Accepting the global reality of “self-help” abortions

20/07/2015 § Leave a comment

Taking medical abortion pills at home to have an abortion, mostly before ten weeks of pregnancy, though not always, is happening in most countries across the world, and each year more than ever. It is happening both in countries where terminating most pregnancies is still a criminal offence and registered abortion services are not available, and also increasingly where legal abortion may be available but is very expensive, and/or fraught with barriers and burdensome requirements, and/or requires travelling a long distance for services, including having to cross a border.

The fact is that almost all abortion laws and policies, and most health services, are way behind the times in acknowledging that early abortion with mifepristone + misoprostol is both easy and safe ‒ so easy and so safe that women are sharing information with each other on how to do it, bypassing formal service delivery and doing-it-themselves. Moreover, other women ‒ and a growing number of health professionals ‒ are helping women to self-induce abortions, giving them simple instructions based on proven guidance on how to do it and advising them to have somewhere to turn if they are worried or need help.

The permutations of how this plays out in different settings are worth spelling out.

In countries where there are almost no legal abortions, women buy the pills from pharmacies, street drug sellers, and the internet. They may have been given good information from a health professional or someone else on how to use the pills, or not. But use them they do, and although there is no way to obtain accurate data on how many do so, nor the extent to which they have had complete abortions, the numbers are probably in the millions internationally, annually.

Many of these women make their way to hospitals or doctors after self-inducing their abortions. Unlike those who have used an unsafe method (drinking a poisonous substance, inserting a twig or coat hangar into their uterus, or throwing themselves down the stairs), they do not present with the well-known range of serious complications ‒ sepsis, haemorrhage, uterine rupture or other major organ damage ‒ as were the only option in the past and killed many women. No, very few of those who have used misoprostol alone ‒ because mifepristone was not available, which means the method is less effective ‒ have a major complication. However, they may have an incomplete abortion unless they know the formula for taking additional doses of misoprostol until they are sure the abortion is complete. Some get frightened in the process, since they are often doing this alone, and they seek help when what they needed most was reassurance.

In places like Poland and Ireland and Northern Ireland, for many decades now, women have been crossing their national borders in large numbers to obtain legal abortions. However, it is now becoming well known that medical abortion pills can be obtained via the internet from trustworthy suppliers ‒ e.g. Women Help Women and Women on Web ‒ who provide them with accurate information, based on WHO guidelines, send them the pills, and are there for advice afterwards if required. Hence, more and more women are obtaining information and the pills that way. And they are having their abortions at home ‒ safely. From these two internet providers both mifepristone and misoprostol are available, and with the combination of these two medications, which is much more effective, the complete abortion rate up to 9-10 weeks of pregnancy is around 98% ‒ or higher if used even earlier.

In the past 5-10 years, in order to help women find this information, safe abortion information hotlines have been set up in a growing number of countries where abortion is legally restricted. These have been started mainly by women’s rights activists, who maintain a free phone line that women can ring and get information on how to do an abortion safely. These hotlines are found in Latin America, sub-Saharan Africa, and Asia. They work with each other across countries and regions and with other groups doing women’s rights work. They use public meetings and statements, blogs, text messaging, social media and graffiti to publicise their existence. They often have manuals, leaflets, and videos that have been written for women in their own languages, often using visuals to make explanations clear. Because they supply information but not pills, they are not doing anything illegal.

This situation is not always rosy or ideal, and all of us involved in supporting the legitimacy of self-help abortions know that well. For one thing, everywhere abortion is subject to criminal law, prosecution is always a risk. For another, where abortion is legally restricted, the pills may only be obtainable on the black market, which makes it hard to find them and means they can be very expensive. In addition, it is important to be aware that the quality of pills sold on the internet by dubious sources is a major issue, as there are many, many websites offering the pills that are not trustworthy. Such pills may or may not be of a high quality, or they may contain only small amounts of the medications. Some may even be completely fake and totally ineffective. Moreover, if they are not vacuum sealed in blister packs they may lose their effectiveness in transit. Hence, the source of the pills is crucial. Some safe abortion hotlines, knowing this, have helped pharmacies to stock the right pills. In at least one case, a group has even started their own pharmacy.

