Caesarean section in the late second trimester as an alternative to a refused abortion: an unethical and clinically unjustifiable practice
17/02/2016 § Leave a comment
In 2013, I published a paper about the death of Savita Halappanavar in Ireland, who died completely unnecessarily from uterine sepsis during pregnancy. Her death was due to the refusal of the Catholic-run hospital providing her maternity care to terminate her 17-week non-viable pregnancy, apparently because there was still a fetal heartbeat. In that paper, I said that termination of pregnancy to save a woman’s life, which is legal in all but 5-6 countries globally, should be understood to mean “to prevent a pregnancy from becoming life-threatening before it is already life-threatening…One would have thought that that includes termination to complete an inevitable miscarriage and to end an unviable pregnancy, both of which could easily become septic ‒ as well as termination when the woman has or develops a life-threatening illness while pregnant.” 
In that paper, I was concerned only about unviable pregnancies and saving the life of the woman involved. I did not take into account what I believe is a newly developed policy among some Catholic physicians to act to save the life of the fetus, not just the woman, as their main or only basis for action. Since 2012, several new cases have come to light that suggest what appears to be a new way to refuse a woman an abortion before the pregnancy goes to term or ends spontaneously in a miscarriage.
These are cases where the pregnant woman (or girl) is not seen to be at immediate risk of dying, is kept in hospital until such time as the pregnancy is viable in the late second trimester, and is then “offered” or forced to have a caesarean section as an alternative to carrying the pregnancy to term ‒ in order to “save the unborn baby”. Ironically, as far as the baby is concerned, the earlier in pregnancy it is delivered, the more risk there will be to its life. The failure of the anti-abortion proponents of such a policy reveals not only how little they value the life of the girl/woman involved but also how profoundly uninterested they seem to be in whether the “unborn baby” has the best chance of staying alive, let alone being healthy.
This paper describes five such cases, from Costa Rica, El Salvador, Ireland, Paraguay, and most recently a bill tabled in February 2016 in the Alaska USA state legislature.  It argues that the denial of the abortions concerned is unethical, violates a woman’s right to health, and deserves to be condemned just as much as cases in which the woman is left to die rather than being allowed an induced abortion. The Alaska bill requires doctors to terminate pregnancies in such a way that the fetus has the best chance to be born alive.
Two cases from Costa Rica: old style vs. new style
Two cases from Costa Rica show how the change in practice has manifested itself. In 2007, a 27-year old Costa Rican woman with an anencephalic pregnancy was refused an abortion and forced to carry the pregnancy to term. After seven hours of labour, she gave birth to a dead baby. According to a report by the Colectivo por el Derecho de Decidir in Costa Rica, as a result of this experience she was still fighting depression, anxiety attacks, chronic diarrhoea, and social withdrawal in 2013. 
In 2012, “Aurora”, also from Costa Rica, was a very different case. The Colectivo por el Derecho de Decidir reported  that Aurora, aged 32, became pregnant after months of trying. However, at eight weeks of pregnancy, the doctors informed her that the fetus had multiple severe malformations that would not allow it to survive outside the uterus, including severe scoliosis, decreased level of amniotic fluid, and a complete absence of abdominal wall, which meant the internal organs (e.g. liver and intestines) were sitting outside the body. Further tests confirmed the diagnosis of a non-viable pregnancy. A little after her first appointment, Aurora started experiencing strong abdominal and back pain that prevented her from working and seriously affected her physical and emotional health. She described “in addition to the physical pain, the stress and suffering resulting from the news, which has provoked constant sadness, depression, severe stress, insomnia, nightmares, and constant tears”. She requested an abortion numerous times. However, the medical professionals and medical authorities in Costa Rica repeatedly denied her the right to a therapeutic abortion, even though it is permitted under Costa Rican law, Article 121. When she was 29 weeks pregnant, her waters broke, and then she was “allowed” to have a caesarean section.
The offer or rather imposition of a caesarean section on a woman who has asked for an abortion, following the denial of the abortion, is a new phenomenon, and it is happening in more countries than just Costa Rica.
A case in El Salvador
Abortion is illegal in El Salvador, even to save the life of the woman. In June 2013, “Beatriz”, 22 years old, underwent a caesarean section at 27 weeks of pregnancy, giving birth to a baby without a brain,  who died five hours later.  The previous week, having delayed a decision, the country’s Supreme Court had refused to allow an abortion for Beatriz. Her plight drew international attention and a ruling from the Inter-American Court on Human Rights, which said that El Salvador should protect her life and help her to end the pregnancy. As far as the Health Ministry was concerned, that is what they did. The Health Ministry said it would allow a caesarean section because the pregnancy was already at 26 weeks, and the country’s strict abortion laws (which it seems do not consider an abortion to be an abortion by that stage) were no longer at play. Thus they felt they had done what the Human Rights Court asked. This is not the case.
A caesarean section is not an induced abortion even if it terminates the pregnancy. One of the main aims of a caesarean section is to deliver a live baby as a form of emergency obstetric care ‒ unless the baby is already dead. Ensuring the woman survives the pregnancy is the other aim, of course.
In early April 2013 doctors advised Beatriz that continuing her pregnancy was very high risk, so she requested an abortion.  Yet the Health Ministry was reported as saying it could determine what was most medically sound for “the mother versus the unborn baby”, and a news report at the time claimed they were lauded internationally for working to save her life, though lauded by whom is not clear. “Doctors at the Maternity Hospital,” it was reported, “had been preparing to perform the c-section at the slightest danger signs to save Beatriz’s life, said Maria Isabel Rodriguez of the Health Ministry. A majority of judges on the high court rejected the appeal by Beatriz’s lawyers, saying physical and psychological exams by the government-run Institute of Legal Medicine found that her diseases were under control and that she could continue the pregnancy.” 
Beatriz was as good as imprisoned in the hospital and unable to care for her 20-month-old son for some two months while this went on. Compounding the emotional stress during her hospitalization, anti-choice groups managed to contact her by phone to attempt to convince her to change her mind about requesting an abortion. They offered to move her from the under-funded and overcrowded public maternity hospital to an exclusive private hospital, which they described as equivalent to a five-star hotel, and to take care of all her expenses. The most inhumane episode occurred when an anti-choice group brought Beatriz a basket of baby clothes, including small knitted caps to cover the head of the unviable fetus she was carrying. 
