13/07/2012 Comments Off on Making change happen is in the air
Editor, Reproductive Health Matters
Below, are excerpts from my editorial in RHM 20(39) May 2012. This issue is about reducing maternal mortality, but the more I reflected on it the more I realised it had implications for this week’s summit on family planning.
Making change happen is in the air, from the UN Secretary-General down to the most remote village… Yet, in certain ways, the world is moving backwards when it comes to dealing with women and pregnancy. Simone Diniz calls it a return to “materno-infantilism” – treating pregnant women like children who need looking after… Today, in much of the literature, all pregnant women are called “mothers” whether they’ve ever had a baby or not. Yet pregnancy has more than one outcome and is not only about women who “deliver”. It’s also about women who experience miscarriages, stillbirths, infant deaths, lack of access to contraception, unwanted pregnancies, unsafe abortions, and lifelong obstetric, reproductive and sexual morbidity. Yet these are nearly invisible in PMNCH these days, and safe abortion – an integral part of women’s right to decide the number and spacing of their children – may be made invisible in the new Family Planning Initiative as well…
The papers [in this journal issue] show that some countries are making serious efforts at strengthening and improving their health systems in relation to reproductive health care and maternity services. Based on data that show who is dying and why, they are making policy and programme changes, such as low-cost delivery services for poor and migrant women, opening new obstetric emergency care and referral centres in hospitals, training more health professionals, and providing health education for women, as in Shanghai (Du et al)…
Others are strengthening the whole public health system, especially in rural areas where most poor women live, ensuring better leadership and governance, increasing health workforce skills, supporting community-based health insurance, and increasing contraceptive services, as in Rwanda (Bucagu et al). They’re promoting peace, stability, economic growth, poverty reduction, improved primary education, better roads and communications, access to information on health and health services, and making health care free of cost for the poor, as in Cambodia (Liljestrand & Sambath)…
In contrast, in some countries, appalling, chaotic, uneven, negligent and abusive situations persist. Among the 22 million women each year who have unsafe abortions, adolescents suffer the most from complications and have the highest unmet need for contraception (Shah & Åhman). Custom, lack of perceived need, distance, lack of transport, lack of permission from husbands, cost, unwillingness to see a male doctor are still preventing women from seeking antenatal and delivery care, e.g. in northern Nigeria (Doctor et al), but in many places, these services barely exist anyway…
In the poorest of countries, women may have more pressing health needs even than for maternity care, e.g. in Haiti, where women identified access to any affordable health care, potable water, enough food to eat, any employment, sanitation and education as their most crucial problems (Peragallo Urrutia et al)…
Even more broadly, lack of national commitment has been identified as critical in 33 sub-Saharan African countries, as well as very low levels of public financing for health and health services (let alone maternity services), poor coordination between key stakeholders and partners, poorly functioning health systems with poor logistics for supply, distribution and management of essential medicines, family planning commodities, and equipment, and a chronic shortage of skilled health professionals (Ekechi et al).
In several South Asian countries, cash is being given to pregnant women to deliver in facilities, but some studies are finding, e.g. in India, that when women arrive, there is limited or no antenatal care, no birth attendants with midwifery skills, no emergency obstetric care in obvious cases of need, and referrals that never result in treatment (Subha Sri et al). And now, these same women have a sense of entitlement, and they are protesting.
Several governments in Latin America may be embarrassed to learn that their levels of budget transparency in spending on specific aspects of maternity care were found to be very low, and that they need better budgeting modalities, better health information systems and guidelines on how they might better capture data on expenditure, in order to track and plan local and national progress (Malajovich et al). Similarly, an assessment of cash transfer and voucher schemes designed to stimulate demand for services and reduce cost barriers to maternity care found increased use of maternity services in several south Asian countries, but also a need for more efficient operational management, financial transparency, plans for sustainability, evidence of equity and, above all, proven impact on quality of care and maternal mortality and morbidity (Jehan et al).
The papers [in this journal issue] describe a range of models for advocacy and taking action to expose violations of human rights, poor public health practices, absence of monitoring and regulation, failure to ensure national accountability for sexual and reproductive rights and to provide remedies and redress in the event of violations (Kismödi et al).
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!
16/08/2011 Comments Off on Why is abortion – and particularly repeat abortion – still perceived as a problem?
A study of repeat teenage pregnancies in women under 20 years old presenting for an abortion in England and Wales from 1991-2007 found that the number of women with recorded previous pregnancies had risen steadily from 1991 to 2007, both in absolute numbers and in proportion. The proportion of those who had a repeat abortion also rose.
However, this paper states that “it is difficult to fully ascertain the number of teenagers in the UK who have had more than one pregnancy before the age of 20 years” because figures for children born outside marriage are not recorded by the Registry Office. It was only data collected on abortions that allowed this study to be carried out. Because the number and proportion of abortions has risen, this author concludes that there is a worrying situation here – a conclusion that can only be based on the belief that more abortions are a bigger problem than fewer abortions.
I would suggest that this is not the correct perception. Younger people appear to be starting to have sex earlier than in the past (or perhaps they’ve been asked the question more often). That means that more of them may be at risk of unintended pregnancy. Teenage pregnancy is also perceived as a problem. And it certainly is, among those who cannot cope with a baby after it is born. According to recent research, approximately 50% of teenage conceptions end in abortion, not motherhood. But if more teenage pregnancies are ending in abortion, that should be seen as a good thing, because at least potentially it means fewer young women having children they cannot cope with.
Why then is abortion still perceived as a problem, particularly, though not only, if it happens more than once?
Every new generation of women and men has to learn things from scratch. Just because a growing range of contraceptive methods has been available since the 1960s, it doesn’t follow that adolescent girls and boys have any experience whatsoever with contraceptive use when they first start to have sex. Human beings often learn things the hard way – by making mistakes. Why is this frowned upon and treated as a major moral failing with contraception and even more so with abortion?
