from scratch. Just because a growing range of contraceptive methods has been available since the 1960s, it doesn’t follow that adolescent girls and boys have any experience whatsoever with contraceptive use when they first start to have sex. Human beings often learn things the hard way – by making mistakes. Why is this frowned upon and treated as a major moral failing with contraception and even more so with abortion?

If 100 sexually active women don’t use any contraception, 80–90 will become pregnant within a year. Prevention of unintended and unwanted pregnancies is something that heterosexually active couples have to concern themselves with and take action on throughout their fertile years, especially since most people now have only a few children (and many have none or only one) and many want to delay childbearing for ten years or more after starting sexual relationships.

An unintended/unwanted pregnancy usually comes as a shock, and often acts as a wake-up call that no one is immune to getting pregnant, and to do better with contraception. Thus, the large majority of women who have an abortion have only one abortion. Given this fact, I believe it is a mistake to think that it is possible to reduce the abortion rate extensively – unless everyone using contraception uses long-acting or permanent methods that have almost no failure rate or user error.

That would mean no natural methods, no condoms (but what about protection from sexually transmitted infections and HIV?), no oral contraceptives (which are the most commonly used method), no diaphragms or caps, and no vaginal rings. Even injectables are only highly effective if you always remember to go back for the next injection on time. Female sterilisation and vasectomy have a very low failure rate and are well-liked, but only for those who have completed their families.

Implants last 3 years, the IUS lasts up to five years and the copper IUD up to ten years, but are they the method of first choice among women who may want to get pregnant in less than 3-10 years’ time? Should they be the only methods recommended to women perceived to be at risk of unwanted pregnancy? Do we really want to go down this limited and limiting road? The Department of Health appears to think the answer to this question is yes, but where is the evidence that women will accept it, that it will cost less than providing early abortions without problematising or punishing those who have more than one, or that it will reduce the number of unintended pregnancies, let alone abortions?

The fact is, as Lisa Hallgarten, Director of Education for Choice, pointed out to me when we were discussing repeat abortions this week, “someone who has taken sufficient risks to get pregnant the first time will probably do so again unless something changes – i.e. she and her partner experience a useful intervention”.[3]

International comparisons

In case anyone thinks the UK is doing so badly in regard to repeat abortions, let’s look briefly at other countries. In Sweden a study published this year found that almost 40% of induced abortions were repeat abortions among women aged 20-49 having abortions. And Sweden is a country with long established sex and relationships education and a public health policy to enhance sexual and reproductive health. The highest “risk factor” found was parity. In other words, women who already had children were most likely to have one or more repeat abortions. This implies they had the number of children they wanted and were getting pregnant more than once when they didn’t want more. Other risk factors were lack of emotional support, unemployment or being on sick leave, tobacco use (probably related to lower socioeconomic status), and low educational level.[4] In short, in addition to not wanting more children, they were among the most vulnerable women in society.

This and other articles make several useful recommendations. One is to look at the content and quality of sex and relationships education for those in school, to see whether it might be adapted better for vulnerable groups.

Another recommendation is to examine the barriers to effective contraceptive use and in contraception provision in abortion clinics themselves, following abortion. Studies have variously found that only a limited number of contraceptives may be offered in post-abortion care, and that methods requiring more skills may not be available. If women have to be referred elsewhere for some methods, timing of getting contraceptive advice and starting a method may not be optimal, and lead to lower levels of uptake and long-term usage.

A New Zealand study found that “compared to women who left the clinic with combined oral contraceptives, those leaving with an IUD at baseline were less likely to return for a subsequent abortion. Among women who had not had a previous termination, however, younger women were less likely than older women to have had an IUD inserted post-abortion. With every additional live birth, women were three times as likely to have left the abortion clinic with an IUD. Among women who had had a previous termination, age was no longer significantly associated with post-abortion IUD insertion. However, parity was still significantly associated, as was having a negative sexually transmitted infection test.”[5]

Perhaps the most useful study I found was carried out by Sangeeta Das and colleagues from the Department of Obstetrics and Gynaecology, Royal Oldham Hospital, Oldham.[6] They start by saying that in the UK, there are no agreed criteria for defining “’recurrent abortion seekers”. This is important, since it is possible for a woman to have an abortion every year – or as rarely as 3 or 5 or 10 or even 15 years apart. Hence, it is important from the outset to decide how frequently repeat abortions must occur before they are indicative of a “problem”, given the long duration of fertility and sex.

The Das et al study aimed to review the characteristics of women requesting termination of at least two consecutive pregnancies within 24 months of the first termination.The incidence of repeat abortion within a 24-month period was only 2.3%. This is far lower than the figures one usually sees.

Financial circumstances were the most common reason for seeking abortion (75%). The combined oral contraceptive pill and condoms were the most common forms of contraception used by these patients before the first abortion (35% and 38%, respectively). Long-acting reversible contraception (LARC) was used by only 8% of women before their first termination. However, although 58% accepted LARC following abortion, which would appear to support Department of Health policy, only 2% continued its use thereafter. And 50% of women were not using any contraception at the time of the repeat abortion. Hence, LARC may not be the answer at all in some cases. The fact is, contraceptive use itself may be the source of the difficulty.

