Family planning and safe, legal abortion go hand in hand

19/07/2012 Comments Off on Family planning and safe, legal abortion go hand in hand

Marge Berer

Editor, Reproductive Health Matters

One in three women in the UK will have an abortion in her lifetime, most of whom will have been using contraception of some kind. Yet since as long ago as the late 1930s, there has been a split in the UK between those who insisted on promoting contraception on its own because they thought abortion was too controversial and would hold back acceptance of family planning, and those who insisted that the two go hand in hand. This split exists in many countries, not just the UK, and also within many organisations with a large membership in different countries, such as the International Planned Parenthood Federation (IPPF). It is reflected most recently in a comparison of the list of 600 groups and individuals who have endorsed the International Campaign for Women’s Right to Safe Abortion this year, and the 1300 that signed a letter circulated by the IPPF supporting the Family Planning Initiative – very different groups are on those lists. Yet all of them support the right to control fertility.

In 1994, the ICPD Programme of Action, a consensus document on the integration of sexual and reproductive health and rights, was only able to be passed if it included a “compromise” clause that called for abortion to be safe only if it was legal. This compromise was and remains a violation of public health principles and women’s human rights. ICPD failed to condemn the often 19th century, often colonial laws on abortion still in place in the criminal code in many countries. However, the Programme of Action did recognise that unsafe abortion was a major public health problem, one which to this day still affects some 22 million women every year, among whom 5 million end up in hospital with complications annually and tens of thousands die (WHO, Guttmacher). And young women, whom everyone wants to be  seen to be supporting these days, are in fact most at risk of unsafe abortion and also have the least access to contraception (Shah & Åhman, RHM, May 2012).

The answer is not to promote contraception in order to reduce unsafe abortion, as the FP Summit did. The answer is to promote contraception to reduce unwanted pregnancy and provide safe abortion to every woman who finds herself with an unwanted pregnancy. That is the way to make unsafe abortion history. Abortion will not go away unless men and women stop having sex with each other or everyone is sterilised. So forget it! The growing number of countries in both the north and south, east and west, where there is 60-80% contraceptive prevalence proves that. Research shows that women and men take up contraception in large numbers if they feel they have the right to control their fertility and have access to the means to do so. There is a huge need for information, because every new generation of young women and men will know nothing about contraception or abortion unless they have access to this information. But there is no need for “demand creation”, a retrograde concept which implies lack of interest. The steadily falling fertility rate globally, falling since the 1970s, proves that, and in every country, abortion is in there, safe or unsafe, reducing the number of births. Forty-four million abortions globally and hundreds of millions of people using contraception and sterilisation prove the huge demand for the means of fertility control. “Unmet need” is more than just lack of knowledge or interest on the part of the women and men who aren’t using contraception, or using it erratically or unsuccessfully.

Women seek an abortion if they have an unwanted pregnancy, legal and safe or not, because it’s too late for contraception. There is no split between contraception and abortion from women’s perspective, they are two sides of the same coin. Even so, many of the biggest supporters of “family planning” refuse to support women’s need for safe, legal abortion. Even worse, they always talk about abortion in negative terms. They mention it along with STIs, as if it were a disease, or treat it as an annoying problem that they wish would go away, and consider it inferior to use of contraception. They even claim that use of contraception will (or should) make it go away. But this is about the realities of people’s sex lives and how sex happens, not just about well-thought-out, planned-in-advance decisions about family formation. Many pregnancies are started without any forethought at all, and all too often as one of the consequences of sexual pressure and coercion.

Campaigns for women’s right to safe, legal abortion have been going on for at least 100 years. Many of us involved in these campaigns are still seen as annoying by people who are supposed to be our colleagues. We’re told it’s sensitive, controversial, difficult, it can’t be put on the agenda, including in the FP Summit. At the same time, many of us who are fighting for abortion rights stopped supporting “family planning” years ago, because of what happened in the past, when coercive programmes put many people off “family planning” and gave it a bad name. Some family planning supporters have blamed ICPD for the neglect of family planning, because it placed family planning in a wider context. But as Gita Sen said at the Summit, ICPD in fact sought to rehabilitate family planning and restore its good name, while the barriers to safe abortion were left in place.

