24/02/2012 Comments Off on In defence of abortion on a woman’s request, including on grounds of fetal sex
Published on the British Medical Journal Guest Blog, 24th February 2012
Ach, what a furore. The Daily Telegraph is in its element and having a ball printing nasty allegations about doctors doing abortions illegally on grounds of sex selection. Let’s look at the issues a bit more dispassionately. First, is it actually illegal? Yes and no. The 1967 Abortion Act does not permit abortion on grounds of sex selection per se, it is true, and the law is framed so that anything that cannot be defended as coming under one or more of the named legal grounds is technically illegal. However, the question remains whether abortion on grounds of sex selection can be defended under the existing legal ground for abortions. I believe the answer is yes.
Sex selective abortion, like late second trimester abortion, lends itself to easy condemnation and stigma, and many otherwise pro-choice people are opposed to it. In India and China, where the laws on abortion are otherwise very liberal, sex selective abortion is subject to several laws banning it, all of which are totally ignored ̶ both because women are under great pressure to have boys, especially women whose first child was a girl and who have only one or two chances, and because those doing the ultrasound scans are making a lot of money from them.
This isn’t a question of designer babies, though it is always the case that where something is possible technically, and is available for a range of reasons, e.g. determining whether there is a risk of sex-specific genetic anomalies, it will also be used in other ways. In this sense, finding out fetal sex during an ultrasound scan is inevitable and justified. This information belongs to the parents and should not be withheld. The baby is theirs after all. Preferring a baby of one sex over the other is nothing new, but has become more of an issue, according to the literature on sex selection in Asia, precisely because people are having so few children. But this is not just a cultural or ethnic issue. I watched my next-door neighbour treat her second child, a boy, badly throughout his childhood because she had wanted a second girl. She never forgave him for being born, at a time when there was no ultrasound for finding out fetal sex. Is this so uncommon?
I believe doctors faced with a request for abortion from women whose cultures practise discrimination against women and girls can justify it under the existing abortion law on the following grounds: taking the woman’s social situation into account, and because the woman’s physical and mental health and well-being may be at risk, and also her existing children. The potential for abuse of a woman by her husband and family, and poor treatment of and even purposeful neglect of girl children (leading to poor development and even death), are common outcomes in Asian cultures that demand that women produce boys. Women can be rejected and their lives made miserable. No one that I am aware of has ever investigated the existence or extent of such abuse and neglect in the UK among families from these cultures, but perhaps it’s time someone did. Moreover, it is also the case that a woman may not want another baby anyway, for other valid reasons, and fetal sex may be the only acceptable excuse she can give in her family situation for seeking an abortion.
Lastly, if anyone thinks that incrimination, condemnation and prosecution of pro-choice doctors is going to make this situation go away, they need to think again. Women will simply say they have a different reason and doctors will duly record it.
I believe health professionals and everyone who is pro-choice on abortion should support pro-choice doctors and women seeking abortions, whatever their reasons, even when sex selection may be involved.
The Daily Telegraph’s stories and the cowards who remain unidentified who went under false pretences to abortion providers and doctors who authorise abortions with the intention of incriminating them, should be condemned. Their aim is not to stop sex selection, which will not go away until discrimination against women and girls becomes history. Their aim is to stigmatise abortion and women who have abortions, to frighten women and abortion providers that they are breaking the law, and to seek to restrict the law on abortion. Their behaviour is unethical and under-handed, and constitutes harassment, which should be rejected and even subject to prosecution for wasting the Health Department’s and police time.
The UK needs to make abortion available legally on the request of the woman, and to decriminalise abortion altogether. This is an idea whose time would have come long ago if misogyny and harassment of women were illegal ̶ and prosecuted ̶ instead.
16/08/2011 Comments Off on Why is abortion – and particularly repeat abortion – still perceived as a problem?