The Health Ministry’s claim that she was in safe hands was patently false and their description of the c-section as a “premature delivery”, when the baby had no chance of survival, was appalling.  What could possibly have gone on in the minds of people working in health who were so dismissive of this woman’s life, let alone her physical and mental health and well-being? Why did they consider they owed a duty of care to a fetus that had no sentience, no life and no chance of life?
A clue to their answer may be found in a comment made by an anti-abortion spokesperson who claimed that “the rights of all had been respected”, and that “it wasn’t necessary to perform an abortion, the point was to respect the baby’s life and to give Beatriz the care and the right to health that she deserved.” 
In fact, three months after the caesarean section, Beatriz was struggling daily with poor health resulting from the denial of an early abortion, while trying to rebuild a life for herself and her son in a poor rural area. Although she was holding her own when she was interviewed by RH Reality Check, her future, both short- and long-term, was uncertain because of permanent health problems, including aggravated lupus and kidney disease.  Where was the hospital and the anti-abortion movement for her then?
Forcing a woman to deliver a live baby against the woman’s wishes: Ireland
In Ireland, under the new law brought in following Savita’s death, the only time a woman can legally have an abortion is if her life is at risk.
Ms Y: the cruellest story of them all
Ms Y, a young asylum seeker, had been raped in her country of origin and found she was pregnant when she was about eight weeks gone, not long after arriving in Ireland. She immediately expressed a desire to die rather than bear the rapist’s child. She was referred to the Irish FPA for help to go to England for an abortion but although the details of what happened are not clear, it must have taken some 8 weeks to try and arrange everything, and by then she would have had to pay for a second trimester abortion. The cost was too high and she could not afford it. At that point, being 16 weeks pregnant, it was reported that she attempted to take her own life. A friend advised her to go to her GP and get help. The GP referred her to a hospital, where she saw two psychiatrists and was then taken to another hospital. There she had a scan and was apparently told the pregnancy was 24 weeks and one day, as if such accuracy were feasible. They said they could not do an abortion that late. She said: “You can leave me now to die. I don’t want to live in this world anymore.”
After that, she said she was watched all the time, and she stopped eating and drinking. A doctor came and told her they would do an abortion in several days but that she had to start eating and drinking, so she did. Then, she was told the plan had changed and they couldn’t do it. This happened more than once until, finally, they claimed that because she was too far gone, they could only do a caesarean section. She said: “They said wherever you go in the world, the United States, anywhere, at this point it has to be a caesarean. [8,9] That was of course a lie, but she didn’t know that at the time.
A spokeswoman for the Health Service Executive (HSE), when asked about the allegation that Ms Y was not offered a right to appeal the decision to carry out a caesarean section, said her request for a termination on the basis of suicide risk had been acceded to. Her words were that “a pregnancy can be terminated by way of delivery through caesarean section, as it was in this instance.” Thus, caesarean section is magically turned into an abortion method, even though what they had done was to force her to accept the delivery of a live baby. Moreover, the spokeswoman said that as they had acceded to Ms Y’s request for a termination, there was no requirement for a review of what had happened. 
In short, they said they could not do an abortion, and then afterwards when they had forced her to accept the early delivery of a live baby, they claimed they had done an abortion. George Orwell would have been proud of the double-think.
Ms Y said: “When I came to this country I thought I could forget suffering… The scar [from the c-section] will never go away. It will always be a reminder. I still suffer. I don’t know if what has happened to me is normal… I just wanted justice to be done. For me, this is injustice.” 
Saving the life of the baby against the wishes of a pregnant child’s mother: Paraguay
The case of the 10-year-old girl in Paraguay made international news in May 2015. The girl was apparently sexually abused by her stepfather for something like two years and became pregnant. Her mother took her to the hospital when she complained of stomach pains, and it was only discovered then that she was 20 weeks pregnant. Her mother claimed she had previously reported the sexual abuse to the police, but they had done nothing. She requested an abortion for her daughter, but this was refused. Instead, the mother was arrested and charged with conspiring in the sexual abuse. The stepfather was found some days later and also arrested. The little girl was kept in hospital until she reached 26 weeks of pregnancy and was then subjected to a caesarean section. 
This case prompted a national debate in Paraguay about the prevalence of child sexual abuse and underage pregnancies, but the focus was it seems more on stopping adult sexual violence than the right of sexually abused girls to a safe abortion. The Guardian reported that the Clinicas hospital has recently reported almost 400 pregnancies in girls under the age of 16 years which they said had gone to term without complications. The gynaecologist in charge of the 10-year-old’s case said in a press release that he was surprised at the fuss because the previous year a nine-year-old girl had given birth. 
Nonetheless, the case led to a large demonstration in the country’s capital, Asunción, and other parts of the country, as well as a worldwide protest. For example, the UN Working Group on the issue of discrimination against women in law and in practice, composed of five independent experts from all regions of the world, made the following statement regarding this case:
“The Paraguayan authorities’ decision results in grave violations of the rights to life, to health, and to physical and mental integrity of the girl as well as her right to education, jeopardising her economic and social opportunities.
“Despite requests made by the girl’s mother and medical experts to terminate this pregnancy, which puts the girl’s life at risk, the State failed to take measures to protect the health as well as the physical and mental integrity and even the life of the 10-year old girl. No proper interdisciplinary and independent expert assessment with the aim to insure the girl’s best interests was done before overturning life-saving treatments, including abortion.
“According to the World Health Organization, child pregnancies are extremely dangerous for the health of pregnant girls as they can lead to complications and death in some cases, especially as girls’ bodies are “not fully developed to carry a pregnancy.
“In Latin America, in particular, the UN reports that the risk of maternal death is four times higher among adolescents under 16 years old with 65% of cases of obstetric fistula occurring in the pregnancies of adolescents. In addition, early pregnancies are also dangerous for the babies with a mortality rate 50% higher.” 
On 23 June 2015, it was reported that the doctors in Paraguay had finally acknowledged it would be too risky for this little girl’s health to allow her pregnancy to go to term.  Having refused to do an abortion, they too did a caesarean section when she was more than six months pregnant. Both children survived the operation. What the future holds for either of them is uncertain, especially if the girl’s mother is kept in jail.
Caesarean section as an alternative to a refused abortion: a coincidence or an emerging policy? Developed by whom?