Nevertheless, even though this situation is far from ideal, it is the best alternative in what is not the best of all possible worlds. The numbers of deaths from complications of unsafe abortion have been falling rapidly in the past ten years around the world ‒ not because the laws have been substantially changed and safe services set up across the global South, where more than 90% of the deaths have been occurring in the past 20 years, but because women have taken a safe abortion method into their own hands.

This reality is well-known in the global South, particularly in urban areas, but it has been ignored where the legal practice of abortion is the norm, e.g. in North America, Europe or Australia. This benign neglect is changing rapidly, however, because women in the global North are also starting to avail themselves of medical abortion pills via the internet and bypassing their health system and its costs and controls altogether. Cases that have emerged to date have mainly been of women who are too late for a legal abortion, or are poor and cannot afford a clinic, or who live in rural areas where services are scarce or non-existent, or who are migrants from countries where self-use of abortion pills is common. Unfortunately, these women sometimes seek medical help after self-inducing and that is how the trouble has started.

Many health professionals don’t like the idea of women taking the means of abortion into their own hands, even if they themselves are not willing to help women in the first place, and like some of their brethren in Central America and elsewhere, they are reporting women to the police. Even in India, where so many abortions remain unsafe because the government has failed to make services accessible in spite of a liberal law dating back to 1972, the widespread self-use of abortions pills is suddenly being vilified. In the USA, UK and Australia more than once already, the justice system is responding by bringing the full force of the criminal law down on the heads of those who have been “caught in the act”. They have finally noticed that self-help abortion is not just a “third world” issue.

In Ireland, about five years ago, a Chinese woman who owned a pharmacy was caught selling medical abortion pills she had brought in from China. Luckily for her, she was fined but not jailed.

In Northern Ireland this year, more than 200 people wrote a public letter stating they had purchased medical abortion pills through the internet ‒ in solidarity with a woman who had done so for her daughter, and who was caught and is awaiting trial. A woman in a rural area of Pennsylvania, USA, was also jailed 9-18 months for purchasing pills for her daughter, even though there were no abortion providers anywhere near where she was living.

A young couple in Australia were also caught after purchasing and using the pills and both were charged. However, their defence successfully argued that the pills are not a “noxious substance” but rather WHO-approved essential medicines, and the couple were let off. A woman in Idaho, USA, was similarly charged and using this same argument, also successfully argued that it was unconstitutional for her to be prosecuted. A recent case to come to light is a woman in Georgia, USA, who took misoprostol, purchased allegedly from Canada, and had a miscarriage in her car (she was some 22 weeks pregnant) and had to call for help. She was initially charged with murder, a charge that was withdrawn within 24 hours because under current Georgia law, this charge did not seem to be permitted.

In the UK, about three years ago a woman who sought an abortion beyond the 24-week time limit, and was turned down for help by three clinics, successfully purchased medical abortion pills through the internet and terminated her pregnancy. She was reported when she did not turn up to deliver the baby, was charged and sentenced to eight years in jail by an anti-abortion judge, a sentence that was later reduced on appeal to “only” three years. She was not charged with infanticide under a 1929 UK law, which would have carried a much longer sentence, only because the fetus was not found.

Also this year, a woman in a London ayurvedic shop was caught selling medical abortion pills when women who had purchased them went to hospital for treatment after using them. She was sentenced to 27 months in prison. One can only hope an appeal will reduce this sentence as well. In this case, the charge was again to do with the sale of a “noxious substance” under an 1861 law that is still on the statute books in the UK, as in Australia and probably many other former British colonies. A spokesperson for the Medicines and Healthcare Products Regulatory Agency, the agency that investigated the case with the police and brought the charges, was quoted in an article describing the case to say: “Selling mifepristone with no medical qualifications is illegal and can be extremely dangerous for patients. If you require medical advice, we recommend you visit your GP, as a healthcare professional is best placed to advise you.”

This “hook” of using the noxious substance line from the 1861 Act to hang criminal charges on and sentence women to prison, wilfully ignores the fact that mifepristone and misoprostol are not noxious substances. Medical abortion pills, used both legally and illegally, with medical involvement and without it, are reducing, not causing deaths and complications.

