Framework Convention on Global Health (FCGH) – a blog in response to the May 18 Geneva meeting minutes

24/09/2013 Comments Off on Framework Convention on Global Health (FCGH) – a blog in response to the May 18 Geneva meeting minutes

A blog by Marge Berer, Editor Reproductive Health Matters. Originally posted on the blog of JALI – the Joint Action and Learning Initiative on National and Global Responsibilities for Health

I asked JALI if I could write a blog after I had read the minutes of the May 18 meeting in Geneva on the way forward for an FCGH,  to raise some issues that I’ve been confronting in the seemingly endless consultations and statements circulating on the internet on the post-2015 world – to do with what an MDG replacement would look like, whether or not universal health coverage as currently conceived is the answer to how to address health, and whether and where my issues of sexual and reproductive health and rights might fit into the “Sustainable Development Goals”, the most likely successor to the MDGs, when they have had such short shrift in the MDGs.

I was particularly struck by the paragraph on the two animating principles of a Framework Convention on Global Health mentioned in the minutes, that is, ‘global health equity (within and between countries) – “global health with justice,” as offered by Larry Gostin – and the right to health… setting clear standards to make it more concrete, measurable, and enforceable… addressing global governance for health… shifting international law towards health. It would ensure for all people the conditions required for health, including health care, public health, and social determinants of health, setting standards and establishing a national and global financing framework to enable universal access to and coverage of health care and public health measures (e.g., clean water, sufficient nutritious food)… directly address domestic inequities…[and] promoting Health in All Policies.’ (pp.2-3)

Just as people in the meeting raised the fact that some participants in the FCGH process required more explicit attention, e.g. health workers and health worker unions, as did some issues, e.g. mental health, I would like to raise three aspects that I think need to be part of the FCGH discussions:

i. Gender issues – that is, the differences between men and women in their health needs, their access to health and health care, and the inequities in that differential access. Gender issues in relation to health are crucial to any convention. There has been a lot of work by women’s health advocates on gender issues in relation to women’s health but far less work by either men or women on gender issues in relation to men’s health. In the same ways as girls’ and women’s health issues were at one time almost invisible in the previous century, attention to boys’ and men’s health issues has not been developed in the past 30 years, in spite of the growing attention to women’s health issues and wide-ranging work on gender, both in academia, by the women’s health movement and even in WHO. In a recent paper I was considering for publication, for example, it was said that gender-based violence against women was the most common form of violence, when in fact men experience far more violence globally overall, but between each other, whereas women experience violence mostly from men. Thus, work is needed on how to address gender issues within an FCGH in relation to the right to health, the social determinants of health, health financing, etc, and how this might be approached needs much more thought and consideration.
ii. Religious, political and “cultural” opposition to what an FCGH would stand for, being used most vocally today to justify why access to crucial aspects of health and health care related to sexuality and reproduction are being withheld and denied, and many sexual and reproductive rights condemned and criminalised. Underlying this opposition are two forms of hate: misogyny and hatred of any form of sexuality that is not heterosexual and heteronormative.

One of the reasons I support a Convention is that it would give greater weight to all these issues by requiring not only non-discrimination and equality, but also regular examination, analysis and critique of country programmes, along with official recommendations for policy and programmes, and demands for accountability and action through interpretation of the implementation of the convention. We are beginning to see such a framework making a difference in relation to sexual and reproductive rights issues, particularly via the work of CEDAW. So I recommend studying CEDAW’s history, functions, and procedures particularly and how they might be applied more broadly across health. I would be interested in being involved in this in the future.

iii. The process of developing the successor to the MDGs may cut out the few specific aspects of health and health care that were allowed into MDG 5, where they were mostly reduced to their lowest common denominator and stripped of their complexity, e.g. universal access to reproductive health was a late add-in to MDG 5, which never moved beyond superficial attention to a few aspects of reducing maternal mortality, diluted heavily by tacking newborns, infants and children onto “maternal” health, and omitting the great majority of interlinked sexual and reproductive health problems.