A study of repeat teenage pregnancies in women under 20 years old presenting for an abortion in England and Wales from 1991-2007 found that the number of women with recorded previous pregnancies had risen steadily from 1991 to 2007, both in absolute numbers and in proportion. The proportion of those who had a repeat abortion also rose.
However, this paper states that “it is difficult to fully ascertain the number of teenagers in the UK who have had more than one pregnancy before the age of 20 years” because figures for children born outside marriage are not recorded by the Registry Office. It was only data collected on abortions that allowed this study to be carried out. Because the number and proportion of abortions has risen, this author concludes that there is a worrying situation here – a conclusion that can only be based on the belief that more abortions are a bigger problem than fewer abortions.
I would suggest that this is not the correct perception. Younger people appear to be starting to have sex earlier than in the past (or perhaps they’ve been asked the question more often). That means that more of them may be at risk of unintended pregnancy. Teenage pregnancy is also perceived as a problem. And it certainly is, among those who cannot cope with a baby after it is born. According to recent research, approximately 50% of teenage conceptions end in abortion, not motherhood. But if more teenage pregnancies are ending in abortion, that should be seen as a good thing, because at least potentially it means fewer young women having children they cannot cope with.
Why then is abortion still perceived as a problem, particularly, though not only, if it happens more than once?
Every new generation of women and men has to learn things from scratch. Just because a growing range of contraceptive methods has been available since the 1960s, it doesn’t follow that adolescent girls and boys have any experience whatsoever with contraceptive use when they first start to have sex. Human beings often learn things the hard way – by making mistakes. Why is this frowned upon and treated as a major moral failing with contraception and even more so with abortion?
If 100 sexually active women don’t use any contraception, 80–90 will become pregnant within a year. Prevention of unintended and unwanted pregnancies is something that heterosexually active couples have to concern themselves with and take action on throughout their fertile years, especially since most people now have only a few children (and many have none or only one) and many want to delay childbearing for ten years or more after starting sexual relationships.
An unintended/unwanted pregnancy usually comes as a shock, and often acts as a wake-up call that no one is immune to getting pregnant, and to do better with contraception. Thus, the large majority of women who have an abortion have only one abortion. Given this fact, I believe it is a mistake to think that it is possible to reduce the abortion rate extensively – unless everyone using contraception uses long-acting or permanent methods that have almost no failure rate or user error.
That would mean no natural methods, no condoms (but what about protection from sexually transmitted infections and HIV?), no oral contraceptives (which are the most commonly used method), no diaphragms or caps, and no vaginal rings. Even injectables are only highly effective if you always remember to go back for the next injection on time. Female sterilisation and vasectomy have a very low failure rate and are well-liked, but only for those who have completed their families.
Implants last 3 years, the IUS lasts up to five years and the copper IUD up to ten years, but are they the method of first choice among women who may want to get pregnant in less than 3-10 years’ time? Should they be the only methods recommended to women perceived to be at risk of unwanted pregnancy? Do we really want to go down this limited and limiting road? The Department of Health appears to think the answer to this question is yes, but where is the evidence that women will accept it, that it will cost less than providing early abortions without problematising or punishing those who have more than one, or that it will reduce the number of unintended pregnancies, let alone abortions?
The fact is, as Lisa Hallgarten, Director of Education for Choice, pointed out to me when we were discussing repeat abortions this week, “someone who has taken sufficient risks to get pregnant the first time will probably do so again unless something changes – i.e. she and her partner experience a useful intervention”.
In case anyone thinks the UK is doing so badly in regard to repeat abortions, let’s look briefly at other countries. In Sweden a study published this year found that almost 40% of induced abortions were repeat abortions among women aged 20-49 having abortions. And Sweden is a country with long established sex and relationships education and a public health policy to enhance sexual and reproductive health. The highest “risk factor” found was parity. In other words, women who already had children were most likely to have one or more repeat abortions. This implies they had the number of children they wanted and were getting pregnant more than once when they didn’t want more. Other risk factors were lack of emotional support, unemployment or being on sick leave, tobacco use (probably related to lower socioeconomic status), and low educational level. In short, in addition to not wanting more children, they were among the most vulnerable women in society.
