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.

“Human beings have only a 50-50 chance of surviving to the end of the 21st century”

On 25-26 May, I attended a conference in London, organised by University College London Centre for Global Health, called Population Footprints, on sustainability.

The prediction that we humans have only a 50–50 chance of surviving to the end of the 21st century serves to focus the mind wonderfully. It is based on the seriousness of the environmental problems created by climate change and rising carbon emissions, over-consumption, scarcity of education and employment, population growth, scarcity of resources such as potable water, failure to develop renewable energy, maldistribution of food, the threat of rising sea levels, which could destroy coastal cities and change coastlines worldwide. Health in the context of environmental stress. Urbanisation. Migration. And so on.

Sitting there, I asked myself: What will I do differently starting tomorrow morning, in response to this prediction? In fact, shame on me, I didn’t do anything different. And that’s the problem!

Then I thought: If you were told you had a disease that, only with treatment and only if you changed your behaviour, you would have a 50-50 chance of surviving, would you change your behaviour then? What about 60-40 or 70-30? Not good odds for the whole of humanity, is it? But this is where we stand.

So what’s it got to do with sexual and reproductive health and rights? Some people came to the conference to push for renewed efforts to reduce population growth – a group called Population Matters, for example (no relation to RHM). What was heartwarming, then, was the fact that almost everyone else there had realised that it was a whole string of issues calling for radical change in the direction of sustainability that matter. Including policy on development, trade and health care, and food distribution; access to clean water, education and social welfare; care of the environment and recycling of waste; the role of war; the damage caused by both wealth and poverty; changing economic policy from a 19th century growth model; stabilising population levels, increasing family planning, and seeking demographic balance in population age. But above all, dealing with climate change by capping and reducing carbon emission levels as soon as possible. Family planning  was no longer being presented as the solution on its own. Whew!

We (that is, my generation) who opposed population “control” policies in the 1970s and 80s that abused the right of women and couples to decide the number and spacing of their children, don’t have to go back to square one and start over. But wait – family planning needs to go back on national agendas, with increased funding, with choice of methods and generic production, and popular education about the importance of planning one’s family. The fertility rate is falling almost everywhere but the unmet need for contraception and safe, legal abortion remains enormous; as does the broader need, for reproductive and sexual health.

I started to think about policies in the past that said: one kid or two kids and you’re sterilised. The Chinese have had a one-child policy for 30 years now, and their population has stopped growing. The policy is open to abuse, yes, and it’s incredibly controversial, but it is also widely supported, seen to be a necessity. Could anyone do better, being responsible for a quarter of the whole world’s population? The debate about whether the policy can be relaxed, and when, and how much, is heated, according to the one Chinese participant there. Fantastic! In what other country is population policy the subject of heated public debate?

I’m worried about carbon emissions. We’re already at the stage of not-OK. What happens if we don’t bring down carbon emissions soon enough? Will we get the equivalent of ‘two kids and then you’re sterilised’? For example, you won’t be allowed to fly more than so many miles and once a year. Trains instead of planes. Imagine that! Grounded on a global scale.

Uganda is worried about how they will ever feed, educate, house and find jobs for the 50% of their population who are currently under 15 years of age. Even if things weren’t falling apart there, it would be near impossible.

On the other hand, I was so heartened to hear someone say we have to drop the 19th century model of economic growth and find a 21st century way to organise our economies. Fantastic! Could it lead to the end of production of junk?? A move away from a militarised economy which is expensive and wasteful? Required recycling of all waste? Acknowledgement of wealth and over-consumption as a major source of problems? Limitations on upper income levels? Solar and wind power a must? Less complex technology, more jobs? Yes, yes, yes!

Sustainability. That’s the key. Roll up your sleeves – we have work to do!!

Privatising the NHS can bring down a government

LETTER TO MPs, SENT 28th MAY 2011 – INTERNATIONAL DAY OF ACTION FOR WOMEN’S HEALTH

I am writing to urge you to call on the Prime Minister and the Secretary of State for Health to withdraw the NHS Bill, as recommended by the British Medical Association and many others with expertise in health care and health systems. This Bill is the wrong response at the wrong time. It is far too complicated, with potentially costly and negative consequences, to be amended piecemeal.

Everyone recognises that the cost of health care is a major issue, particularly with an ageing population. However, this Bill does not address the costs of an ageing population. Indeed, it says nothing about it.