Universal health coverage in my opinion may also succeed in shortcutting and eliminating the “controversial issues” in whatever is included under a “unified health goal” post-2015, and it may also make support for addressing specific aspects of health equally or even more difficult. Having devoted two recent issues of Reproductive Health Matters to privatisation in sexual and reproductive health services, where articles provided evidence of a resulting increase in inequity of access to health care among the 4th and 5th socioeconomic quintiles of many African and Asian countries, I am worried that the health goal that is eventually agreed is likely to be biased one way or another towards consumerism, commercialisation and privatisation of health and health services, and their financial underpinnings such as health insurance. I am very uncertain of the value of what has emerged so far as regards universal coverage from WHO, given the pressure on the agency from the World Bank, big pharma, world trade policies, and the influence of private/foundation donors, when measured against what we would like to see as the basis for the Framework Convention on Global Health.

 

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.

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.

All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant!

11/07/2012 Comments Off on All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant!

Marge Berer, Editor, Reproductive Health Matters

I was among the first generation of women in the 1960s to experience the miracle of the pill just at the age when I was wanting to start having sex. All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant if I didn’t want to, and it worked! But oh, if only it had all turned out to be that easy! Like one in three women in the UK today, a country where contraceptive prevalence is almost as high as it can get, I needed an abortion several years later. Again, I was lucky, the 1967 Abortion Act meant I was able to get a legal abortion. The lesson is simple – while contraception continues to be a miracle, because it helps people not to have children if and when they don’t want to, it is not enough on its own and it never has been.

Family planning has been out of the news for a long time, and suddenly it’s back. Welcome!! Bring out the red carpet, and I mean it!! Women and men need contraception now as much as they have ever done, and young women and men who are beginning to explore their sexuality together need contraception and condoms more than anyone. But there has been a lot of water under the bridge since family planning was promoted as the cure-all for the world’s ills in the 1960s when the pill came out, and everyone needs to study that history anew so that the same mistakes, of which there have been many, and the same narrow vision, are not repeated.

My generation of women’s health activists, along with a whole generation of researchers, service providers and policymakers who brought their knowledge together at the International Conference on Population and Development in 1994, got the world to recognise that the need for the means to control fertility, which is as old as history itself, was part of a much broader set of needs related to reproduction and sexuality, and that these were inextricably connected. These include: being able to have sex without fear of negative outcomes, being able to have sex if and only if we want to and only with whom we want to, being able to have the children we want, being able to get pregnant at all, being able not only to survive pregnancy but also still be in good health, being able to have a safe abortion without fear of death or condemnation when an unwanted pregnancy occurs, being able to protect ourselves from sexually transmitted diseases, and being able to get treatment for all the many causes of reproductive and sexual ill-health, which start with menstruation and menstrual problems, and continue into old age with things like breast and prostate cancer and uterine prolapse.

There is indeed a huge unmet need in today’s world, but the unmet need for contraception is only a fraction of the unmet need for sexual and reproductive health, and for sexual and reproductive rights. The results we should be working for encompass every aspect of the issues I have just named, and those in turn must be seen in the even wider context of the right to health, social justice and an end to poverty and violence – which were the real point of the Millennium Development Goals – not the measurable targets.

I will be blogging about these issues in the light of the FP Summit over the next weeks – watch this space!

Jingle pills indeed

16/12/2011 Comments Off on Jingle pills indeed

This post first appeared on the BMJ Group Blog, 12th December 2011

Many years ago now, when news of female sterilisation first came out, Catholic priests in Puerto Rico and other Catholic countries preached from their pulpits against women being sterilised. As a result many more women learned that sterilisation existed, and many went out from church asking where to get it. In effect, the church gave family planning free advertising space by opposing it. Recently, the Daily Mailand others who rant against emergency contraception and abortion have played a similar role.

The British pregnancy advisory service (Bpas) received widespread coverage for their Christmas morning-after pill campaign, in which they offer to send women who request it free emergency contraception if they phone in and discuss it with a nurse.

This campaign represents several major advances in support of women who may be having sex without using a regular contraceptive method, but do not want to get pregnant. First, Bpas are making the service available by phone in advance of the “emergency” nature of the need. Thus, just as we keep pain medication in the medicine cabinet in case we get a headache, women are being encouraged to have morning-after pills on hand, in case they need them. Second, they are making the pills free when many chemists charge £25 for one dose, which many young and unemployed women would find prohibitive, and the phoneline will be open when GPs and chemists are closed. Third, they are able to broach regular contraceptive use with the women who phone and encourage them to start regular method use.