The real message from those who are prosecuting women is: Get back in line! You are not permitted to be in control here! The real offence in their eyes is having had an abortion “outside the system”.

In Ireland, the “new” abortion law, which has allowed a handful of abortions so far (the pathetic sum of 26 in 2014) also created a prison sentence of up to 14 years for having an abortion inside the country but outside the system, was meant I assume to warn women in thinly veiled terms not to purchase pills over the internet.

These prosecutions are both very threatening and at the same time frankly absurd. Nothing is going to stop medical abortion pills from being manufactured, distributed, purchased and used widely on a global scale. It is already happening. It has been happening since at least 1988 in Brazil, and the practice spread like wildfire from there because it is meeting a need among the one in three of the billions of women on earth who need an abortion in their lifetime.

Countries in both the global North and the global South need to recognise this and act rationally and reasonably in response ‒ in a way that is to women’s benefit, not to punish them.

The evidence exists for all to read that the use of medical abortion with mifepristone + misoprostol from the point soon after a woman first misses her period is both extremely safe and very effective. Why make women wait weeks or months because the health system is fraught with hurdles and delays that make women wait and then have to beg for permission?

Criminalising safe, self-help abortions and the people who make them possible is not the answer. What is the answer is bringing the reality of safe medical abortion into health systems and abolishing the criminal laws against abortion in every country. Contraceptive information helplines have been funded by governments for years. It is time to fund safe abortion information hotlines and let women buy medical abortion pills over the counter and have abortions as early as possible in the privacy of their own homes.

At the same time, health systems need to continue to ensure help is available when needed, and that there is a safe space for women to have abortions in a primary care setting when home is not a safe place, and when women are beyond 10 weeks and safety means being in a clinic. It must also not be forgotten that not all women are organised or aware enough to have abortions early, and others have medical conditions (including fetal conditions) that lead to the need for wanted pregnancies to be terminated, often well into the pregnancy. Instead of demonising women in any of these situations, health systems must ensure that first and second trimester abortions continue to be available in the health system for those who need them.

For details of the cases mentioned in this blog, see the newsletter of the International Campaign for Women’s Right to Safe Abortion, 20 July 2015. To receive the newsletters, join the Campaign: http://www.safeabortionwomensright.org 

To sign the petition calling on the Northern Ireland government to drop the charges against the woman who bought medical abortion pills for her daughter: www.thepetitionsite.com/takeaction/716/597/066/

Berer Blog statistics

20/07/2015 § Leave a comment

Readers of this blog might be interested to know that it has been viewed by people from 86 countries, ranging from 1 per country to 435 from the UK. The numbers of posts and views since it started have been as follows:

2011  15 posts    1,432 views

2012  26 posts    4,346 views

2013   7 posts     4,653 views

2014  10 posts    1,637 views

2015   8 posts     1,422 views to 20 July

Cheers! Marge

Global Strategy for Women’s, Children’s and Adolescents’ Health: A Comment on the new Zero Draft for the Post-2015 Agenda

18/07/2015 § Leave a comment

(This blog was first published on BMJ Blogs on 22 June 2015.)

This week in New York, the Zero Draft of the Outcome Document of the Post-2015 Development Agenda ‘Transforming Our World,’ will be negotiated at the United Nations (UN). The document provides the main framework for the Post-2015 Development Agenda that will be adopted during the UN Summit in September. A Post-2015 Women’s Coalition, coordinated by the Center for Women’s Global Leadership in the US (http://www.post2015women.com), has been contributing to the development of these frameworks in support of a comprehensive gender equality strategy which is inclusive, addresses inequalities, and is accountable to all. While the Outcome Document does highlight women’s rights and gender equality prominently, it is not a given that this focus will remain, since women’s rights are often used as a bargaining chip and dropped during negotiations.

Moreover, according to the Post-2015 Women’s Coalition, the Zero Draft of the Outcome Document falls short of ensuring the universal realisation of women’s and girls’ human rights as a core principle. Other important criticisms of it by Coalition members are that it creates only voluntary follow-up mechanisms, which are disconnected from existing human rights monitoring mechanisms, and its restricted targets and indicators fail to capture the ambition needed for transformative change (The Zero Draft for Post-2015 Development Agenda contains gaps on key feminist issues, 17 June 2015. http://www.awid.org/node/3574).