This and other articles make several useful recommendations. One is to look at the content and quality of sex and relationships education for those in school, to see whether it might be adapted better for vulnerable groups.
Another recommendation is to examine the barriers to effective contraceptive use and in contraception provision in abortion clinics themselves, following abortion. Studies have variously found that only a limited number of contraceptives may be offered in post-abortion care, and that methods requiring more skills may not be available. If women have to be referred elsewhere for some methods, timing of getting contraceptive advice and starting a method may not be optimal, and lead to lower levels of uptake and long-term usage.
A New Zealand study found that “compared to women who left the clinic with combined oral contraceptives, those leaving with an IUD at baseline were less likely to return for a subsequent abortion. Among women who had not had a previous termination, however, younger women were less likely than older women to have had an IUD inserted post-abortion. With every additional live birth, women were three times as likely to have left the abortion clinic with an IUD. Among women who had had a previous termination, age was no longer significantly associated with post-abortion IUD insertion. However, parity was still significantly associated, as was having a negative sexually transmitted infection test.”
Perhaps the most useful study I found was carried out by Sangeeta Das and colleagues from the Department of Obstetrics and Gynaecology, Royal Oldham Hospital, Oldham. They start by saying that in the UK, there are no agreed criteria for defining “’recurrent abortion seekers”. This is important, since it is possible for a woman to have an abortion every year – or as rarely as 3 or 5 or 10 or even 15 years apart. Hence, it is important from the outset to decide how frequently repeat abortions must occur before they are indicative of a “problem”, given the long duration of fertility and sex.
The Das et al study aimed to review the characteristics of women requesting termination of at least two consecutive pregnancies within 24 months of the first termination.The incidence of repeat abortion within a 24-month period was only 2.3%. This is far lower than the figures one usually sees.
Financial circumstances were the most common reason for seeking abortion (75%). The combined oral contraceptive pill and condoms were the most common forms of contraception used by these patients before the first abortion (35% and 38%, respectively). Long-acting reversible contraception (LARC) was used by only 8% of women before their first termination. However, although 58% accepted LARC following abortion, which would appear to support Department of Health policy, only 2% continued its use thereafter. And 50% of women were not using any contraception at the time of the repeat abortion. Hence, LARC may not be the answer at all in some cases. The fact is, contraceptive use itself may be the source of the difficulty.
The authors suggest that social workers and perhaps psychologists should be part of the peri-abortion counselling team, that contraceptive counselling should be geared to improving compliance and that follow-up to ensure continuing contraceptive use and involvement of partners in decision-making could help to reduce the incidence of repeat abortions.
Policy ignoring evidence?
Given the need for better education and guidance, I was disturbed to learn this week from a Guardian article  that with council budgets under pressure from government cuts, the posts of Teenage Pregnancy Coordinators (TPCs), who provide advice on sexual health, pregnancy and contraception to young people, often by mobile phone, have been axed since the beginning of 2010 in 56 Primary Care Trusts in England, or over a third of PCTs. These include Walsall, Tameside, and Waltham Forest in east London, who now have no dedicated TPCs, despite being among the 20 areas in England with the highest levels of teenage pregnancy.
Several TPCs interviewed in the article expressed concern that, because some areas have succeeded in reducing teenage pregnancy rates, attention to the issue was being downgraded as a priority because the policy had succeeded. This is obviously a very flawed understanding of the need for ongoing work with those needing support and attention from among the many new young people who are growing up and starting to have sexual relations every year.
Here are some of the issues that emerge from this brief look at the issues:
1. Is repeat abortion a problem? Or, how frequently must it happen before it should be treated as a problem?
2. Isn’t the real problem poor or intermittent or no contraceptive use? If so, surely it is imperative to support consistent and correct contraceptive use rather than assume that only by pushing specific methods (LARC) you will solve the problem on its own.