The morning-after pill has been available over the counter from chemists without a prescription for over-16s since 2001. So all the palaver about Bpas suddenly making it as easy as dialling for a pizza is silly. In any case, if you’ve had unprotected sex, the morning-after pill will help you far more than pizza. There are people who simply don’t want any form of birth control to be easily accessible and who still claim that emergency contraception (and abortion) promote promiscuity, just as their anti-abortion forbears claimed about the contraceptive pill and female sterilisation in their day. In the end, it’s sex they’re against. Perhaps Nadine Dorries should try putting that on prescription!

A Cochrane review in 2010 found that women who received an advance supply of the morning-after pill had the same chance of becoming pregnant as those who did not have early access to the method. However, these pills do prevent pregnancy when they are used. It seems that many of the women who have unprotected sex and get pregnant without wanting to are not the ones actually obtaining and using the morning-after pill. Perhaps Bpas’ campaign, with the help of all the media who have given it space, will help to change that.

According to the Bpas press office, 1,000 women phoned in the first 48 hours. If many more women find out about this method and start to keep a dose or two at home in case they need it, there is a far better chance they can avoid an unwanted pregnancy.

Andrew Lansley, the Health Secretary who doesn’t want responsibility for the NHS, told the Daily Telegraph that he would prefer there to be face-to-face counselling. Is that actually necessary when only a few questions need answering? And, someone has to seek face-to-face counselling first. For those who don’t, or won’t, this can only be a good thing.

Indeed, helplines for health-related issues are becoming more common and their value is clear. The FPA, for example, has run a helpline for years and has an excellent record of informing and referring for services for family planning and sexual health. The new aspect of Bpas’ campaign, sending the pills through the post, is like ordering something on the internet. Why not?

As for the under-16s, let’s get real. The under-16s who have sex may only do so very irregularly. But if they’re going to have sex, they need access to contraception. The morning-after pill may not be their best option in the long run, but it should be there if they need it.

We need contraception to be in the news more often – it’s good news. I applaud Bpas and all the media who have publicised their campaign. Jingle pills indeed!  Happy holidays!

On 11th January 2012 an update of the situation appeared on Abortion Review.

Fighting the English Health and Social Care Bill

03/10/2011 Comments Off on Fighting the English Health and Social Care Bill

I have just written a letter to 16 members of the House of Lords, asking them to intervene and make sure the Health & Social Care Bill is thoroughly examined and if possible rejected to prevent it passing into law as it is.

The letter was designed to support the efforts of those among the Lords already working actively to subject the Health & Social Care bill to the in-depth scrutiny it did not receive in the House of Commons via a special committee, and to urge them at the minimum to find ways to substantively amend it so as to reduce the damage from its worst clauses. Even more, what I really wanted was to convince the House of Lords to reject it altogether. The bill is fatally flawed. If it is passed, even with amendments, it will turn the “NHS” in England into a mere logo.

I believe one of the reasons why the Bill did not fall in the Commons was that the opposition did not attempt to defeat it per se, but rather put forward many amendments without consensus or unity among all those who were seeking to oppose/amend the bill. Cross-party opposition was totally absent on a subject that cries out to be treated in a cross-party manner because it affects us all (though not equally). Moreover, the time for debate was so limited that it made a farce of any serious examination of the bill itself, let alone the many amendments that had been tabled.

Many people who oppose the bill called on both Labour and the LibDems in the Commons to hold a consultation with expert key parties – in the NHS, in health professional associations, civil society health advocacy groups and patients’ groups. We wanted them to draft an alternative bill for which to campaign, as well as table a united set of amendments to this bill. This did not happen, to our great disappointment.

Many people are therefore looking to the Lords to play the role it is justly famous for – stepping into the breach in a crisis and putting things right.

Here are some compelling arguments against the Bill:

My blog, 17 reasons to oppose the bill, which outlines all the forms of privatisation envisaged in the bill, none of which have been ameliorated or cancelled out by amendments in the Commons, why they are a mistake and what to support instead.

 “It’s already happened” by James Meek writing in the London Review of Books is the best description I have seen to date of the negative consequences for hospitals of privatisation of the NHS. It uses the example of what has happened over recent years to the Wrightington Hospital near Wigan and its orthopaedic centre of excellence for hip and other joint replacements.