Equally problematic are omissions in the 2015  Zero Draft of the Global Strategy for Women’s, Children’s and Adolescents’ Health, which will feed into the final Outcome Document as regards women’s and children’s health. Its authors claim it is based on stakeholder consultations with over 4,500 participants, that subsequent drafts will reflect updated content from working papers and further consultations, and that a consensus process is underway to finalise its goals and targets (Global Strategy for Women’s, Children’s and Adolescents’ Health: Zero Draft for Consultation, 5 May 2015). But will it call for sexual and reproductive health and rights?

The UN Secretary-General, Ban Ki-moon, launched the first Global Strategy for Women’s and Children’s Health in 2010, in order to focus attention on the lack of progress towards Millennium Development Goals 4, 5 and 6 (to improve child and maternal health and combat HIV/AIDS, malaria and other diseases) and highlighted how these goals also play a role in the other MDGs. That first Global Strategy called for urgent increases in resources and coordinated efforts to accelerate progress for women and children, and it specifically identified safe abortion as an essential intervention for women. Yet in its 2015 iteration, no longer in the hands of Ban Ki-moon, the focus on women has been reduced to a focus on maternal health only, reverting back to the narrowness of MDG 5, anchoring the needs of women to childbearing.

I applaud the many people who put so much effort into documents like this, but a far greater commitment to democratic representation of women’s proven needs is called for. Women are far from just mothers, and neither adolescents’ health nor women’s health can be reduced to maternal health. Unless they are amended substantially, these documents will take us back several generations. Improving maternal health in isolation, and tying women’s health needs to those of infants and children, failed women during the 15 years of the MDGs, and will continue to do so.

The 2015 Global Strategy for Women’s, Children’s and Adolescents’ Health only mentions abortion once, referring briefly to unsafe abortions among adolescents and the potential for reducing unsafe abortion through the use of contraception. This is a major omission and is particularly disturbing given that the 2010 Strategy did call for abortion to be made safe. It is critical that the key stakeholders in this process demonstrate their support for explicit inclusion of women’s right to safe abortion in the strategy.

Along with the 20 prominent individuals and over 60 international and national NGOs who signed the “Joint statement on the importance of including safe and legal abortion as a key approach in Round 2 of the Global Strategy for Women’s, Children’s and Adolescents’ Health” on 1 June 2015, http://www.ipas.org/~/media/Files/Joint-Statement-on-Zero-Draft-Global-Strategy.ashx), initiated by Ipas, the International Campaign for Women’s Right to Safe Abortion is concerned that the Zero Drafts of the Outcome Document and the Global Strategy for Women’s, Children’s and Adolescents’ Health fail to address sexual and reproductive health and rights adequately, and in particular, fail to make any call for women’s right to safe abortion.

Fertility control is essential to the earth’s future and safe abortion is essential to fertility control. Abortion needs to be decriminalised globally as an integral part of sexual and reproductive rights. If documents purporting to be about gender and women’s rights do not reflect this, then, I’m sorry, they do not support women’s health.

Upwards of a million women have died from unsafe abortions internationally since the Programme of Action of the International Conference on Population and Development was approved in 1994. Although the death rate has fallen a lot since 1994, it is mainly because women have taken the law (and medical abortion) into their own hands. The Programme of Action was passed only with a fatally compromised position on safe abortion, but 20 years on, this compromise should not remain written in stone. The world has moved forward on this issue ‒ and so have women themselves. 42 million women have abortions every year, and half of them are still unsafe.

The International Campaign for Women’s Right to Safe Abortion has members in 21 African countries, 20 Asian countries, 6 Pacific countries, 11 Central and Eastern European countries, 19 Latin American and Caribbean countries, 8 Middle Eastern/Mediterranean countries, 14 Western European countries and both North American countries. These more than 900 organisations and individuals are the voice of women internationally on this issue. Maternal health demands that every mother should be a willing mother. The sustainable development goals need to call for women’s right to safe abortion ‒ to reduce maternal deaths from the complications of unsafe abortion, to ensure access to safe, legal abortion on request as a legitimate form of fertility control ‒ and as a public health, gender equity and human rights issue.