Today’s supporters of family planning would like everyone to forget the coercive programmes of the past, which were target-based. But they may yet become target-based again because of “results-based financing”. So let’s not confuse opposition to coercive family planning policies with being anti-family planning. Yet, it is absolutely true that provision of contraception has been neglected in recent years – and yes, this neglect must stop. At the same time, neglect also characterises how women’s unmet need for safe abortion is treated. What needs to change is that both forms of unmet need should be taken into account – together – starting with donor and national government policies.

For example, although DFID’s development aid policy has long been to fund both family planning services and abortion services, in their roll-out of these policies, funding for family planning is (I am told) separated from funding for safe abortion. That is, it is managed by different people and in different programmes within DFID and in the recipient countries, and these different people may not work closely together or know what each other are doing. Yet DFID did not see a problem in agreeing to a family planning initiative in which funding for abortion is excluded. They fund abortions anyway, they say, so what’s the problem? The problem is that separating abortion from family planning at the programmatic level allows some countries to keep abortion legally restricted and not take responsibility for unsafe abortion.

Then there’s the US, where support for family planning by USAID has been the highest in the world for many years now, while safe abortion services are not funded by them at all. Since ICPD, however, the US has funded post-abortion care, which was invented at ICPD as a way to save women’s lives who had had an unsafe abortion. Unfortunately, the evidence that post-abortion care has in fact saved many women’s lives since ICPD is sparse and not compelling. Yes, the number of deaths from complications of unsafe abortion has fallen a lot, but this may be due to self-medication with misoprostol replacing life-threatening methods.

In fact, once ICPD was over, this so-called post-abortion care should have been rejected as unethical, because it allows harm to be done unchallenged and forces health care providers to clean up the mess without the support of the law. Under US aid policy, even countries where abortion is legal who tried to use USAID funds for safe abortions as well as for contraception and sterilisation, in integrated programmes, had their “family planning” funding stopped. Research has now shown that this leads to higher rates of unwanted pregnancies and abortions in those very same countries, proving how illogical such a policy is/was. Will that evidence, published only recently, lead to a change in USAID policy? Unlikely. Too sensitive. And meanwhile, a violent and fanatical anti-abortion movement flourishes in the US, where some of the most punitive and misogynistic barriers to safe abortion are being implemented with near impunity, in one state after another.

The anti-abortion movement is also anti-family planning. For years, they were very circumspect about this as they feared, quite rightly, that it would lose them support. But the current Vatican has helped to bring anti-abortion opposition to contraception and assisted conception out in the open again. This is evidenced in campaigns to ban emergency contraception and assert conscientious objection to providing contraceptives, e.g. by pharmacists. But still, many in the family planning movement do not support the right to safe abortion.

In light of the Family Planning Summit, it is a good time for abortion rights activists who have ignored family planning to link up with the family planning movement, and help to ensure that services have a rights-based approach. It is also a good time for all family planning colleagues to support the right to safe, legal abortion alongside the right to access contraception and sterilisation – and talk about abortion as a legitimate part of fertility control, a solution to unwanted pregnancy, a public health necessity for women, and a legitimate health care service. All of us should acknowledge the huge unmet need for safe, legal abortion services as well as for contraception and sterilisation services, and ensure that they are provided – and funded – together.

Many effective contraceptive methods, condoms, two types of emergency contraceptive pill and two very safe methods of early abortion – all on the WHO essential medicines list – can and should be provided at primary health care level. This includes medical abortion pills and manual vacuum aspiration for abortions up to 9-10 weeks. Some of these can even be provided during home visits by community-based health workers – the pill, condoms, injectables, emergency contraceptive pills and medical abortion pills for early abortions – as long as there are nurses, nurse-midwives or other mid-level providers who have been trained to do so. The evidence is there– this is all safe and effective. Moreover, the legitimate sort of post-abortion care, i.e. the kind that happens after safe abortions, needs to include information about and provision of contraception, just as post-partum care ought to do. So, even programmatically and clinically, the integration of family planning and abortion makes more sense than ever.