Overall, I believe that the cases summarised here, even though there are only four, could not have happened coincidentally in such a short space of time. There is actual policy under Guidance for health professionals in the Irish Protection of Life during Pregnancy Act 2013 (clause 6.4), 19th September 2014. The text reads as follows:
6.4 Gestational age
“An important consideration in relation to the carrying out of the medical procedure is the issue of the gestational age of the unborn. There is no time limit imposed by the Act in carrying out the medical procedure. However, the Act legally requires doctors to preserve unborn human life as far as practicable without compromising the woman’s right to life. Therefore, there is no specific stage of pregnancy below which the certifying doctor will not have to consider the possibility of preserving the life and the dignity of the unborn where practicable without compromising the life of the mother.
“Once certification has taken place, a pregnant woman has a right to a termination of pregnancy as soon as it can be arranged. The clinicians responsible for her care will need to use their clinical judgment as to the most appropriate procedure to be carried out, in cognisance of the constitutional protection afforded to the unborn, i.e. a medical or surgical termination or an early delivery by induction or Caesarean section.
“Following certification, if the pregnancy is approaching viability, it is recommended that a multidisciplinary discussion takes place to ascertain the most appropriate clinical management of the case.”
This, in turn is in line with the 8th Amendment to the Irish Constitution, which is in line with Catholic health doctrine related to pregnancy, abortion and “protection of life”:
“The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right.” (Article 40.3.3°, Irish Constitution)
Taking this one step further, we can refer to a 2012 statement from the Standing Committee of the Irish Catholic Bishops’ Conference:
“Whereas abortion is the direct and intentional destruction of an unborn baby and is gravely immoral in all circumstances, this is different from medical treatments which do not directly and intentionally seek to end the life of the unborn baby. Current law and medical guidelines in Ireland allow nurses and doctors in Irish hospitals to apply this vital distinction in practice while upholding the equal right to life of both a mother and her unborn baby.” (Standing Committee, Irish Catholic Bishops’ Conference Statement, November 2012)
Cases have now “popped up” in four different countries within a few years of each other, when formerly this practice was completely unheard of. Is the main link between them, as occurred with cases like Savita’s, which was also not a unique case, a recent (and as yet unwritten) addition to Catholic health policy? I suspect that this policy was developed in order to avoid being held responsible for more deaths like Savita’s. However, as an alternative to forcing a woman to go to term after denying her request for an abortion, it “allows” an unwanted pregnancy to be ended earlier, but is nevertheless an abuse of the purpose of a caesarean section and of the woman’s decision not to deliver a live baby.
A c-section is an emergency procedure whose primary aims are to deliver a live baby to a live woman. Abortion is intended to prevent a live baby being born to a live woman. While the pregnancy is ended in both cases, these two procedures have nothing else in common. This policy, whoever thought it up, is a new, unethical form of imposing an unwanted medical procedure on girls and women to avoid providing an abortion. It is occurring in some of the same Catholic church-dominated countries and health systems where a safe abortion is practically unobtainable for all but rich women. While the USA does not fit this description, there are many anti-abortion politicians who would like to make it that way.
The recently tabled bill in the USA
It is likely that what appears to have been the individual treatment of a few women actually reflects or has become a new policy. That at least is what seems to have happened with the bill tabled in the Alaska USA state legislature this month, which contains a requirement that doctors terminate pregnancies “in a way that affords ‘the best opportunity for the unborn child to survive’ after the procedure, without jeopardizing the woman’s life” ‒ and at the same time also “mandates Alaska physicians to judge if a fetus is viable and outlaws abortion care in those cases”.  This bill has just been published.
It cannot be a coincidence that the language is so similar to the language in the Irish law and policy. Information about its intended clinical consequences is needed, and its implications need further analysis. The bill makes exceptions to the restriction in cases of incest or sexual assault, or if “the abortion is medically necessary.” Is it calling for pre-viable pregnancies to be aborted in such a way that the fetus can survive? Or does it intend only that in the case of viable fetuses, efforts to save the fetus must be made? In either case, doesn’t this inevitably mean by caesarean section?? Moreover, the bill says: “fetuses that are ‘born alive’ can be turned over to the state’s care under its ‘children in need of aid’ provision”. The implications are mind boggling.
There is no information that I know of, of who is behind these policies. They cannot be ignored, however, as they represent yet another twisted form of trying to deny women abortions.
I would welcome information from anyone who has any evidence of where this is coming from, or from anyone who has a different theory about why these cases have appeared, particularly now that this legislation has suddenly emerged in the USA.
- 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. http://www.rhm-elsevier.com/article/S0968-8080(13)41711-1/pdf.
- Knight Shine N. Alaska GOP: Doctors should try to save fetuses during abortions. RH Reality Check. 16 February 2016. http://rhrealitycheck.org/article/2016/02/16/alaska-gop-doctors-try-save-fetuses-abortions/?&utm_medium=email&utm_source=reality&utm_content=4+-+Alaska+GOP+Doctors+Should+Try+to+Save+Fe&utm_campaign=daily-enews-2-17-2016&source=daily-enews-2-17-2016.
- http://safe-abortion-womens-right.tumblr.com/post/39475005027/costa-rica-acci%C3%B3n-urgente-para-ayudar-a-aurora. 2 January 2013.
- Ill Salvadoran woman denied abortion has c-section. Associated Press, 3 June 2013. http://safe-abortion-womens-right.tumblr.com/post/53840867560/beatriz-in-el-salvador-has-a-caesarean-section.
- Baby born to El Salvador woman denied abortion dies after C-section, Guardian, 4 June 2013. http://www.theguardian.com/world/2013/jun/04/baby-el-salvador-woman-abortion-dies.
- Bougher K. El Salvador: no longer a front-page story, ‘Beatriz’ continues to struggle from denial of abortion care. RH Reality Check. 26 September 2013. http://rhrealitycheck.org/article/2013/09/26/no-longer-a-front-page-story-beatriz-continues-to-struggle-from-denial-of-abortion-careberate-in-salvadoran-society/.
- Berer M. Does a C-section make it OK for Beatriz in El Salvador? 01 June 2013. http://safe-abortion-womens-right.tumblr.com/post/53839227861/does-a-c-section-make-it-ok-for-beatriz-in-el.
- Holland K, Mac Cormaic R. They said they could not do an abortion. I said, ‘You can leave me now to die. I don’t want to live in this world anymore’. Irish Times, 19 August 2014. http://www.irishtimes.com/news/health/they-said-they-could-not-do-an-abortion-i-said-you-can-leave-me-now-to-die-i-don-t-want-to-live-in-this-world-anymore-1.1901258.