UK Parliamentary Hearing on Population Dynamics in the Post-2015 World – urbanisation, migration, climate change and conflict – 12 March 2015

12/07/2015 § Leave a comment

Proposed questions and responses from Marge Berer

  1. You suggested in your RHM editorial May 2014 that we need to start thinking very differently about ‘population’. What did you mean by this?

What I meant were several things: 1) that given the growing risk of disasters arising from climate change, Hanna Zlotnik, a long-time expert at the UN Population Division, said in 2011 in a conference in London about Population and sustainability issues that in 50 and 100 years from now, population growth and its consequences may no longer be the main population-related issue to confront but rather that huge numbers of people may be killed in natural disasters, reducing population levels enormously. Almost no one seemed to hear her. Consider for example just in the last few years the after-effects of the tsunami in Thailand, the tornado-related storms in the Philippines, the nuclear power station disaster in Japan  ‒ yet these are just the dress rehearsal.

2) To put it in another way, the future of human life on this planet is at stake. The planet will survive, but the question is: will we? Already, many species of animals are becoming extinct. On 6 March the Guardian letters page was all about threats to global food security. The meaning of sustainable development to me is about making changes that will ensure the future of human life beyond the next few generations. That includes in industry and economic production, food and energy production and consumption, and reduction in pollution and waste. Yet much of this is considered a minor irritant on the political agenda; only the Green Party and a few NGOs like Greenpeace take it seriously enough here in the UK, and the media give it far too little attention. It’s good that Alan Rusbridger has finally decided the Guardian will begin to do so, I hope it makes a difference. I believe these issues need to become a major focus of national and European Parliaments and the UN system.

  1. Can you expand on your comment that family planning did not save the world in the 1960s and will not do so again now?

I said this because I do not believe that reducing population growth by greater use of contraception is “the answer” to sustainable development. It is not. Fertility control is crucial for both men and women. Keeping fertility rates low in countries which have achieved low fertility is crucial. Like Britain. So why is our FPA getting almost no funding anymore? They are a shadow of what they used to be. Education for Choice had to close because it couldn’t get funding. So I recommend that you try to ensure the government prioritises funding for groups like them again.

Reducing fertility rates in countries with above replacement fertility levels, i.e. most middle-income countries, or high fertility, as in the poorest countries, is equally important. But it is also important to recognise that the total fertility rate globally by 2005 was already as low as 2.6, that is, near the replacement level of 2.1, and it has fallen further since then. In the more developed countries it was already well below replacement at 1.6 by 2005. And although in the least developed countries (which are only 18% of the global total) it was 5.0,[1] that is far lower there than it was even 20 years ago.

“Development is the best contraceptive” ‒ was the slogan of the global South at the first ICPD in 1974, because development was not being prioritised enough. So my second recommendation is definitely to support the delivery of contraception to everyone who wants it, but also to ensure women are given a choice of method and supported to use it because the drop-out rate is still high, and that targets and coercion should not be permitted. At the same time, contraceptive use alone will not take care of the environment and development, nor will it erase the problems of gross inequality that we face on the earth today, nor reduce poverty on its own.

Let me stress also that there are almost 44 million abortions globally every year which cannot be ignored. I consider abortion a legitimate health service for women, not a problem. But half of all abortions are still illegal and unsafe. That is unacceptable. So I have to ask why everyone is not more critical of those who promote contraception but are anti-abortion and of the target of getting 220 million women on contraception by 2020. I thought we had dealt with the risk of abuse arising from targets and incentives in the 1980s ‒ these gave family planning a bad name then and could do so again. It wasn’t just the focus of ICPD on sexual and reproductive health that took the focus away from family planning; it was coercive practices and the failure to ensure informed choice and consent that did it.

  1. Would you like to explain in a bit more detail your suggestion to ‘re-conceptualise’ family planning?

I said this because we still underestimate how much access to the means of fertility control has changed how people see having children. Most people want fewer children and a growing percentage want no children at all. With total fertility at less than two children, women spend only 1-2 years of their lives pregnant. Many women are postponing first births until their late 20s. Over 60% of women born in 1965 in England & Wales were childless at age 25. So the need to prevent pregnancy covers many years, starting in adolescence. The rest of the time, people are not planning their family, but managing their fertility. The phrase “family planning” is not what is going on. What is going on is the wish to have sex without fear of pregnancy or sexually transmitted infections. If programmes were based on this fact, there would be far fewer unwilling mothers and fathers, especially among adolescents who, in many countries, are still not allowed to access contraception.