“An unsuitable case for treatment” by Hackney GP Jonathon Tomlinson describes the serious problems that privatisation and “choice” (highly restricted in reality) have already placed in the way of his treating one of his most vulnerable and ill patients and why he believes he can no longer do what is best for his patient in the face of NHS changes.

A diary by Andrew O’Hagan, also from the London Review of Books, is about Nye Bevan and the history of the NHS, how much the proposed reforms go against the ethos of Bevan to ensure universal access to health care, and a report of his conversations with a GP at the Kentish Town Health Centre in London, who explains what a disaster it will be if GPs have to hold the purse strings locally.

These contain incredibly strong arguments and examples for any debate, and the basis for alternatives to the clauses in this Bill, and to the Bill as a whole.

There are two campaigns being run to try and influence the House of Lords: one by 38 Degrees and the other by the TUC.

Join the fight against the privatisation of the NHS!

Why is abortion – and particularly repeat abortion – still perceived as a problem?

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.[1]

However, this paper states that “it is difficult to fully ascertain the number of teenagers in the UK who have had more than one pregnancy before the age of 20 years” because figures for children born outside marriage are not recorded by the Registry Office. It was only data collected on abortions that allowed this study to be carried out. Because the number and proportion of abortions has risen, this author concludes that there is a worrying situation here – a conclusion that can only be based on the belief that more abortions are a bigger problem than fewer abortions.

I would suggest that this is not the correct perception. Younger people appear to be starting to have sex earlier than in the past (or perhaps they’ve been asked the question more often). That means that more of them may be at risk of unintended pregnancy. Teenage pregnancy is also perceived as a problem. And it certainly is, among those who cannot cope with a baby after it is born. According to recent research, approximately 50% of teenage conceptions end in abortion, not motherhood.[2] But if more teenage pregnancies are ending in abortion, that should be seen as a good thing, because at least potentially it means fewer young women having children they cannot cope with.

Why then is abortion still perceived as a problem, particularly, though not only, if it happens more than once?

Every new generation of women and men has to learn things from scratch. Just because a growing range of contraceptive methods has been available since the 1960s, it doesn’t follow that adolescent girls and boys have any experience whatsoever with contraceptive use when they first start to have sex. Human beings often learn things the hard way – by making mistakes. Why is this frowned upon and treated as a major moral failing with contraception and even more so with abortion?

If 100 sexually active women don’t use any contraception, 80–90 will become pregnant within a year. Prevention of unintended and unwanted pregnancies is something that heterosexually active couples have to concern themselves with and take action on throughout their fertile years, especially since most people now have only a few children (and many have none or only one) and many want to delay childbearing for ten years or more after starting sexual relationships.

An unintended/unwanted pregnancy usually comes as a shock, and often acts as a wake-up call that no one is immune to getting pregnant, and to do better with contraception. Thus, the large majority of women who have an abortion have only one abortion. Given this fact, I believe it is a mistake to think that it is possible to reduce the abortion rate extensively – unless everyone using contraception uses long-acting or permanent methods that have almost no failure rate or user error.

That would mean no natural methods, no condoms (but what about protection from sexually transmitted infections and HIV?), no oral contraceptives (which are the most commonly used method), no diaphragms or caps, and no vaginal rings. Even injectables are only highly effective if you always remember to go back for the next injection on time. Female sterilisation and vasectomy have a very low failure rate and are well-liked, but only for those who have completed their families.

Implants last 3 years, the IUS lasts up to five years and the copper IUD up to ten years, but are they the method of first choice among women who may want to get pregnant in less than 3-10 years’ time? Should they be the only methods recommended to women perceived to be at risk of unwanted pregnancy? Do we really want to go down this limited and limiting road? The Department of Health appears to think the answer to this question is yes, but where is the evidence that women will accept it, that it will cost less than providing early abortions without problematising or punishing those who have more than one, or that it will reduce the number of unintended pregnancies, let alone abortions?

The fact is, as Lisa Hallgarten, Director of Education for Choice, pointed out to me when we were discussing repeat abortions this week, “someone who has taken sufficient risks to get pregnant the first time will probably do so again unless something changes – i.e. she and her partner experience a useful intervention”.[3]

International comparisons

In case anyone thinks the UK is doing so badly in regard to repeat abortions, let’s look briefly at other countries. In Sweden a study published this year found that almost 40% of induced abortions were repeat abortions among women aged 20-49 having abortions. And Sweden is a country with long established sex and relationships education and a public health policy to enhance sexual and reproductive health. The highest “risk factor” found was parity. In other words, women who already had children were most likely to have one or more repeat abortions. This implies they had the number of children they wanted and were getting pregnant more than once when they didn’t want more. Other risk factors were lack of emotional support, unemployment or being on sick leave, tobacco use (probably related to lower socioeconomic status), and low educational level.[4] In short, in addition to not wanting more children, they were among the most vulnerable women in society.