Instead, it removes the responsibility for health care from the Government altogether. It does this by handing over the responsibility to a body independent of Government, called Monitor. It shuts down the only remaining Government bodies responsible at regional and local level (Strategic Health Authorities and Primary Care Trusts) for managing health care spending and ensuring national standards are met. It places their role in the hands of GPs, who will be forced to create the equivalent of these same bodies, but not in the public sector. And it requires all hospitals to become independent trusts, thereby forcing them to take independent responsibility for balancing their books and leaving them on their own to sink or swim.

Lansley’s Bill also takes away most of the powers of NICE, a body whose contribution to standard-setting and control of costs, such as drug costs (crucial with an ageing population), based on public health expertise and scientific and clinical evidence, has been absolutely essential. This will be a fatal blow to control of spending on drugs and quality of care.

All of this is privatisation of the NHS. The upshot will be fragmentation from within – the postcode lottery instituted as the basis of policy, dressed in deceptive language about “choice” and “local control”.

You will say perhaps that the last Labour government started this process, as if that were justification enough to go so much further. It is not. The Thatcher and Major governments “started it” and Labour certainly took it further, no one disputes this. Under their jurisdiction, since 1990, an internal market was created in the NHS, which led to massive growth in managerial spending.  Whole sections of the NHS were moved out of the public sector – GPs became independent; so too did dentistry, optometry, ambulance services in many places, and much more. Private medicine also grew, e.g. for cosmetic surgery. And private companies came in, offering Strategic Health Authorities and Primary Care Trusts their services (for a profit) in a myriad ways, such as handling hospital appointments and sending reminders to come for screening. Moreover, through private finance initiatives, many hospitals were committed to taking out and paying back expensive private loans to support badly needed modernisation, as the whole system was falling behind, precisely because it had been starved of funds prior to 1997.

What Labour did right was to inject the funds and push modernisation. It set standards of care and targets to ensure those standards were reached. And the reason why the Labour government was able to make so many needed improvements was because the system as a whole was still under the control of the very public bodies that the Lansley Bill will close down – the Ministry and Department of Health, Strategic Health Authorities and Primary Care Trusts.

So, yes, previous Governments started it. Some of what they did turned out to have been a very good thing, but not all of it. Not all by far. The internal market is the main reason why bureaucracy has grown so much, and it and private finance initiatives have increased costs greatly. The question is, does the Lansley Bill address the real problems? Unfortunately, it does not. It is likely to exacerbate them.

Privatisation takes many forms. Lansley’s Bill does it first and foremost by moving all the remaining parts of the NHS in the public sector out of the public sector. At the same time, it opens the door even wider to private health companies and service providers. How? Under European trade regulations, the bulk of the NHS will be independent of government, so it will be required to allow competitive tendering – from which only the public sector is exempt. Thus, the replacements for Primary Care Trusts (set up by GPs), GPs themselves and all foundation trust hospitals will have to open themselves to competition – privatising the NHS in all but name.

It is a false assurance by the Secretary of State that competition will not be permitted. If he does not know this, his competence must be questioned, and if he does know it, then he is trying to pull the wool over our eyes.

The Conservative Party supports privatisation of public services. It would therefore be disingenuous of Conservative MPs to pretend that, unlike all the other reforms they are pushing through at breakneck speed, the Lansley Bill does not aim to privatise the NHS, and radically.

Labour and the Liberal Democrats have tried to have it both ways for too long It would be disingenuous to think that mere amendments could remove the profound effects this Bill will have. The time has come for both parties to take a stand against privatisation of public services. Together, you have the power to force the withdrawal of Lansley’s Bill. The fact is –  as has been shown in country after country – that the public will soon be paying user fees for health care in one form or another as a result of these reforms, as we already do for dentistry. The poor, the disabled and the elderly will be especially hard hit.

Every medical professional body and health trade union has expressed opposition to and/or grave concerns about this Bill. The public do not fully understand how this Bill privatises the NHS, but they have taken on board the message that it does. Week after week on Question Time they have shown it. Some 420,000 voters have signed the 38 Degrees petition against the Bill as I write. That’s a lot of votes.

“Protecting the NHS” is a vote winner, yes. But privatising it can also bring down a Government.

17 reasons to oppose Lansley’s NHS bill – and what to support

Everyone I’ve spoken to wants to oppose privatisation of the health service in England, but many said they wouldn’t know what to say about the NHS bill, currently going through Parliament, because they haven’t read it. I wrote this list of reasons why people should oppose the bill, which has been shared with my local GP Practice Patients Group, Labour Party branch, the discussion website of the housing estate where I live, several MPs and friends working in health advocacy groups in London.