  1. In a footnote you highlighted some negative consequences of below-replacement fertility. Can you expand on this?

Below-replacement fertility is, in my opinion, a very good thing. Few countries put enough resources into jobs, housing, education for their young, health services, money for benefits for the poor, or pensions for older people. However, below-replacement fertility makes a lot of governments very nervous ‒ Russia, Iran, Turkey are examples. Countries see a growing population as a symbol of status and power among nations, necessary for economic growth, or for having enough men to fight wars, and so on. Racism prevents many low fertility countries from encouraging in-migration from countries with high fertility. Instead, countries try to increase birth rates by restricting access to safe abortion, contraception and sterilisation, as well as offering positive incentives, as in France. Global education on this issue and why below replacement fertility is a good thing for sustainable development and the environment is badly needed.

  1. What are the main obstacles to expanding family planning and sexual and reproductive health and rights laws/policies and services at a global level and in particular developing countries?

The main obstacle is misogyny, and the fact that so many men are unwilling to give up their power over women and over women’s sexuality and reproduction.

The second is the anti-choice movement. Abortion is a major method of fertility control: one in three women in Britain has had an abortion and yet we have a very high contraceptive prevalence rate. It’s past due time to stop treating abortion as less acceptable than contraception. Efforts to make even some abortions illegal should be buried in the history books.

The Vatican and the Catholic church are the world leaders in opposing safe abortion and family planning, and I believe they have encouraged anti-women fundamentalism and a conservative backlash against women’s autonomy among other conservative religious as well, serving as an example of how to gain political power. I have just been reading Good Catholics,[2] which is a history of the extent to which the Vatican and Catholic bishops in the USA have gained political power, not only to influence national politics but also to influence who stands for election, and who wins and loses. I think it should be required reading for politicians, and that the ethics of these actions must be challenged.

My last recommendation to you as Parliamentarians is to stregthen your own APPG, support the European Parliament’s SRHR group, who made an important commitment to safe abortion a month ago in Brussels, and try and get our Parliament to agree that sexual and reproductive health and rights are crucial for the wellbeing of the whole population.

References

[1] Prof. Hans Rosling. www.gapminder.org .

[2] Patricia Miller. Good Catholics: The Battle over Abortion in the Catholic Church. University of California Press, 2014.

________________

These perspectives are spelled out in more depth in my editorial: The sustainable development agenda and unmet need for sexual and reproductive health and rights. Reproductive Health Matters 2014;22(43):4‒13. http://www.rhm-elsevier.com/article/S0968-8080(14)43775-3/pdf

New beginnings: farewell but not goodbye!!

12/07/2015 § Leave a comment

The November 2014 RHM journal was my last as RHM’s editor, and I stayed on this year until 30 April to support Shirin Heidari as the new editor during a transition period, edit some of the papers in the May 2015 journal for her, and write a farewell editorial. My best wishes go with Shirin! I hope everyone will give her their full support in continuing to make RHM a critical journal for the field as the world moves into the post-2015 agenda, a period when continuing support for sexual and reproductive health and rights is and will remain crucial.

It’s hard to believe that it’s been 23 years and leaving has been very hard. But I am proud to have been RHM’s founder and editor ‒ with (more than) a little help from my friends! Moreover, there’s no need to say goodbye, as I’m not disappearing. Far from it; I’ve never felt more like engaging with the issues, and I’ll be doing so as an advocate, writer, editor and lecturer.

In these last few months, I’ve returned full-time to my roots as an abortion rights advocate to become the Coordinator of the International Campaign for Women’s Right to Safe Abortion, which I also helped to found in May 2012 and have been the listserve editor for ever since.

The Berer Blog has followed me, and I plan to start writing it more regularly again. So farewell, but not goodbye!