- Holland K, Mac Cormaic R. Woman in abortion case tells of suicide attempt. Irish Times, 19 August 2014. http://www.irishtimes.com/news/health/woman-in-abortion-case-tells-of-suicide-attempt-1.1901256.
- Paraguay march poised to draw record crowd after 10-year-old denied abortion. Guardian. 28 May 2015. http://www.theguardian.com/world/2015/may/28/paraguay-abortion-child-rape-protest.
- UN experts deplore Government’s failure to protect 10-year-old rape survivor. 11 May 2015. http://www.un.org/apps/news/story.asp?NewsID=50826#.VVGJZ9pVhBc.
- 11-year-old Paraguay girl ‒ denied abortion after rape ‒ pregnancy to be induced. 23 June 2015. http://www.telegraph.co.uk/news/worldnews/southamerica/paraguay/11694009/11-year-old-Paraguay-girl-denied-abortion-after-rape-to-be-induced.html.
16/01/2016 § Leave a comment
A response to all the articles on so-called “permanent contraception” in Contraception 2015;92(2):89-176)
It is with a deep sigh, after more than 10 years, that I sit down to respond to your articles on “permanent contraception”, particularly the one by Jack Lippes pushing quinacrine sterilisation, that dead letter, to the fore once again, in your August journal issue (Contraception 2015;92(2):89-176).
Dr Lippes whitewashes the history of why quinacrine was rejected as a female sterilisation method, rejected not only because of concerns about its carcinogenic potential but for many other reasons as well. Dr Jaime Zipper from Chile, who invented the method, would never be allowed today to get away with the “research” he carried out on women with quinacrine for tubal sterilisation in the absence of any pre-testing of the drug for safety, dosage or efficiacy ‒ before it was ever injected into a single woman. Women were treated like guinea pigs in his and other “research”, and no proper long-term work on safety or optimal dosage was ever completed. Not was the method in fact ever properly approved or registered in any country. There were only a handful of countries where quinacrine sterilisation was ever used, and even in those cases, it was always individual doctors who used it, while others carried suitcases full of quinacrine pellets across borders to share with them, e.g. in a remote rural area of India.
The early high failure rates Dr Lippes reports of 9-12% were indicative of the absence of proper research, since they should have led to a rejection of the method early on. The far lower failure rates shown in the studies in his Table 1 were all from very small studies except for one; most had too short follow-up periods and the findings were never confirmed in larger randomised, controlled studies. The very large study by Dr Do Trong Hieu of Viet Nam, published in the Lancet, in which over 30,000 women were subjected to the procedure, led to the closure of the programme in Viet Nam following a critical analysis of its findings. I was personally involved in creating an outcry about it at that time. (I will return to this below.)
The dismissal by Dr Lippes of the data on cancer risk arising from inflammation in rats, and indeed his whole article, is an example of how the proponents of quinacrine did then and continue to minimise the negative evidence and exaggerate the positive evidence to claim the method is safe.
Dr Lippes’s review of the literature ignores several articles I published in the early days of Reproductive Health Matters (RHM) and one in the BMJ almost ten years later. In 1993 in RHM, Amy Pollack and Charles Carignan examined the same evidence examined in Contraception by Lippes. They noted, for example, that in the Viet Nam paper, 20,000 of the 31,000 women in the total study sample were excluded from follow-up for pregnancy rates, and the finding in one province of 91 pregnancies out of 937 women was also excluded. A year after their article was published, concern was expressed by Ralph Heywood, consultant toxicologist to WHO in 1994, that more research needed to be done to exclude toxicological effects related to mutagenicity, teratology and persistence of the compound in tissues. He recommended that toxicological testing of quinacrine in animals should be done prior to any further clinical trials or any other provision of the method to women.3 Dr Lisa Rarick, the then Medical Officer at USFDA, also raised concerns, given the uncertain failure rate, that a quinacrine failure might increase the risk of ectopic pregnancy.3 Yet despite this published concern, a number of individual doctors continued to promote and perform quinacrine sterilisations ‒ e.g. in rural India and Pakistan. I asked what should be done when consensus views are ignored or rejected by individual providers. The question still holds. A year later, and following a further statement on toxicity and quinacrine by Ralph Heywood, quinacrine sterilisations were still being done in Chile too, led by Dr Jaime Zipper, but challenged by the Foro Abierto de Salud y Derechos Reproductivos (Open Forum for Reproductive Health and Rights). It was this and other feminist activism that led to the decision by WHO not to recommend quinacrine sterilisation of women to be continued, until far more rigorous examination of safety and efficacy was carried out.
But the problem of promotion of untested methods remains with us. In 2004, the BMJ published an article about a “clinical trial” in India evaluating the antibiotic erythromycin as a female sterilisation method, following the ban by India on the use of quinacrine for that use, due to safety and efficacy doubts. Quinacrine’s dwindling supporters were looking for an alternative. They tried erythromycin tablets, which were placed in the upper part of the uterine cavity in 790 women “volunteers”. The failure rate was unacceptably high at 28–35% after 12 months. This “trial” was criticised as illegal and unethical, and highlighted the ease with which unethical clinical trials could still be conducted in India on vulnerable populations by errant doctors.
The FHI360 article was a real eye-opener for me, as it seems they were responsible for the erythromicin study in India, which I do not recall. It is not surprising, however, as FHI was a driving force in this whole history. The history revealed in this article is indicative of the determination not to let this idea go, and even to bring unnamed advocates on board to try and legitimise what could not be justified.
Turning to the other articles on the subject of non-surgical sterilisation in your August edition, I was interested to see how the article by Elizabeth K Harrington et al quietly denigrated the whole idea of surgical sterilisation because it is surgical, in that it requires training and a decent service delivery setting. Is training and a decent service delivery setting still not a reasonable expectation for women in the global South? She is right, not everyone prefers a surgical method. Yet she admits that surgical female sterilisation has not only been shown to be very safe but is also the most widely used fertility control method globally.
Interestingly, none of these articles takes up the alternative of vasectomy ‒ an unfinished job if ever there was one ‒ let alone the idea of a permanent non-surgical male method. Odd that no one has tried inserting quinacrine in men’s nether parts, or is it? The biases may not seem obvious in the absence of a thorough review of the issues, but bias there is indeed among the cluster of authors who populate this whole journal edition.