17 reasons to oppose Lansley’s NHS bill – and what to support

1. The bill would privatise the National Health Service in England by removing all major bodies in the NHS from government control, either closing them or making them independent (= private). It would:

• Remove responsibility for the NHS from the Secretary of State for Health to a new NHS Commissioning Board

• Abolish Strategic Health Authorities. These are currently responsible for plans to improve health services in their local area, making sure they are of high quality and performing well,  increasing capacity and ensuring national priorities are integrated locally – with no intention of replacing them

• Abolish the 151 Primary Care Trusts (PCTs). PCTs manage all aspects of primary care provided by GPs, dentists, opticians, NHS walk-in centres and NHS Direct. They purchase services from hospitals and other specialist services, such as mental health services and manage screening, patient transport and NHS pharmacies

• Create 500-600 GP consortia in place of PCTs, who would probably hire independent bodies to manage and spend 80% of the NHS budget, some £100 billion

• Force all NHS hospitals to become Foundation Trusts, removed from the NHS balance sheet and responsible for ensuring in their own income and sustainability

• Privatise almost 1 million NHS staff by 2014.

2. Under European trade laws governing services (GATS), making all major NHS bodies independent from government will open the provision of health services to competition. All private providers, including large corporate heath bodies from the USA and Europe, would be able to compete for contracts. Lansley’s denial of this fact does not make it less true and expert lawyers for 38 Degrees have confirmed this is the case.

3. The NHS Commissioning Board will have a huge amount of power, and ‘local control’ may be pure spin.

4. Prior to amendment, the bill had 353 pages with 281 clauses, 234 pages of explanatory notes and an impact assessment of 165 pages. Very few people have read it all, let alone understood its consequences and costs.

5. Because of its size and complexity, most of the bill did not get proper scrutiny before or during its third reading in the Commons. Opposition in the Lords is crucial. The Tories are pushing it through far too quickly.

6. The Government has been justly criticised for constantly distorting the NHS’s record to justify restructuring it, and using “cynical and misleading” information to downplay its achievements in recent years. They have also failed to publish evidence that levels of public satisfaction with the NHS are at their highest in years, following from Labour’s inputs and increased funding.

7. The Foundation Trust Network has warned that due to the £20 billion of “efficiency savings” (= cuts) the Government has demanded, hospitals are under “financial stress that will lead to the loss of many thousands of jobs and will seriously endanger waiting times and services for vulnerable patients, as well as threatening organisational survival”. This warning, early in 2011, has proven to be true in many local areas already.

8. It is unclear:

• Whether GPs can choose which GP consortium they join
• What responsibilities GP consortia will have
• Who will monitor their commissioning decisions and their spending
• Who they will report to without Strategic Health Authorities
• What will happen if they overspend their budgets.

9. 71% of 800 GPs surveyed by the Nuffield Trust expect that GP commissioning will force GP consortia to focus on controlling costs.

10. Squeezed by spending cuts, GP consortia may be forced to:

• Restrict access to hospital and specialist care (indeed recent evidence shows that many GPs have begun doing this already)
• Make decisions about whether to keep or exclude specific treatments from the NHS
• Give patients the “choice” between paying privately for care or going without.

11. In Hounslow, as a sign of what’s to come, UnitedHealth, a profit-making corporate health company, has been brought in to cut a local GP consortium’s spending by reducing GP referrals of patients for hospital care.

12. Patients may have to lobby GPs for services and drugs, and GPs have to negotiate services for their patients that they used to be able to count on. There is evidence that this is happening already.

13. Foundation trusts may be forced to close services that don’t bring in enough income. To get more income, they will be able to take many, many more private patients than has been permissible in the past. NHS patients are likely to lose access to hospital and specialist services as a result. Waiting lists could lengthen (they already have) and private patients may begin to get preferential treatment.

14. Private providers will compete with and seek to undercut NHS providers, cherrypick which services they offer and patients they treat, no matter the protestations of Andrew Lansley or any amendments to the contrary, and will see patients needing chronic care initially, for the income, and then dump them back on the NHS, increasing costs. This too is already happening and it could end up bankrupting many GPs and hospitals.