This and other articles make several useful recommendations. One is to look at the content and quality of sex and relationships education for those in school, to see whether it might be adapted better for vulnerable groups.

Another recommendation is to examine the barriers to effective contraceptive use and in contraception provision in abortion clinics themselves, following abortion. Studies have variously found that only a limited number of contraceptives may be offered in post-abortion care, and that methods requiring more skills may not be available. If women have to be referred elsewhere for some methods, timing of getting contraceptive advice and starting a method may not be optimal, and lead to lower levels of uptake and long-term usage.

A New Zealand study found that “compared to women who left the clinic with combined oral contraceptives, those leaving with an IUD at baseline were less likely to return for a subsequent abortion. Among women who had not had a previous termination, however, younger women were less likely than older women to have had an IUD inserted post-abortion. With every additional live birth, women were three times as likely to have left the abortion clinic with an IUD. Among women who had had a previous termination, age was no longer significantly associated with post-abortion IUD insertion. However, parity was still significantly associated, as was having a negative sexually transmitted infection test.”[5]

Perhaps the most useful study I found was carried out by Sangeeta Das and colleagues from the Department of Obstetrics and Gynaecology, Royal Oldham Hospital, Oldham.[6] They start by saying that in the UK, there are no agreed criteria for defining “’recurrent abortion seekers”. This is important, since it is possible for a woman to have an abortion every year – or as rarely as 3 or 5 or 10 or even 15 years apart. Hence, it is important from the outset to decide how frequently repeat abortions must occur before they are indicative of a “problem”, given the long duration of fertility and sex.

The Das et al study aimed to review the characteristics of women requesting termination of at least two consecutive pregnancies within 24 months of the first termination.The incidence of repeat abortion within a 24-month period was only 2.3%. This is far lower than the figures one usually sees.

Financial circumstances were the most common reason for seeking abortion (75%). The combined oral contraceptive pill and condoms were the most common forms of contraception used by these patients before the first abortion (35% and 38%, respectively). Long-acting reversible contraception (LARC) was used by only 8% of women before their first termination. However, although 58% accepted LARC following abortion, which would appear to support Department of Health policy, only 2% continued its use thereafter. And 50% of women were not using any contraception at the time of the repeat abortion. Hence, LARC may not be the answer at all in some cases. The fact is, contraceptive use itself may be the source of the difficulty.

The authors suggest that social workers and perhaps psychologists should be part of the peri-abortion counselling team, that contraceptive counselling should be geared to improving compliance and that  follow-up to ensure continuing contraceptive use and involvement of partners in decision-making could help to reduce the incidence of repeat abortions.[6]

Policy ignoring evidence?

Given the need for better education and guidance, I was disturbed to learn this week from a Guardian article [7] that with council budgets under pressure from government cuts, the posts of Teenage Pregnancy Coordinators (TPCs), who provide advice on sexual health, pregnancy and contraception to young people, often by mobile phone, have been axed since the beginning of 2010 in 56 Primary Care Trusts in England, or over a third of PCTs. These include Walsall, Tameside, and Waltham Forest in east London, who now have no dedicated TPCs, despite being among the 20 areas in England with the highest levels of teenage pregnancy.

Several TPCs interviewed in the article expressed concern that, because some areas have succeeded in reducing teenage pregnancy rates, attention to the issue was being downgraded as a priority because the policy had succeeded. This is obviously a very flawed understanding of the need for ongoing work with those needing support and attention from among the many new young people who are growing up and starting to have sexual relations every year.

Here are some of the issues that emerge from this brief look at the issues:

1. Is repeat abortion a problem? Or, how frequently must it happen before it should be treated as a problem?

2. Isn’t the real problem poor or intermittent or no contraceptive use? If so, surely it is imperative to support consistent and correct contraceptive use rather than assume that only by pushing specific methods (LARC) you will solve the problem on its own.