The comparison I felt was most relevant and most missing in these papers, however, was that between surgical vs. medical abortion, the only existing surgical and non-surgical methods of fertility control. Both these abortion methods are easy to provide in the first trimester of pregnancy, and both have been shown by WHO to be safe for mid-level providers to offer at primary care level, with simple training. Both have advantages as well as disadvantages, but the real value is that women have a choice between them.
My generation put the notion of “choice” in fertility control on the global map and showed that the more and varied methods there were to choose from, the more people were likely to find at least one method that was acceptable and met their needs. Your authors in this edition have quite a different perspective. They want something that will end fertility, and the less likely it is to “fail” or “fail to be used” the better. From this position, Elizabeth Harrington et al3 and Jeffrey Jensen seem to assume that a long-acting method of contraception is always preferable to the others. This has not been shown, nor is it likely to be true ‒ if one asks a large enough number of women and their partners, and especially young people. And in spite of the still rising numbers of people with HIV and other sexually transmitted infections, the importance of condoms seems to have passed these authors by altogether. In fact, both qualitative studies by Elizabeth Harrington et al3, find the demand for safety to be uppermost as a value among study participants. Moreover the preference expressed for a non-surgical sterilisation method is hypothetical and with caveats ‒ and not based on the experience of surgical sterilisation or an actual non-surgical method.
I would also question these authors’ preference for the term “permanent contraception” rather than “sterilisation” and “vasectomy”. Both these surgical methods can be reversed, and although Jeffrey Jensen likes to think women’s fertility intentions fall rigidly into only three categories, there are quite a few people who have opted for sterilisation or vasectomy who have later changed their minds, and for whom reversal methods were consequently developed. To use the term “permanent” belies that availability, and might even put people off. It would certainly mislead them into thinking there is no going back. Perhaps that is what the supporters of quinacrine sterilisation are aiming for. They seem not to have considered that the lack of potential for reversal with quinacrine might greatly decrease its appeal, even among those for whom “something non-surgical” may be preferable. Of course, no one has attempted to reverse a quinacrine sterilisation. Once the fallopian tissue is thus scarred, it is presumably very permanent indeed.
Lastly, I must say that for a journal that publishes first class research on abortion, I was very disappointed to see you allowing remarks about the need for abortion as a sign of failure ‒ whether of contraceptive methods themselves or of the women who choose them. Can we not finally acknowledge contraception as a fallible form of prevention and abortion as a solution when prevention fails? The belief that contraception which never fails is possible is, in my view, a chimera. Moreover, if women were given proper information and unrestricted access to safe abortion methods, most abortions would take place well before 8 weeks LMP, and even (with medical abortion) as early as 35 days of pregnancy (Beverly Winikoff, personal communication, July 2015). Let’s try developing new non-surgical post-fertilisation methods of birth control, for example.
However, whether or not one thinks a non-surgical method of sterilisation would be preferable to a surgical method, quinacrine is not the answer. Let’s re-bury it and keep it buried.
 Lippes J. Quinacrine sterilization (QS): time for reconsideration. Contraception 2015;92(2):91-95. http://www.sciencedirect.com/science/article/pii/S0010782415002322.
 Pollack AE, Carignan C. The use of quinacrine pellets for non-surgical female sterilisation. Reproductive Health Matters 1993;1(2):119-22. http://www.rhm-elsevier.com/article/0968-8080(93)90018-O/pdf
 Berer M. The quinacrine controversy one year on. Reproductive Health Matters 1994;2(4):99-106. http://www.rhm-elsevier.com/article/0968-8080(94)90016-7/pdf.
 Berer M. The quinacrine controversy continues. Reproductive Health Matters 1995;3(6):142-44. http://www.rhm-elsevier.com/article/0968-8080(95)90169-8/pdf.
 Shallat L. Business as usual for quinacrine sterilisation in Chile. Reproductive Health Matters 1995;3(6):144-46. http://www.rhm-elsevier.com/article/0968-8080(95)90170-1/pdf.
 Mudur G. Use of antibiotic in contraceptive trial sparks controversy. BMJ 2004;328(7433):188.
Summarised in: Law and Policy Round Up. Reproductive Health Matters 2004;12(24):2111. http://www.rhm-elsevier.com/article/S0968-8080(04)24153-2/pdf.
 Katz KR, Nanda K. A nonsurgical permanent contraception stakeholder advisory committee: FHI 360’s experience. Contraception 2015;92(2):139-42. http://www.sciencedirect.com/science/article/pii/S0010782415000384.
 Harrington EK et al. Conceptualizing risk and effectiveness: a qualitative study of women’s and providers’ perceptions of nonsurgical female permanent contraception. Contraception 2015;92(2):128-34. http://www.sciencedirect.com/science/article/pii/S0010782415000955.
 Health worker roles in providing safe abortion care and post-abortion contraception. Geneva: WHO Department of Reproductive Health and Research; July 2015. http://www.who.int/reproductivehealth/topics/unsafe_abortion/abortion-task-shifting/en/.
 Jensen JT. Nonsurgical permanent contraception for women: let’s complete the job. Contraception 2015;92(2):89-90. http://www.sciencedirect.com/science/article/pii/S0010782415002486.
 Harrington EK et al. Interest in nonsurgical female permanent contraception among men in Portland, Oregon and eastern Maharashtra, India. Contraception 2015;92(2):135-38. http://www.sciencedirect.com/science/article/pii/S0010782415001006.
 Berer M. Compelling arguments for developing new post-fertilisation methods of birth control. Berer Blog. 11 July 2015. https://bererblog.wordpress.com/2015/07/11/compelling-arguments-for-developing-new-post-fertilisation-methods-of-birth-control/.
The history and role of the criminal law in anti-FGM campaigns: Is the criminal law what is needed, at least in countries like Great Britain?
24/12/2015 Comments Off on The history and role of the criminal law in anti-FGM campaigns: Is the criminal law what is needed, at least in countries like Great Britain?