Advertisement

The morning after: the beginnings of an assessment of the FP Summit

16/07/2012 Comments Off on The morning after: the beginnings of an assessment of the FP Summit

Marge Berer
Editor, Reproductive Health Matters

13 July 2012

From a communications point of view, the FP Summit was a raving success. Newspapers, TV and radio all over the world covered it. Around the globe everyone reached by the media heard how wonderful family planning is and how neglected it has been, the Lancet launched a special edition , Guttmacher and others released facts and figures showing the extent of unmet need. Across the women’s health movement the listserves, Facebook and Twitter were full of it. All in all, the day – and many of the messages it gave birth to – had enthusiastic, even missionary, overtones.

On the absolutely fabulous side, Melinda Gates’ challenge to the Pope to acknowledge that contraception is ‘not controversial’ even amongst Catholic women, is likely to rock the foundations of the Vatican’s whole policy on abstinence, condoms and contraception from the grassroots of the Catholic church up. It was God’s gift to Catholics for Choice, who will be promoting Condoms-for-Life and safer sex at the upcoming AIDS conference later this month.

Also on the plus side, there were representatives of governments and many, many others who are making progressive change happen in their countries, and who spoke out about it. These are people who can make a big difference when they get home who did support comprehensive sexual and reproductive health and rights from the podium and the floor of the meeting, and who insisted that family planning services can only be provided within that wider remit. There were people who needed to learn what it was all about, some of whom were too young to have lived the history, but who came with strong pro-choice views.

The media exposure of the value of family planning has a huge potential for good, because it will have reached people who didn’t know family planning existed or whether it’s good for them and safe, and others who have never had a chance to talk about these matters with others. It will also have put fertility control as a public good on the map around the world. And hopefully it will spur those with expertise in sexuality and reproduction to start talking about what they know, and what is and is not true amongst all the hoopla – and to assert that the power of money must not be allowed to take precedence over public health values and human rights principles, or the values of knowledge and truth.

On the oh-God-help-us-no-no-no side, though, Melinda Gates anointed herself as the new saviour of women’s and children’s health, and the press ate it up in both pictures and words. Some of the best people in the field of sexual and reproductive health, were unexpectedly uncritical, singing the praises of this wonderful opportunity. Perhaps not surprising given the historical shortfall in funding for family planning.

A golden moment, the kind that big money and a Tory government are at home in, stage-managed by a slick public relations company called McKinsey (who describe themselves as “the trusted advisor and counsellor to many of the world’s most influential businesses and institutions”). With big pharma, having abandoned contraceptives for many years, talking about the opportunity (“70% of this market is under-served”) to make a profit from family planning needs and then give some of it back to women – as a charitable gift. Patting each other on the back for being so wonderful as to finally have recognised that women have health needs they can exploit. A truly Hollywood event, except this is not entertainment. This is women’s lives.

This golden moment, which had to happen mainly because so many governments have failed to take responsibility for the public health needs of their citizens, for maternal health, family planning, abortion, sexual health, in the only equitable manner that works – by providing publicly funded, well-resourced services.

It was a day that showed the world it was possible for one very well-meaning woman, backed by the power and money of her husband, to direct global policy and claim ownership of the provision of family planning to 120 million women and at the same time, to disparage and stigmatise women’s need for abortion to the entire world – and get away with it without being challenged. She had the courage to challenge the Pope. It is a shame that a summit attended by many of the world’s experts on these subjects could not emulate her bravery and challenge her in return.

She was not the only one who got away with it. The Summit also gave the podium to and applauded politicians from countries where millions of women have the very unmet need for contraception in whose name this Summit was called: women who are still dying from unsafe abortions because their governments are too cowardly to make abortion legal and safe; and women who are dying from complications of pregnancies because they have no access to life-saving maternity care. Countries that since the 1960s have received hundreds of millions if not billions of US dollars for family planning, which have as good as disappeared, or been squandered and misspent.

It included representatives of the very same private sectors whose services and prices for contraceptive methods and safe abortions remain inaccessible to and unaffordable for many in the world’s population who need them, especially young women and men. And not only in low- and middle-income countries, but also in the United States, a country whose health industry has made life hell for Barack Obama for trying to make health care even a little bit more affordable, excluding abortion of course, for millions of disenfranchised people. The United States – a country that has the biggest and most violent and aggressive anti-abortion movement on earth, second only to the Vatican, and some of the highest unintended pregnancy rates in the developed world, especially among poor women.