3. What social support is needed by those perceived to have a problem? Are TPCs available locally? Should they be? What other support is needed? Is it available? Who should provide it, where?

4. Does contraceptive counselling, provision, and choice of method for young people need to be improved? Are there dedicated services for young people? What about for women of any age who are at risk and vulnerable? What are the barriers to good contraceptive access and use? How can services be improved? All local FP clinics should be examined from this point of view – those in the community in primary care centres, those in hospitals, and those attached to abortion clinics.

5. What is the quality of sex and relationships education on the subjects of both contraception and abortion locally? Does it speak to the problems of those who are perceived to be at risk of unintended and unwanted pregnancy? Does it give sufficient information about abortion and seeking an abortion? Or does it merely moralise on the subject?

Before acting we need to find out the extent of the problem and who is at risk; to talk to women themselves, find out what their needs are and then decide what to provide, and how. Just blaming women doesn’t help; the role of partners is also key, as is social and economic and family circumstances.

Complex doesn’t have to mean problematic

Consistent and correct use of contraception makes it possible to space and limit births, and the UK has a high prevalence of contraceptive use.

Internationally, it has been shown that young age, lack of experience, lack of information, poor sexuality and relationships education, difficult home and living situations, abusive partners, poverty, low sense of self-worth and self-efficacy, and limited life choices all contribute to less than effective contraceptive use.

Single adolescent girls who become pregnant unintentionally may welcome a pregnancy and baby, especially those with limited life choices, because a baby gives them something to live for and a sense of self-worth. Some may have thought they wanted to get pregnant, but when it happens, the reality of a baby makes them realise that they wouldn’t be able to cope with it. Many young women seek abortions when they learn they are pregnant precisely because they could not cope with a baby, and/or in order to pursue other life choices, whether work or further education.

The longer women stay single, the more likely they are not to want a baby. If they are also not using contraception effectively, the more likely it is that they may experience one or more unintended pregnancies and seek an(other) abortion. Abortion is a solution for an unwanted pregnancy. It is legal, it is available, and it does not adversely affect health or fertility in this country anymore.

Unintended pregnancies remain common because fertility lasts from as early as age 12 to as late as age 49, contraception fails, people fail to use it consistently and correctly, they may stop using a method and not replace it with another for some time, a new partner may refuse to accept using a method, and so on. The literature on this is extensive.

One in three women in Britain will have an abortion in their lifetime. It’s time to see abortion as a solution, not as the problem.


[1] Collier J. The rising proportion of repeat teenage pregnancies in young women presenting for termination of pregnancy from 1991 to 2007. Contraception 2009;79:393-96.

[2] Hoggart L, Phillips J. Young people in London: abortion and repeat abortion. Research report. Department for Children, Schools and Families; Government Office for London. January 2010. At: < http://www.bpas.org/js/filemanager/files/tpyoungpeopleinlondonabortionandrepeatabortion.pdf&gt;.

[3] See: Hallgarten L, Misaljevich N. Reducing repeat teenage conceptions: a review of practice. Education for Choice, 2007. At: <http://www.efc.org.uk/professionals/efc_research.html&gt;.

[4] Makenzius M, Tydén T, Darj E, Larsson M. Repeat induced abortion – a matter of individual behaviour or societal factors? A cross-sectional study among Swedish women. Eur J Contracept Reprod Health Care 2011 Jul 21. [Epub ahead of print]

[5] Roberts H, Silva M, Xu S. Post abortion contraception and its effect on repeat abortions in Auckland, New Zealand. Contraception 2010;82(3):260-5. Epub 2010 Apr 14.

[6] Das S, Adegbenro A, Ray S, Amu O. Repeat abortion: facts and issues. J Fam Plann Reprod Health Care 2009;35(2):93-95.

[7] Williams R. Cuts threaten to undo progress on reducing teenage pregnancies. The Guardian (Society). 10 August 2011. p.30-31.

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.

Can we ever say a woman can’t choose?: a response to Frances Kissling

14/01/2011 Comments Off on Can we ever say a woman can’t choose?: a response to Frances Kissling

Can we ever say a woman can’t choose? It’s hard for pro-choicers to admit sometimes a woman shouldn’t be allowed to choose abortion – but we have to
by Frances Kissling Salon, 21 June 2009.