With best regards,

Marge

New email: info@safeabortionwomensright.org

This is an excerpt from my farewell editorial for RHM45 May 2015, Doi: 10.1016/j.rhm.2015.07.001

Compelling arguments for developing new post-fertilisation methods of birth control

11/07/2015 § Leave a comment

A 2013 article by Elizabeth Raymond et al[1] makes a compelling case for encouraging reproductive health researchers to develop new post-fertilisation methods of birth control. As she points out, post-fertilisation can cover the time periods both before and after implantation, which in every woman will not happen in the exact same number of minutes, hours or days. But as they argue, and Sally Sheldon[2] also discusses, the greater difficulty is not the scientific challenge but the political one.

Developing new and improved methods of contraception, emergency contraception and abortion has been one of the priorities of the UN’s Human Reproduction Programme (HRP),[3] based at the World Health Organization, for over 40 years now. HRP’s public sector research has had a huge influence on pharmaceutical companies’ research, production, sale and distribution of birth control and abortifacient methods.[4] Without their research and collaboration with the French company that developed mifepristone, for example, it is unlikely that medical abortion with mifepristone+misoprostol would exist, nor that work would have been done on effective regimens for using misoprostol alone for inducing an abortion.

While HRP are not researching post-fertilisation methods of fertility control, they are, according to their website,[5] working on a just completed “proof of concept” study on the use of a levonorgestrel pill that can be taken 24 hours before or after intercourse up to six times a month.[6] All praise to them for this ‒ a pericoital method that can be used more than once a month ‒ what a great idea!

HRP’s current research projects also include a study of three possible pain control approaches for medical abortion, and another on the burden and severity of complications related to unsafe abortion.[7] Might it be possible to get them to engage in new research on a post-fertilisation method or even a very early abortion method? After all, mifepristone and misoprostol have been around for 25 years now, and if we think about how much pre-fertilisation contraceptive methods have changed during that 25 years, perhaps the motivation to get back to the bench would increase.

Women are definitely interested. A recent survey of more than 1,000 women in Britain by Bpas found that 48% of women would consider a once-a-month pill to stop development of early pregnancy by detaching any fertilised egg from the lining of the womb. Only a quarter (26%) said they would not, with the remainder (26%) unsure.[8] Why take a pill every day if you could take one once a month ‒ and perhaps only if your period is late.

Meanwhile, the rest of us need to get to work on the political difficulties new methods like this might raise. As Sally Sheldon discusses, the legal difficulty is that such methods would not be considered contraception but would fall within current legal definitions of abortion, potentially limiting their approval by governments. Thus, in countries like Great Britain that define pregnancy as beginning at implantation, approving them would require a change in the law.

Which is only one of many good reasons why abortion should be treated like every other form of medical care, subject to approval, availability and use based on its public health benefits, safety and efficacy.

References

[1] Raymond EG, et al. Embracing post-fertilisation methods of family planning: a call to action. Journal of Family Planning & Reproductive Health Care 2013; 39(4):244-246.

[2] Sheldon S. The regulatory cliff edge between contraception and abortion: the legal and moral significance of implantation. Journal of Medical Ethics http://jme.bmj.com/content/early/2015/06/17/medethics-2015-102712.full

[3] UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP).

[4] http://www.who.int/reproductivehealth/projects/en/

[5] http://www.who.int/reproductivehealth/projects/contraception/en/

[6] http://www.who.int/reproductivehealth/projects/HRX3_Pericoital-levonorgestrel.pdf?ua=1

[7] http://www.who.int/reproductivehealth/projects/pua/en/

[8] http://www.reproductivereview.org/index.php/rr/article/1711/ .

A Quiet Inquisition

26/03/2015 § Leave a comment

A Quiet Inquisition

A film by Holen Sabrina Kahn and Alessandra Zek, Chicken & Egg Pictures, 2014 (65 min), in Spanish with English subtitles

A review by Marge Berer

This is a film about Daniel Ortega’s betrayal of Nicaraguan women. Made over a period of several years, this documentary film features the experiences of young, rural, pregnant women who arrive at a public hospital’s emergency room in Nicaragua, many of them adolescents, many as young as 13 years old, and anywhere from 16-17 weeks pregnant onwards, with life-threatening obstetric conditions.