It was addressed by the Prime Minister of the UK, the Right Honourable David Cameron, who got a standing ovation for a speech about the importance of empowering women, a speech that stank of hypocrisy. A Prime Minister who is responsible for indefensible, swingeing spending cuts that are adversely affecting women, young people and children above all, including cuts in family planning, sexual health services and welfare, at a time when it has never before cost so much to raise a family. Whose Secretary of State for Health is selling off our National Health Service piece by piece, who has wasted public time and at least £1 million in public money harassing some of the real heroes of women’s rights, that is, abortion service providers, for no credible reason. Whose Minister for Public Health put an anti-abortion group on the government’s sexual health advisory group “for the sake of balance” and to propitiate anti-abortion fanatics in Parliament – a Minister who described abortion as a “sensitive” issue, after 45 years of safe, legal abortions (except for women in Northern Ireland, of course).

And now it’s the morning after. How to go on from here and engage in what will happen? It’s a pity about Melinda Gates’ prejudices against abortion. I hope she will reconsider them because it would make her a far more credible ambassador for this cause which, after all, does not belong to her.

Medical abortion in Britain and Ireland: let’s join the 21st century!

15/02/2011 Comments Off on Medical abortion in Britain and Ireland: let’s join the 21st century!

Medical abortion – popularly known as the abortion pill – has been in the news almost non-stop for several months now in both Britain and Ireland, though for very different reasons. That’s good news because more women are getting to hear about it. Although the method has been around since the late 1980s, most women didn’t start hearing about it until the last ten years or so. But as it’s become more known, so has controversy begun to brew around it. Why? Because the abortion pill potentially puts the control over abortion into women’s hands, and a lot of conservative men and women aren’t sure they like that.

Medical abortion, when used from the time a woman first misses her period until up to 9 weeks of pregnancy (dated from the first day of the last menstrual period), is more than 95% effective, and the earlier it is used, the closer to 100% effective it is. The method consists of two kinds of medication.

First, mifepristone (one 200mg pill) is taken by mouth, swallowed with some water. Then, misoprostol (four pills of 200mcg each) is used 24–48 hours later. These 4 pills can be inserted high up in the vagina, which a woman can do herself, or a nurse or doctor can do for her. Or, they can be taken buccally, that is, placed inside her mouth, two on the inside of each cheek, where they will slowly start to melt and should remain for up to 30 minutes, and then whatever is left should be swallowed with water. Within 4-5 hours later, the woman will (in almost all cases) have a miscarriage.

Spontaneous miscarriages almost always happen at home; women cope with them. There will be menstruation-like bleeding and fluids, but far heavier than a period, more with every week of pregnancy, often with clots. When the embryo is passed with the bleeding, the bleeding will slowly become lighter. It is likely to continue for several days, or somewhat longer, and then gradually stop. The woman will experience cramps and commonly nausea, and she should take ibuprofen for the pain when the cramping starts and more when needed.

For most women, at this early stage, this will terminate the pregnancy. This method is both safe and, yes, easy. Easy for women, and easy for the health service provider, who in almost all cases only has to give the woman information, give her a choice between this method and an early aspiration abortion, and then give her the pills (and insert them vaginally for her if the woman prefers that). With training, this person can be a family planning nurse, a regular nurse, a midwife, a GP, or if no one else is allowed, a gynaecologist. [1]

Three things may go wrong. First, nothing may happen and the woman will need to take a repeat dose of four more 200mcg misoprostol tablets, or opt for an aspiration abortion. Second, bleeding will start and the embryo will be expelled, but the abortion will be incomplete and treatment will be needed to complete it, again a repeat dose of four more 200mcg misoprostol tablets or aspiration. Third, very very rarely, bleeding will become very heavy and the woman will need immediate medical treatment to stop it.