15. Patients may be allowed to register with any GP practice. While the majority may stay with their current GP, many may decide to move away from suburban and rural practices to GPs near their workplaces. The consequences for home visiting, patient funding and GP practice size would be great. Choice of registration may be determined by economic status, existing health problems, or age. Vulnerable patients will be most affected.

16. The postcode lottery – masquerading as local choice – will not only become the rule but serves as the ethos of this new system. The evidence is that patients want quality of care in a public health service, not spurious choice.

17. The Labour Party and the Green Party are opposed to Lansley’s bill. The LibDem conference expressed major concerns about it. Some Tory MPs are also very worried, including on the Health Select Committee.

The following health professional/advocacy bodies are opposed to or have major concerns about the bill: British Medical Association; NHS Consultants Association; Royal College of GPs; Royal College of Nurses; NHS Support Federation; Foundation Trust Network; Keep Our NHS Public; Health Emergency; National Association of Links Members; NHS DirectAction; 38 Degrees; Save Our NHS (medical students).
What to support

1. All publicly funded health services should be provided by health professionals and health service bodies in the public sector. Moves to privatise GPs, hospitals, ambulance and other emergency services, dentists, administrative and financial management, and social care should be reversed. The example of privatisation of dentistry, which has meant a large proportion of the population no longer receive regular dental care, should be a warning and an example of what is coming and why it should be avoided.

2. The NHS should be based on co-operation, not competition, promoting access, quality and fairness.

3. Improvements can be made without top down re-organisation.

4. Competition within the NHS and with NHS services should not be permitted.

5. Strategic Health Authorities and PCTs should not be abolished but improved.

6. The Secretary of State and the government should remain responsible for the NHS. Hospitals and all other services should remain in the public domain.

7. The internal market, whereby Primary Care Trusts (and under Lansley’s bill GP consortia) commission services, and hospitals and others sell them those services, should be abolished. This system, instituted in 1992, is the main source of increased bureaucracy in the NHS, and a costly and inefficient way of arranging service delivery.

8. The cap on the number of private patients treated in NHS facilities should remain low and tightly controlled, and be based on an assurance that the NHS can afford to treat all patients in need of care in the public sector.

9. The siphoning off of funds from the NHS by private services who accept patients they cannot treat and then send them back to the NHS to obtain treatment should be subject to investigation and regulations developed to prevent it happening.

10. All members of both Houses of Parliament and staff of the Department of Health should be investigated to learn who has personal interests in and connections with private medicine. Those found to have such interests should be required to recuse themselves when anything related to the future of the NHS is debated in Parliament or at issue in the Department of Health.

Lansley’s bill should be withdrawn in its entirety.

What you can do

1. Write to your MP and express your concerns.

2. Join a patients advocacy group and work to save the NHS.

3. Propose resolutions in support of the NHS and against Lansley’s bill in your professional association, trade union, community group, political party branch, women’s group or students group, and send them to national bodies and members of Parliament.

4. Sign a petition:

Save Our NHS

Stand Up for the NHS

International Women’s Day: what happened

I want to acknowledge the many demonstrations that took place on International Women’s Day last week around the world, which were reported after my last blog. That includes:

i) a brave women’s demonstration in Côte d’Ivoire commemorating the killing of seven people the week before by voted-down president Gbagbo’s troops. Those seven were themselves marching to call on Gbagbo to stand down after he lost the recent election.

ii) the Million Women march in Cairo, calling for amendments to the constitution because it doesn’t give women the right to run for presidential elections, and there are still no equal rights for women in Egypt. The march ended in violence but it also led to a new federation for women being formed, to ensure that women are involved and represented in policymaking in the new Egypt.

iii) On March 12, 2011, 250 Palestinian & Israeli Women human rights defenders marked the centenary of International Women’s Day with a historic conference in the West Bank on Civil Disobedience.

Amnesty International today called on the Iranian authorities to release immediately all women detained arbitrarily in Iran, including political activists, rights defenders and members of religious and ethnic minorities. Highlighting the cases of nine women prisoners of conscience submitted to the UN Commission on the Status of Women in August 2010 under its communications procedure and published today as a ten-page document, the organization deplored that despite the calls for their release or for charges against them to be dropped, Hengameh Shahidi, Shiva Nazar Ahari, Alieh Aghdam-Doust, Ronak Safazadeh, Zeynab Beyezidi, Mahboubeh Karami, Behareh Hedayat, Ma’soumeh Ka’bi, and Rozita Vaseghi are all either imprisoned or facing imminent imprisonment…”