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: <;.

[3] See: Hallgarten L, Misaljevich N. Reducing repeat teenage conceptions: a review of practice. Education for Choice, 2007. At: <;.

[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.


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: <;. Reprinted with kind permission at: <>.

[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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