This article was published online in Reproductive Health Matters 2015;23(46):145-57. DOI: http://dx.doi.org/10.1016/j.rhm.2015.10.001. Here is the abstract in English, French and Spanish:
The history of campaigns against female genital mutilation (FGM) began in the 1920s. From the beginning, it was recognised that FGM was considered an important rite of passage between childhood and adulthood for girls, based on the importance of controlling female sexuality to maintain chastity and family honour, and to make girls marriageable. How to separate the “cut” from these deeply held norms is a question not yet adequately answered, yet I believe the answer is key to stopping the practice. Since the 1994 ICPD, national and international action against FGM has grown and resolutions have been passed in global forums which define FGM as a form of violence and a violation of children’s human rights. These resolutions have contributed to building consensus against FGM and developing national legislation criminalising FGM. Prosecutions or arrests involving FGM have been reported in several African countries and Great Britain, but apart from France, there have been very few. This paper summarises this history and how FGM has been criminalised. It argues that criminalisation may not be the best means of stopping FGM, but can have serious harmful effects itself. It calls for community-led educational information and more support for dialogue within FGM-practising communities, and argues that what is important is addressing the sexual and reproductive health consequences of FGM and gaining the understanding of women who have experienced it and their families as to why they should not make their daughters and grand-daughters go through it too.
Les campagnes contre les mutilations sexuelles féminines (MSF) ont commencé dans les années 20. Dès le début, il a été admis que les MSF représentaient pour les filles un important rite de passage entre l’enfance et l’âge adulte, fondé sur l’importance du contrôle de la sexualité féminine afin de préserver la chasteté et l’honneur familial, et de permettre aux filles de se marier. Comment séparer la mutilation de ces normes profondément ancrées est une question encore sans réponse ; ce serait pourtant, à mon sens, une démarche essentielle pour mettre un terme à cette pratique. Depuis la CIPD, en 1994, l’action nationale et internationale contre les MSF s’est étendue et des forums internationaux ont adopté des résolutions qui définissent les MSF comme une forme de violence et une violation des droits fondamentaux de l’enfant. Ces résolutions ont contribué à dégager un consensus contre les MSF et à élaborer des législations nationales qui répriment cette pratique. Des poursuites ou des arrestations liées aux MSF ont été signalées dans plusieurs pays d’Afrique et en Grande-Bretagne, mais, à part en France, elles ont été très rares. L’article résume cette histoire et montre comment les MSF ont été sanctionnées par la loi. Il avance que cette pénalisation n’est peut-être pas le meilleur moyen de faire cesser les MSF et qu’elle peut avoir elle-même de graves conséquences. Il préconise une information éducative collective et davantage de soutien au dialogue au sein des communautés qui pratiquent les MSF. Il fait valoir qu’il est important de traiter les conséquences des MSF pour la santé sexuelle et génésique et de faire comprendre aux femmes qui les ont subies et à leur famille les raisons pour lesquelles elles ne devraient pas obliger leur fille ou leur petite-fille à en passer aussi par là.
La historia de las campañas contra la mutilación genital femenina (MGF) comenzó en la década de 1920. Desde el principio, se reconoció que la MGF era considerada un importante rito de paso entre la niñez y la adultez para las niñas, basado en la importancia de controlar la sexualidad femenina para mantener castidad y el honor de la familia, y para preparar a las niñas para el matrimonio. Cómo separar el “corte” de estas normas tan arraigadas es una interrogante que aún no ha sido contestada adecuadamente; sin embargo, creo que la respuesta es clave para eliminar la práctica. Desde la CIPD de 1994, la acción nacional e internacional contra la MGF ha incrementado y se han aprobado resoluciones en foros mundiales que definen la MGF como una forma de violencia y una violación de los derechos humanos de las niñas. Estas resoluciones han contribuido a fomentar consenso contra la MGF y a formular leyes nacionales que penalizan la MGF. En varios países africanos y en Gran Bretaña se han reportado enjuiciamientos o arrestos relacionados con la MGF, pero aparte de Francia, ha habido muy pocos. En este artículo se resume esta historia y cómo la MGF ha sido penalizada. Se argumenta que la penalización quizás no sea el mejor medio para eliminar la MGF, ya que puede tener graves efectos dañinos. Se hace un llamado a la información educativa dirigida por la comunidad y a brindar más apoyo para el diálogo con las comunidades que practican la MGF. Se argumenta que lo importante es tratar las consecuencias de la MGF en la salud sexual y reproductiva y lograr que las mujeres que han pasado por esta experiencia y sus familias entiendan por qué no deben obligar a sus hijas y a sus nietas a hacer lo mismo.
24/12/2015 § Leave a comment
At the 5th Research Meeting on Unwanted Pregnancy and Unsafe Abortion, Mexico City, 28-30 September 2015, Silvina Ramos presented an excellent new CLACAI publication (in Spanish) on a renewed agenda for abortion research in the LAC region: “Investigacion sobre aborto en America Latina y el Caribe: una agenda renovada para informar politicas publicas e incidencias”. I was asked to comment in the session:
DATA FOR ADVOCACY
-We need to know more about what post-abortion care involves in order to showcase the failure of post-abortion care to resolve the serious public health problem of unsafe abortion. In 2012 an estimated 6.9 million women globally were treated for complications of unsafe abortion. In Latin America, new estimates of the rate of complications show a 31% decline between 2005 and 2012, from 7.7 per 1,000 women to 5.3 women per 1,000. (Singh et al, 2015) But this is still far too high and there is no excuse for it.
-As regards the incidence of abortion, we need to know more about pregnancy among girls aged 8-14 resulting from sexual abuse and whether or not they have access to safe abortion, including as a form of emergency obstetric care given how small they are. This emerged as an issue in Paraguay this year. There is little information on this subject though some research has been done (see http://conta.cc/1NNx4FD, http://conta.cc/1NN3sIn and http://conta.cc/1NMS9zS).
-It is important to underscore the importance of the attitudes towards abortion of health professionals, and the importance of promoting training in abortion provision only for those who support women’s right to safe abortion. The current deficit in training should be a major advocacy issue. Why nurses should be less supportive to women needs to be better understood because abortion no longer requires doctors except in emergencies. Abortion care should be in hands of nurses and/or midwives at primary care and community level today.
-The prevalence of abortions among nurses/midwives and how they themselves are treated as patients might help to explain their views and bring them on board as a profession (http://www.rhm-elsevier.com/article/S0968-8080(07)30314-5/pdf).
-Attitudes towards 2nd trimester abortion are a particular problem. Can the number/proportion of second trimester abortions be reduced with better laws and services? Evidence from Sweden and Norway, particularly with good access to medical abortion, shows this can be done. If we knew why women have abortions after 12 weeks of pregnancy in more countries, it would contribute to change. However, this is not an issue of “women’s fault” but of systemic failures on the part of health and sexuality education, laws and policies, and health systems.