This article, which I’ve only recently discovered, was posted on the Salon website last year. Salon long ago closed the discussion, but alongside Ann Furedi,[1] I feel compelled to respond, because I want to exclude myself from the group she has placed herself in, one she wants to call pro-choice but now believes has the right to refuse women a late abortion.

Frances would not be the first person to move from being pro-choice on abortion to being against some aspects of it, if not becoming completely against it. This article appears to be indicative of such a shift on her part. Yet the Frances I know has been a formidable force in challenging official Catholic  doctrine on abortion. As a board member and later first president of Catholics for a Free Choice she became the face of an organization that brought together Catholics from all over the world to take a public stand against a profoundly anti-women doctrine, all of them people who refused to give up their identity as Catholics. She argued then that according to Catholic theology, acting upon one’s own conscience was the most profoundly ethical stance on abortion that a person can take.

So what has moved Frances from there to here, where she calls for refusing some women an abortion?

The case that she says first moved her to rethink her views, which she was asked to respond to on an ethics panel, was the kind of case an anti-abortionist would come up with, of a woman with a seemingly “frivolous” reason for wanting an abortion . There were few details offered, only that the couple didn’t want a second boy (“oh, it’s just that we wanted a girl”, presented as if it were equal to “oh, but I wanted the blue dress, not the red one”). There was no apparent gender discrimination mentioned, as there mostly is when fetal sex is given as a reason for abortion. The couple are one-dimensional; they have no history, no background. Their “case” for abortion is easy to reject. And of course there are always some women and couples who have “lightweight” reasons for seeking an abortion, and many more who could and should have prevented the pregnancy, but should they become the basis for compromising the whole ethos of women’s choice on abortion? You can’t be involved in abortion issues, read the literature or work in an abortion clinic without knowing that people with trivial reasons for abortion form a small minority of abortion seekers and that those who have to confront an unwanted pregnancy do learn (the hard way) about taking responsibility. Mostly they learn well because they never come back. So why didn’t Frances reject the example given and ask for a serious case to exercise her judgement on?

Instead of asking whether the couple should have been refused an abortion, perhaps the meeting should have asked: 1) whether a woman should ever have to justify or give reasons for her need for an abortion to the abortion provider at all, and 2) whether the provider should have the power to refuse a woman a procedure the outcome of which, one way or another, will have a major bearing on the rest of her life. The pro-choice answer to both these questions is no.

In making her case for refusing the woman an abortion, Frances fails to focus on the woman and the woman’s life, or what will happen if she has the baby, and instead decides she has to punish the woman and bring the baby into the world because the request comes late in pregnancy. A baby for which Frances has no duty of care and for whose life she will take absolutely no responsibility. But it is in fact the absence of responsibility for what happens to the woman and the baby, if the pregnancy is carried to term against the woman’s will, that explains why an abortion provider must never pass judgement on the validity of a woman’s need for an abortion. In my opinion, it is only possible to be anti-abortion if you will never be the one left holding the baby, nor be around to see or take responsibility for what happens to those who are.

And yes, for me that means that abortion providers should act as technicians with a clinical skill to offer, as all other medical professionals do, not as judges. Health professionals are not forced to provide abortions, and abortion providers who are only willing to do abortions up to a certain number of weeks of pregnancy should make this clear to everyone who seeks their help, and refer women to someone who can and will help them. The fact that there are so few doctors willing to provide late abortions in the United States is surely due as much to the fear of aggressive and oppressive anti-abortion harassment, violence and the very real threat of assassination as anything else. No morality in that.

This article makes the assumption that a person can be pro-choice sometimes and not at other times. How is this possible? “Pro-choice” is short for “supporting a woman’s choice on abortion”. It’s an unfortunate terminology, because it assumes that women really do have a choice and have more than one viable option to choose from. But this does not reflect the reality of most women’s lives or what women themselves say. Women risk their lives, if they have to, to end an unwanted pregnancy. It is not a matter of choice for them, but of overwhelming need. Nevertheless, even accepting the terminology, if the decision is not the woman’s, then the “choice” has either been denied altogether or it has been transferred to someone else – and that could as easily include George W Bush or the Pope as well as Frances. In my moral universe, anyone who thinks they have the right to refuse even one woman an abortion can’t continue to claim they are pro-choice. It’s a contradiction in terms.