Because these three things may happen, even though they will not happen for the great majority of women, access to medical treatment is very important. Moreover, access to assurance that everything is going OK is also important for women using this method for the first time. Waiting is involved and women can become nervous, and may want someone to talk to, so an abortion phone line can be an important part of providing this method in a way that meets women’s needs.

However, for the vast majority of women, early medical abortion consists of taking the tablets as prescribed, having a miscarriage, and it’s over.

So what’s going on?

In both the North and South of Ireland, where almost all abortion is illegal, women have been crossing the border and coming to Britain or other European cities for a safe, legal abortion. But that costs a lot of money and many women in Ireland can ill afford it. It may take them precious weeks or even a month or two to raise the cash and arrange the trip and the abortion. And meanwhile their pregnancy is advancing. And since the financial crisis started, more women are reporting difficulties in coming up with the money necessary to access abortion services, according to the Irish Family Planning Association (IFPA).

Women in Ireland have discovered medical abortion, because the women’s grapevine and the internet are more powerful these days than the 19th and 20th century Irish laws prohibiting abortion. Pills can be transported all sorts of ways, including through the post. And clearly that is now happening. The newspapers in Ireland picked up the story recently of a Chinese woman who brought medical abortion pills into Ireland and was selling them over the counter in her supermarket. Shock, horror! How could this be allowed to happen, and she has had to pay a €5,000 fine and €5,500 costs. I hope the pro-choice movement in Ireland is brave enough to come out publicly and support her.

But the fact is that in almost every country in the world across Latin America, Asia and many parts of Africa where abortion is still mostly illegal, medical abortion pills are available in pharmacies, drug shops, and street markets. This is far from an ideal situation, and no one who supports women’s right to a safe, legal abortion thinks it is fine as it is.

For a start, only misoprostol tends to be available on its own, and it is not nearly as effective (even with the optimum dose) as it is when taken in combination with mifepristone. Secondly, women and drug sellers may not know what the correct dosage and procedure to follow are. Thirdly, when things go wrong, women may or may not have access to medical back-up. However, medical abortion is reducing the number of deaths from unsafe abortion in many of these countries, because the method does not kill women in the same way as unsafe, invasive methods, such as putting a twig or a rubber hose up the vagina into the uterus, did.

The use of medical abortion pills in Ireland is also not ideal, though women in Ireland who know enough to have accessed the pills are also very likely to know where to ask for help if needed, and they will get that help. Everyone who is pro-choice would far prefer this situation to be regularised. However, that requires abortion to be made legal and medical abortion pills made available through national drug registration and health service provision. How likely is that, do you think, in the near future?

Well, it is possible after the recent European Court of Human Rights judgement (16 December 2010)– that Ireland’s strict law violated the right to life of a pregnant woman suffering from cancer – that Ireland will liberalise its abortion law, at least to allow abortion when the health and life of the woman are at risk. But the North? A more reactionary, anti-women set of male politicians in charge of the law would be hard to find.

It is ironic that women can cross the border and leave Ireland for an abortion in Britain, paying anything up to £2000 for the privilege, and do so legally (which it must be added Irish women fought for in the courts up to European level in the late 1980s/early 90s), yet medical abortion pills cannot cross the border into Ireland without the customs seizing them – do they not have anything better to do, like seizing seriously harmful drugs such as heroin? – and the anti-abortion movement making their usual hysterical remarks about the pills being “deadly” and so on and so forth, blah blah blah.

When will these guys get over it? As Agata Chelstowska from Poland says in an article I’m about to publish in RHM: “Is it possible that the purpose of the law is not to reduce the number of abortions, but to serve a purely political role, as a symbolic achievement of the Church and right-wing parties?” Yes, it is!! And the name of that achievement is control over women for its own sake. Unfortunately, women don’t accept that anymore, guys, and medical abortion pills are helping us to bypass all that medieval misogynistic control freakery.

Meanwhile, back in Britain

Yesterday, in 21st century Britain, where abortion has been legal and available since 1967, you would have thought the “guys” involved had got over this issue and accepted that women need abortions, and always will, and that it is the job of the health service to make them available as early and as safely as possible, based on the best evidence-based practice.