The authors suggest that social workers and perhaps psychologists should be part of the peri-abortion counselling team, that contraceptive counselling should be geared to improving compliance and that  follow-up to ensure continuing contraceptive use and involvement of partners in decision-making could help to reduce the incidence of repeat abortions.[6]

Policy ignoring evidence?

Given the need for better education and guidance, I was disturbed to learn this week from a Guardian article [7] that with council budgets under pressure from government cuts, the posts of Teenage Pregnancy Coordinators (TPCs), who provide advice on sexual health, pregnancy and contraception to young people, often by mobile phone, have been axed since the beginning of 2010 in 56 Primary Care Trusts in England, or over a third of PCTs. These include Walsall, Tameside, and Waltham Forest in east London, who now have no dedicated TPCs, despite being among the 20 areas in England with the highest levels of teenage pregnancy.

Several TPCs interviewed in the article expressed concern that, because some areas have succeeded in reducing teenage pregnancy rates, attention to the issue was being downgraded as a priority because the policy had succeeded. This is obviously a very flawed understanding of the need for ongoing work with those needing support and attention from among the many new young people who are growing up and starting to have sexual relations every year.

Here are some of the issues that emerge from this brief look at the issues:

1. Is repeat abortion a problem? Or, how frequently must it happen before it should be treated as a problem?

2. Isn’t the real problem poor or intermittent or no contraceptive use? If so, surely it is imperative to support consistent and correct contraceptive use rather than assume that only by pushing specific methods (LARC) you will solve the problem on its own.

3. What social support is needed by those perceived to have a problem? Are TPCs available locally? Should they be? What other support is needed? Is it available? Who should provide it, where?

4. Does contraceptive counselling, provision, and choice of method for young people need to be improved? Are there dedicated services for young people? What about for women of any age who are at risk and vulnerable? What are the barriers to good contraceptive access and use? How can services be improved? All local FP clinics should be examined from this point of view – those in the community in primary care centres, those in hospitals, and those attached to abortion clinics.

5. What is the quality of sex and relationships education on the subjects of both contraception and abortion locally? Does it speak to the problems of those who are perceived to be at risk of unintended and unwanted pregnancy? Does it give sufficient information about abortion and seeking an abortion? Or does it merely moralise on the subject?

Before acting we need to find out the extent of the problem and who is at risk; to talk to women themselves, find out what their needs are and then decide what to provide, and how. Just blaming women doesn’t help; the role of partners is also key, as is social and economic and family circumstances.

Complex doesn’t have to mean problematic

Consistent and correct use of contraception makes it possible to space and limit births, and the UK has a high prevalence of contraceptive use.

Internationally, it has been shown that young age, lack of experience, lack of information, poor sexuality and relationships education, difficult home and living situations, abusive partners, poverty, low sense of self-worth and self-efficacy, and limited life choices all contribute to less than effective contraceptive use.

Single adolescent girls who become pregnant unintentionally may welcome a pregnancy and baby, especially those with limited life choices, because a baby gives them something to live for and a sense of self-worth. Some may have thought they wanted to get pregnant, but when it happens, the reality of a baby makes them realise that they wouldn’t be able to cope with it. Many young women seek abortions when they learn they are pregnant precisely because they could not cope with a baby, and/or in order to pursue other life choices, whether work or further education.

The longer women stay single, the more likely they are not to want a baby. If they are also not using contraception effectively, the more likely it is that they may experience one or more unintended pregnancies and seek an(other) abortion. Abortion is a solution for an unwanted pregnancy. It is legal, it is available, and it does not adversely affect health or fertility in this country anymore.

Unintended pregnancies remain common because fertility lasts from as early as age 12 to as late as age 49, contraception fails, people fail to use it consistently and correctly, they may stop using a method and not replace it with another for some time, a new partner may refuse to accept using a method, and so on. The literature on this is extensive.

One in three women in Britain will have an abortion in their lifetime. It’s time to see abortion as a solution, not as the problem.

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[1] Collier J. The rising proportion of repeat teenage pregnancies in young women presenting for termination of pregnancy from 1991 to 2007. Contraception 2009;79:393-96.

[2] Hoggart L, Phillips J. Young people in London: abortion and repeat abortion. Research report. Department for Children, Schools and Families; Government Office for London. January 2010. At: < http://www.bpas.org/js/filemanager/files/tpyoungpeopleinlondonabortionandrepeatabortion.pdf>.

[3] See: Hallgarten L, Misaljevich N. Reducing repeat teenage conceptions: a review of practice. Education for Choice, 2007. At: <http://www.efc.org.uk/professionals/efc_research.html>.

[4] Makenzius M, Tydén T, Darj E, Larsson M. Repeat induced abortion – a matter of individual behaviour or societal factors? A cross-sectional study among Swedish women. Eur J Contracept Reprod Health Care 2011 Jul 21. [Epub ahead of print]

[5] Roberts H, Silva M, Xu S. Post abortion contraception and its effect on repeat abortions in Auckland, New Zealand. Contraception 2010;82(3):260-5. Epub 2010 Apr 14.

[6] Das S, Adegbenro A, Ray S, Amu O. Repeat abortion: facts and issues. J Fam Plann Reprod Health Care 2009;35(2):93-95.

[7] Williams R. Cuts threaten to undo progress on reducing teenage pregnancies. The Guardian (Society). 10 August 2011. p.30-31.