3. What social support is needed by those perceived to have a problem? Are TPCs available locally? Should they be? What other support is needed? Is it available? Who should provide it, where?
4. Does contraceptive counselling, provision, and choice of method for young people need to be improved? Are there dedicated services for young people? What about for women of any age who are at risk and vulnerable? What are the barriers to good contraceptive access and use? How can services be improved? All local FP clinics should be examined from this point of view – those in the community in primary care centres, those in hospitals, and those attached to abortion clinics.
5. What is the quality of sex and relationships education on the subjects of both contraception and abortion locally? Does it speak to the problems of those who are perceived to be at risk of unintended and unwanted pregnancy? Does it give sufficient information about abortion and seeking an abortion? Or does it merely moralise on the subject?
Before acting we need to find out the extent of the problem and who is at risk; to talk to women themselves, find out what their needs are and then decide what to provide, and how. Just blaming women doesn’t help; the role of partners is also key, as is social and economic and family circumstances.
Complex doesn’t have to mean problematic
Consistent and correct use of contraception makes it possible to space and limit births, and the UK has a high prevalence of contraceptive use.
Internationally, it has been shown that young age, lack of experience, lack of information, poor sexuality and relationships education, difficult home and living situations, abusive partners, poverty, low sense of self-worth and self-efficacy, and limited life choices all contribute to less than effective contraceptive use.
Single adolescent girls who become pregnant unintentionally may welcome a pregnancy and baby, especially those with limited life choices, because a baby gives them something to live for and a sense of self-worth. Some may have thought they wanted to get pregnant, but when it happens, the reality of a baby makes them realise that they wouldn’t be able to cope with it. Many young women seek abortions when they learn they are pregnant precisely because they could not cope with a baby, and/or in order to pursue other life choices, whether work or further education.
The longer women stay single, the more likely they are not to want a baby. If they are also not using contraception effectively, the more likely it is that they may experience one or more unintended pregnancies and seek an(other) abortion. Abortion is a solution for an unwanted pregnancy. It is legal, it is available, and it does not adversely affect health or fertility in this country anymore.
Unintended pregnancies remain common because fertility lasts from as early as age 12 to as late as age 49, contraception fails, people fail to use it consistently and correctly, they may stop using a method and not replace it with another for some time, a new partner may refuse to accept using a method, and so on. The literature on this is extensive.
One in three women in Britain will have an abortion in their lifetime. It’s time to see abortion as a solution, not as the problem.
 Collier J. The rising proportion of repeat teenage pregnancies in young women presenting for termination of pregnancy from 1991 to 2007. Contraception 2009;79:393-96.
 Hoggart L, Phillips J. Young people in London: abortion and repeat abortion. Research report. Department for Children, Schools and Families; Government Office for London. January 2010. At: < http://www.bpas.org/js/filemanager/files/tpyoungpeopleinlondonabortionandrepeatabortion.pdf>.
 See: Hallgarten L, Misaljevich N. Reducing repeat teenage conceptions: a review of practice. Education for Choice, 2007. At: <http://www.efc.org.uk/professionals/efc_research.html>.
 Makenzius M, Tydén T, Darj E, Larsson M. Repeat induced abortion – a matter of individual behaviour or societal factors? A cross-sectional study among Swedish women. Eur J Contracept Reprod Health Care 2011 Jul 21. [Epub ahead of print]
 Roberts H, Silva M, Xu S. Post abortion contraception and its effect on repeat abortions in Auckland, New Zealand. Contraception 2010;82(3):260-5. Epub 2010 Apr 14.
 Das S, Adegbenro A, Ray S, Amu O. Repeat abortion: facts and issues. J Fam Plann Reprod Health Care 2009;35(2):93-95.
 Williams R. Cuts threaten to undo progress on reducing teenage pregnancies. The Guardian (Society). 10 August 2011. p.30-31.