-Many who support abortion rights call for restrictions on conscientious objection but few oppose it altogether. Joyce Arthur of Canada and Christian Fiala of Austria have written several articles together and separately on this subject, opposing the whole concept.
-Sweden does not permit conscientious objection. This policy was challenged earlier this year at European level and their law was upheld.
-I agree with these views. I believe anyone who is unwilling to carry out an essential task in their job description should find another job. Abortion services are almost unique in allowing conscientious objection. It is a leftover of anti-abortion hegemony and should be removed.
PUBLIC HEALTH vs. HUMAN RIGHTS POSITIONS TO SUPPORT ABORTION
-I would like to disagree with one of the book’s authors that the public health arguments for safe abortion are less radical than those related to women’s bodily autonomy and rights.
-Public health arguments are not only relevant but also extremely powerful. I don’t think we use them enough anymore. Yet they are likely to have more resonance with health professionals.
-How to get past the huge, irreconcilable differences in thinking? Especially in the face of growing anti-abortion fanaticism?
RESEARCH FOR LAW AND POLICY ADVOCACY
-Campaigns for safe abortion often focus on calling for specific grounds for abortion to be decriminalised. For example, health grounds, rape, serious fetal abnormality, and in some countries in Latin America even for risk to the woman’s life to be permitted.
-I recently looked at the history of how abortion laws in several countries have changed over time, from almost complete criminalisation to allowing abortion at a woman’s request. This showed that a step-by-step process has taken place in some countries over a period of years, but often over decades. The current, limited law reform bill in Chile and recent examples in Africa show this has resonance as a way forward. But is it the only or best way forward?
-It would be good for this history to be studied in depth in many more countries, across both the 19th and 20th centuries and today.
RESEARCH ON ABORTION LAWS & GOALS
-For me, one of the biggest unresolved advocacy issues is whether we are seeking legalisation of abortion or decriminalisation of abortion.
-There a difference between these legal categories and we need to study it more.
-What reforms should we propose to our current laws on abortion that will lead to health system changes that will meets women’s needs and protect and fulfill their right to a safe abortion as part of their sexual and reproductive health and rights?
-In different countries, the answers may be different, depending on the origins of the laws, and more research and critical thought and analysis are needed.
Women’s right to safe abortion: interview for London School of Hygiene & Tropical Medicine Online Course
24/12/2015 § Leave a comment
Improving the Health of Women, Children and Adolescents: from Evidence to Action is a free online course of the London School of Hygiene & Tropical Medicine. I was interviewed on the subject of abortion for one of the sessions; this is what I said below. The course first ran in autumn 2015 and is due to be run again from 29 February – 8 April 2016. Find out more at: http://www.lshtm.ac.uk/study/freeonlinecourses/women-children-health/#sthash.tI7kCuOn.dpuf
1. Please introduce yourself
>>My name is Marge Berer. Since May 2015 I have been the Coordinator of the International Campaign for Women’s Right to Safe Abortion (www.safeabortionwomensright.org), which is a network of over 960 groups and individuals in 100 countries who are working for the right to safe abortion. From 1992 to 2015, I was the editor of the journal Reproductive Health Matters, which I founded with TK Sundari Ravindran. The International Campaign is important because abortion is still restricted by the criminal law in almost every country in the world, including countries where it is widely available, yet approximately one in five to one in three women globally will have an abortion in her lifetime. It is also important because the practice is under constant attack from a small but powerful minority of right-wing and conservative groups who believe women should be forced to carry every pregnancy to term whether they can cope with all the children that would result from this or not. We believe that universal access to safe abortion at a woman’s request is essential for women’s health and a necessary aspect of women’s right of autonomy over their bodies and lives.
2. Can you explain the human rights dilemma that affects access to safe abortion?
>> As a human rights issue, access to safe abortion is inextricably linked to the first principle of human rights, that is, the right to life. An estimated one million women have died from the complications of unsafe abortion in the past 20 years, and almost all their deaths would have been prevented had abortion been safe and legal in their countries. The anti-abortion movement claims that the right to life begins at conception. If this were accepted in human rights principles it would subsume a woman’s right to life to that of any pregnancy she was carrying, making her into a vessel, and would mean that no abortion would be permissible. In fact, every human rights body, from CEDAW to the Committee that interprets the Convention on the Rights of the Child, agrees that rights in general, including the right to life, begin at birth
3. What are some examples where the rights of the woman are violated?
>> There are unfortunately many examples of the ways in which the rights of women are violated, and one of them is when abortion is illegal. For example, let’s take 3 cases that were determined by Catholic health policy.
The first is the case of a woman who was 17 weeks pregnant, and began to miscarry. The miscarriage was inevitable, and the baby could not have survived no matter what was done because it was too early in the pregnancy. Because her cervix was open, the woman was highly susceptible to infection even though she was in hospital, and in fact she did develop a life-threatening uterine infection. Yet the hospital failed to provide the only treatment that would have saved her life before the infection became uncontrollable, that is, an abortion, because they waited until there was no longer a fetal heartbeat, even though the fetus was not viable. She was a young healthy woman and she died completely unnecessarily.
The second case is of another young woman who was an asylum seeker. She fled the conflict situation in her country of origin, where rape was being used as a weapon of war. She had been raped herself. After she arrived in the country that gave her asylum, she discovered she was pregnant as a result of the rape. She was unable to obtain a visa to travel for an abortion. She became suicidal and although the threat of suicide should have meant she had a legal right to an abortion, it was refused. Instead, she was locked up in a hospital, supposedly for her own protection, until her pregnancy was far enough advanced that the baby could survive independently and then she was forced to have a caesarean section.
Both these cases come from Ireland. Something similar happened to a ten-year-old child in Paraguay this year who had been sexually abused by her stepfather for two years. She too was locked up in a hospital and subjected to a caesarean section to save the baby, instead of an abortion.
These cases are horrific; they represent the worst sort of misogynistic treatment of girls and women. But there are thousands of cases every day in many countries, especially in the global South, where safe abortions are not available. Some 42 million women have an abortion every year. Half of those abortions are unsafe in the following ways:
- Illegal or legally restricted
- Dangerous method
- Untrained/unskilled provider
- Unsafe conditions
- Self-induced without help or information
- Incorrect usage of abortion pills through lack of information
- Little or no access to treatment for complications
- Stigma, fear and isolation
- Violence, rejection (by family, school, work) and murder, both of women and of doctors providing abortion care
- Threat of arrest, and prosecution and imprisonment.