As it progressed, I began to feel offended by this article because it says things such as “These things should make us pause and think hard.” (The “things” being some of the reasons women have given for seeking an abortion.) As if Frances is the only person in the pro-choice movement who has ever paused and thought hard about these things. By this point in her paper, the “we” and “us” who she claims to speak for begins to shift, however, because she separates herself from those of “us” who are pro-choice by such statements as: “I realize that expressing pro-life values, when you’re pro-choice, is much more complicated.” “Pro-life” is it now?

And then comes the final blow to any lingering concept of “choice” when she says: “But I have come to believe that women’s autonomy does not require that all efforts be made to protect women from pain or from hearing the word ‘no’.” Thus does she reject her own historic respect for women acting on their conscience and reduces them to the moral equivalent of spoilt children whose only problem is that they might feel pain or be refused something. In 1993, Frances encouraged me to publish “An open letter to a Diocesan priest”,[2] a personal statement about the lifelong pain of having to give up a baby for adoption as an alternative to having an abortion. Why does Frances no longer acknowledge this level of pain when she talks about “choice”? What really has made the person who put Catholics for a Free Choice on the map trivialise both much unwanted pregnancy and the women who experience it?

She goes on to say: “I think it’s important for us to be able to say: When a fetus reaches the point where it could survive outside the uterus, is healthy, and the woman is healthy, and she has had five months to make up her mind, we should say no to abortion”. Who exactly are the “we” that she now considers herself to be part of?

But wait a minute. If the actual subject of this inquisition is only women with unwanted pregnancies at 26 or more completed weeks of pregnancy, which is the point at which scientists agree the independent survival of a fetus outside a woman’s body begins to be feasible, she is actually talking about refusing abortions to only a handful of women. In Great Britain in 2009, for example, the number of women who had an abortion at 24+ weeks of pregnancy was 136 out of a total of 189,100 abortions. All 136 were on the ground that there was “a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped”.[3] None of these women had had five months to make up their minds.

Does this demolish her argument? No, I assume she would point to the 2,036 women that year who had abortions at 20+ weeks of pregnancy, on grounds of “risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman”. Those are the women, I think, whom she accuses of having had five months to think about it and should have acted sooner. The fact that a third of them were less than 20 years of age, and none of them had had their abortions when the fetus was capable of independent survival may not alter her stance either.

Still, why has she singled these women out and stigmatised them and their circumstances as unworthy of the respect that legal abortion provision expresses? And if she would indeed force them to carry an unwanted pregnancy to term, why does she think they would want her compassion, let alone her help. Help? What help can she, would she, give them, year in and year out?

Anti-abortion sentiment like this is creating a climate of rejection of second trimester abortions, including those that take place well before “viability”, in countries across the developed world where the abortion law has (more or less) supported women’s choice on abortion for decades.

Everyone who is pro-choice would prefer for women not to need late abortions, just as everyone would prefer, in the best of all possible worlds, for there not to be any unintended pregnancies. But there are millions of unintended pregnancies globally every year, because we are imperfect, make mistakes, and are less in control of our lives and behaviour than we would like to be. The pro-choice answer is not and can never be to refuse women abortions. The pro-choice answer is to remove all the obstacles to getting an abortion as early as possible, provide young women and men with the education on abortion from an early age that would enable them to prevent pregnancy, recognise they are pregnant early on, obtain non-directive counselling and support if they need it , and if the pregnancy is unwanted, ensure there is timely access to abortion services. That combination of education, support and service delivery would allow almost all abortions to take place before 24 or even 20 weeks of pregnancy. Countries like Sweden, where women have the right to choose up to 18 weeks but abortion is legal until 24 weeks, have proved it is possible. But there will always be a handful of women who fall outside the net, even in the best of conditions. The moral thing, the compassionate thing, the pro-choice thing to do is to support them and do the abortions anyway.

Frances, come back!

This article was first posted on the RH Reality Check website on 2nd January 2011.


[1] A moral defence of late abortion. 20 December 2010. At: <http://www.spiked-online.com/index.php/site/article/10015/&gt;. Reprinted with kind permission at: <www.rhmjournal.org.uk>.

[2] Wolch Marsh MJ. Reproductive Health Matters 1993;1(2):87-91.

[3] Department of Health. Abortion Statistics, England and Wales: 2009. London: DoH, 2010.

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