These conditions range from placenta praevia in a twin pregnancy to advanced uterine cancer whose treatment might affect the embryo, to haemorrhage, sepsis and eclampsia. Some are miscarrying, some end up with stillbirths, and some have attempted unsafe abortions on their own. What happens to them in the hospital is shown through the eyes of a highly professional and highly caring obstetrician-gynaecologist, Dr. Carla Cerrato, who is often the first to arrive at the hospital each day and the last to leave. If there are 60 patients in a day, she says, she probably treats 30 of them and supervises three other doctors who treat the rest.

The story that emerges, as the film shows Dr. Cerrato helping one woman after another, is a familiar one by now from Central America, but also one that implicates the one-time superhero of the Sandinista revolution in Nicaragua, Daniel Ortega, who deposed a dictator and began to transform the country. However, when after many years he lost the presidency in an election, he sold out to the Catholic Church in order to obtain enough votes to win again in 2007. The payback, his betrayal of women, was to implement a total ban on abortion even when it is necessary to save a woman’s life ‒ even though Nicaraguan law had permitted therapeutic abortion for 130 years.

When the film opens, several women’s deaths are presented that occurred as a direct result of this law. Pregnant women with wanted pregnancies and serious but treatable complications were left untreated in their hospital beds by medical professionals too frightened to do anything to help. Why? Because although the pregnancies were nonviable, the law forbids terminating the pregnancy as long as a fetal heartbeat can be detected. The doctors involved are caught between implementing the medical protocols they had been taught, which unequivocally tell them to provide the treatment ‒ and an unjust law that forbids them to do so. Yet terminating the unviable pregnancy is the only way to hope to save the women’s lives.

We have published this story before ‒ Savita Halappanavar in Ireland at the end of 2012.[1] This is the Catholic Church’s so-called health policy, enshrined in law, which has a lot of pregnant women’s deaths on its hands.

The heroine of this film, Dr. Cerrato, a lifelong Sandinista supporter, a woman from a rural background who was only able to study medicine because of the Sandinista revolution and who still believes in the revolution and what the Sandinistas have accomplished ‒ but who condemns them on this issue. Her belief in the right of her patients to live, to get help in this hospital because the hospital is there to help them, shines out from this film from beginning to end. And she does help them, quietly and with great warmth and understanding ‒ every one of them ‒ a fact which only slowly emerges during the course of the film. But then one case comes up where she is going home for the weekend on the Friday and the young woman who comes in is bleeding, her life is at serious risk, the pregnancy is not viable, and she tells the resident to give the woman misoprostol to induce the pregnancy, but the resident doesn’t do it. The conversation among the medics in the absence of Dr. Cerrato is fraught; they don’t all support doing it, and the resident caves in. On Monday, when Dr. Cerrato arrives for work she learns that the young woman is still bleeding, and she gets so upset she’s sent home for a week with high blood pressure. In the interim, the young woman dies after lying for eight days untreated in her hospital bed.

The film is hard-hitting politically and heartwarming in equal measures in its portrayal both of the doctor and her patients. How long Dr. Cerrato will be able to go on saving these young women’s lives is the unanswered, breath-stopping question that dogs the entire film. No one is in prison in Nicaragua for illegal abortion, as they are in El Salvador, but that’s no guarantee for the future. Whether the hospital will be forced to let her go now that she has become known is perhaps a bigger risk. However, the film ends on a high note, with her reaffirming her commitment to her patients, come what may.

Like the film Al Jazeera made in 2014 about the young, rural poor women in El Salvador in prison accused of illegal abortion and homicide when they had only had miscarriages or stillbirths, this powerful film is important contribution to the continuing struggle to make abortion safe, which will only come about when pregnant women’s health and rights become more important to governments than the misogynistic ideology of the Catholic church hierarchy which condemns them to death. Don’t miss it!!

Shown at the Human Rights Watch film festival, 25-26 March 2015, in London.

Trailer: http://www.quietinquisition.com/#!video/cde1

To host a screening or bring the film to your University or organization, email: aquietinquisition@gmail.com

On general release for rental from 29 April.

[1] Berer M. Termination of pregnancy as emergency obstetric care: the interpretation of Catholic health policy and the consequences for pregnant women. An analysis of the death of Savita Halappanavar in Ireland and similar cases. Reproductive Health Matters 2013;21(41):9-17.

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