We hear a lot about evidence-based practice today. It’s meant to be what everyone follows because it shows you what is best to do to achieve the ends you want and what can go wrong, so you can avoid it – in lawmaking, in economic policy, in health care. Ha ha. Are you watching the coalition government? Never heard of it. Or rather, mouth the words and then ignore the evidence and do something else.

Yesterday, a High Court judge ruled in a case brought by Bpas[2] that the regulations related to the 1967 Abortion Act, which say that the treatment for abortion must be carried out in hospital premises, would have to be amended to allow women to use the second half of the medical abortion regimen (the misoprostol pills) at home.

At the moment, the procedure is that the woman must take the mifepristone pill in front of the doctor or nurse who hands it to her. Then she can go home and wait and come back 24 or 48 hours later to get the misoprostol pills, which must be inserted in her vagina at the clinic or taken buccally (described above) and then she can either wait 4-5 hours for the abortion to happen in the clinic (if they have the facilties for this) or go straight home again. In some cases, if she goes straight home again, the abortion may happen while she is on her way. This is not best practice, and something that any clinician with a brain would prefer not to see happen.

The judge recommended (and many thanks to him for that, it was the best he could do), based on the substantial evidence provided by Bpas, that the government could amend the regulations, which were written at a time when all abortions were surgical procedures and carrying them out in hospital premises was intended to remove them from the backstreets to make them safe. We have long ago moved on from that, and the regulations need to move on too.

Bpas said:

“Bpas is very pleased that the Hon Mr Supperstone J has ruled that Section 1(3A) of the Abortion Act as amended in 1990 enables the Secretary of State to react to “changes in medical science” as it gives him “the power to approve a wider range of place, including potentially the home,  and the conditions on which such approval may be given relating to the particular medicine and the manner of its administration or use.” …

Since we brought our case to court, the Royal College of Obstetricians and Gynaecologists has produced new guidelines noting the weight of evidence in support of home-use of misoprostol for abortions up to nine weeks and the importance of giving women choice of method. This new, evidence-based guidance was supported by the Department of Health. Given Health Secretary Andrew Lansley’s commitment to evidence-based medicine, patient choice and the liberation of clinicians, we assume he will wish to employ the powers the ruling highlights rapidly so that doctors may provide women legally accessing early abortion with the best possible care.”

What will Andrew Lansley, the Tory Secretary of State for Health, who is planning to destroy the NHS, do? Hard to tell. He’s behind a radical blueprint to privatise and break up the NHS in England, which those who understand how the health service functions, from the medical professional associations to the editors of the BMJ and Lancet, are sure will cause chaos and destruction and cost £3 billion to implement. Does he also have the courage to amend this out-of-date regulation, to bring it in line with current practice in the USA, Sweden, Norway, France, Switzerland, and elsewhere? Probably not, because the anti-abortion fringe in his own party are likely to want to make mincemeat of him if he tries.

Ironically (and this is looking like the century of irony), in this same week the Roman Catholic Diocese of Phoenix, Arizona in the USA, castigated a Catholic hospital for allowing an abortion that saved a woman’s life.

Welcome to the 21st century.


[1] Why should we believe pain and suffering are good for women? Only misogynists and anti-abortionists think that.

[2] Bpas provide abortions for the NHS and for women not eligible for NHS abortions.

References

Chelstowska A. Stigmatisation of abortion and commercialisation of abortion services in Poland: turning sin into gold (working title). Reproductive Health Matters 2011;19(37). (In press)

Donnellan E. More find it harder to afford abortion services. The Irish Times. 29 June 2010.

Bpas disappointed its interpretation of Abortion Act is not deemed viable, but ruling shows Lansley now has power to ensure women receive best possible care. Bpas press release, 14 February 2011.

Hamilton S. Deadly abortion pills on sale in Ireland. Sunday Mirror (Ireland). 2 February 2011. [no link available]

Jacobson J. European Court finds Ireland’s abortion law violates rights of pregnant woman with cancer. RH RealityCheck. 16 December 2010. At:

Jordan A. Woman charged with selling illegal abortion tablets in supermarket. Medical Independent. 27 January 2011.

Where Am I?

You are currently browsing entries tagged with catholicism at The Berer Blog.