Here is what a young girl who was put in prison in Rwanda at the age of 17 for having an abortion said:
“I am 20 years old and… have been in Karubanda prison since 2007 for committing abortion. I am the 3rd born in the family and the only girl. I was raised by my dad after my mum died when I was still young. I was in the 5th year of my secondary education when a teacher at my school started dating me. I needed school materials and since I could not afford them, I allowed to have sexual intercourse with this teacher at that tender age. With limited knowledge on contraceptive use, I got pregnant and had to drop out of school since it’s against school regulations. I decided to have an abortion and my elder brother out of fear reported me to the police. I am supposed to serve a period of 9 years of which I have so far completed 3 years.” Crying she says: “I have lost hope and this is the end of my life”. (Abortion and young people in Rwanda: a collection of personal stories about abortion. Family Planning Association of Rwanda (ARBEF), ARBEF Youth Action Movement Rwanda, Rutgers WPF
This young girl’s story is why I am devoting my time to campaigning for women’s right to safe abortion, along with thousands of others all over the world.
4. Do you see the situation changing? Are more women around the world being given the right to safe abortion?
>> The situation is improving in many ways in many places. Countries are reforming their abortion laws, for example, just this year Mozambique completed a change for the better in its law, and in Chile, Morocco and Malawi positive law reform is being proposed. At the same time, women who do not have access to safe abortion services are learning from other women through safe abortion information hotlines and from courageous health professionals in their countries about how to have a safe abortion with medical abortion pills on their own. They are accessing the pills from pharmacies and from trustworthy providers through the internet, and taking control of their lives in spite of the laws against abortion. This is not an ideal situation but deaths from unsafe abortion have been decreasing rapidly because of it and that can only be a good thing.
Let me close by saying that one in three women is a lot of women who will need an abortion in their lifetimes. It was me once, and it could be many of you who are listening today, or your partners. Safe sex is sex in which you and your partner protect yourselves and each other from unintended and unwanted pregnancy and from sexually transmitted infections. Protection can fail, however, and sometimes people fail to use it. We need our health systems to be there before and after to help us ‒ with contraception, condoms, emergency contraception, safe abortion, and treatment for HIV and other sexually transmitted infections. Each of these is part of a larger package of essential sexual and reproductive health care. I invite you to study how well your countries are doing in offering these services and get involved today to make the situation better for everyone, especially for young women, and also for yourself ‒ in case you may need it.
18/10/2015 Comments Off on Abortion today: what women need and want
This is a presentation I gave to a meeting about medical abortion, organised by Gynuity Health Projects in New York, 9 June 2015.
Click on the link to read it.
05/09/2015 § Leave a comment
Another FGM case, which did not involve the criminal law but family law, and that took place in November 2014 in Leeds, two months before the first criminal trial in London, involved an attempt to take two small children into care: a girl G aged ±3 and a boy B aged ±4, whose parents were of African origin. The children had temporarily been placed with foster parents as the mother was having mental health problems. The judge’s write-up of the case, on which this blog is based, said:
“The suspicion that G had been subjected to FGM first arose in November 2012 in country S after blood had been found in her nappy when she was at nursery. She was examined by two doctors who found (I quote the translation) ‘no sign [she] had any damage to female organs’. A further medical report states ‘outer and inner labia normal and the clitoris is normal. No sign of any circumcision’. The question was raised again in November 2013 when the foster carer reported G’s ‘irregular genitalia’.”27
Three people, invited to examine the girl and give evidence because all were considered to be experts and presented themselves as such, gave testimony in court. According to the judge’s report, Expert 1 was an expert in child sexual abuse and described herself as an expert in the assessment of female genitalia ‒ but not for FGM. She had examined approximately five girls with FGM over the previous three years, but only one was a baby. Expert 2 was a midwife with extensive experience of pregnant women with FGM; she described herself as an FGM, reproductive and public health specialist. She had knowledge of and expertise in many aspects of FGM and its medical and other consequences, which she has published and spoken on extensively, both in Britain and abroad. When she gave oral evidence, however, it became clear she had almost no experience of FGM in babies. Expert 3 had established a specialist clinic in 1999 for women with health consequences of FGM, and had a great deal of experience of them; moreover, her clinic was the only specialist paediatric FGM clinic in the country.
Experts 1 and 2 both examined G and both said in written and oral evidence that they thought they had seen evidence of FGM. However, their descriptions of the mutilation differed from each other’s. Expert 1 later changed her evidence and admitted to having made a mistake. Expert 2’s evidence was described by the judge as: “confused, contradictory and wholly unreliable”. Expert 3 did not examine G in person but saw the reports of the other two and watched the DVD of their examination of G. She said she saw no evidence of FGM. Both parents also denied that G had been subjected to FGM. The judge dismissed the FGM charge.
The local authority who brought the case argued that if G had been subjected to FGM it was reason enough to initiate adoption proceedings. Sir James Munby, President of the Family Division, who heard the case, said there were three issues to consider: Had FGM occurred? Did it amount to significant harm, and if so, what were the implications. Having heard the evidence, he concluded that the “local authority is unable on the evidence to establish that G either has been or is at risk of being subjected to any form of FGM”. In a lengthy and thoughtful consideration of the implications, he also cautioned that even had FGM been found, “local authorities and judges are probably well advised not to jump too readily to the conclusion that proven FGM should lead to adoption”.
This case illustrates that even experts cannot always tell or agree whether a child has had FGM. The implication, as I see it, is that allowing uncalculated numbers of children to be examined for FGM by people who are likely to have even less expertise than the witnesses in this trial, is a recipe for disaster.
 See Berer M. Acquittals in the FGM case in London, justidce was done and was seen to be done, but what now? Berer Blog, 10 February 2015. https://bererblog.wordpress.com/2015/02/10/acquittals-in-the-fgm-case-in-london-justice-was-done-and-was-seen-to-be-done-but-what-now/.
 Sir JamesMunby, President of the Family Division. In the matter of B and G (Children) (No 2). Neutral Citation Number:  EWFC 3. Case No: LJ13C00295. 14 January 2015. https://www.judiciary.gov.uk/wp-content/uploads/2015/01/BandG_2_.pdf.