If 100 sexually active women don’t use any contraception, 80–90 will become pregnant within a year. Prevention of unintended and unwanted pregnancies is something that heterosexually active couples have to concern themselves with and take action on throughout their fertile years, especially since most people now have only a few children (and many have none or only one) and many want to delay childbearing for ten years or more after starting sexual relationships.
An unintended/unwanted pregnancy usually comes as a shock, and often acts as a wake-up call that no one is immune to getting pregnant, and to do better with contraception. Thus, the large majority of women who have an abortion have only one abortion. Given this fact, I believe it is a mistake to think that it is possible to reduce the abortion rate extensively – unless everyone using contraception uses long-acting or permanent methods that have almost no failure rate or user error.
That would mean no natural methods, no condoms (but what about protection from sexually transmitted infections and HIV?), no oral contraceptives (which are the most commonly used method), no diaphragms or caps, and no vaginal rings. Even injectables are only highly effective if you always remember to go back for the next injection on time. Female sterilisation and vasectomy have a very low failure rate and are well-liked, but only for those who have completed their families.
Implants last 3 years, the IUS lasts up to five years and the copper IUD up to ten years, but are they the method of first choice among women who may want to get pregnant in less than 3-10 years’ time? Should they be the only methods recommended to women perceived to be at risk of unwanted pregnancy? Do we really want to go down this limited and limiting road? The Department of Health appears to think the answer to this question is yes, but where is the evidence that women will accept it, that it will cost less than providing early abortions without problematising or punishing those who have more than one, or that it will reduce the number of unintended pregnancies, let alone abortions?
The fact is, as Lisa Hallgarten, Director of Education for Choice, pointed out to me when we were discussing repeat abortions this week, “someone who has taken sufficient risks to get pregnant the first time will probably do so again unless something changes – i.e. she and her partner experience a useful intervention”.
In case anyone thinks the UK is doing so badly in regard to repeat abortions, let’s look briefly at other countries. In Sweden a study published this year found that almost 40% of induced abortions were repeat abortions among women aged 20-49 having abortions. And Sweden is a country with long established sex and relationships education and a public health policy to enhance sexual and reproductive health. The highest “risk factor” found was parity. In other words, women who already had children were most likely to have one or more repeat abortions. This implies they had the number of children they wanted and were getting pregnant more than once when they didn’t want more. Other risk factors were lack of emotional support, unemployment or being on sick leave, tobacco use (probably related to lower socioeconomic status), and low educational level. In short, in addition to not wanting more children, they were among the most vulnerable women in society.
This and other articles make several useful recommendations. One is to look at the content and quality of sex and relationships education for those in school, to see whether it might be adapted better for vulnerable groups.
Another recommendation is to examine the barriers to effective contraceptive use and in contraception provision in abortion clinics themselves, following abortion. Studies have variously found that only a limited number of contraceptives may be offered in post-abortion care, and that methods requiring more skills may not be available. If women have to be referred elsewhere for some methods, timing of getting contraceptive advice and starting a method may not be optimal, and lead to lower levels of uptake and long-term usage.
A New Zealand study found that “compared to women who left the clinic with combined oral contraceptives, those leaving with an IUD at baseline were less likely to return for a subsequent abortion. Among women who had not had a previous termination, however, younger women were less likely than older women to have had an IUD inserted post-abortion. With every additional live birth, women were three times as likely to have left the abortion clinic with an IUD. Among women who had had a previous termination, age was no longer significantly associated with post-abortion IUD insertion. However, parity was still significantly associated, as was having a negative sexually transmitted infection test.”
Perhaps the most useful study I found was carried out by Sangeeta Das and colleagues from the Department of Obstetrics and Gynaecology, Royal Oldham Hospital, Oldham. They start by saying that in the UK, there are no agreed criteria for defining “’recurrent abortion seekers”. This is important, since it is possible for a woman to have an abortion every year – or as rarely as 3 or 5 or 10 or even 15 years apart. Hence, it is important from the outset to decide how frequently repeat abortions must occur before they are indicative of a “problem”, given the long duration of fertility and sex.
The Das et al study aimed to review the characteristics of women requesting termination of at least two consecutive pregnancies within 24 months of the first termination.The incidence of repeat abortion within a 24-month period was only 2.3%. This is far lower than the figures one usually sees.
Financial circumstances were the most common reason for seeking abortion (75%). The combined oral contraceptive pill and condoms were the most common forms of contraception used by these patients before the first abortion (35% and 38%, respectively). Long-acting reversible contraception (LARC) was used by only 8% of women before their first termination. However, although 58% accepted LARC following abortion, which would appear to support Department of Health policy, only 2% continued its use thereafter. And 50% of women were not using any contraception at the time of the repeat abortion. Hence, LARC may not be the answer at all in some cases. The fact is, contraceptive use itself may be the source of the difficulty.
The authors suggest that social workers and perhaps psychologists should be part of the peri-abortion counselling team, that contraceptive counselling should be geared to improving compliance and that follow-up to ensure continuing contraceptive use and involvement of partners in decision-making could help to reduce the incidence of repeat abortions.
Policy ignoring evidence?
Given the need for better education and guidance, I was disturbed to learn this week from a Guardian article  that with council budgets under pressure from government cuts, the posts of Teenage Pregnancy Coordinators (TPCs), who provide advice on sexual health, pregnancy and contraception to young people, often by mobile phone, have been axed since the beginning of 2010 in 56 Primary Care Trusts in England, or over a third of PCTs. These include Walsall, Tameside, and Waltham Forest in east London, who now have no dedicated TPCs, despite being among the 20 areas in England with the highest levels of teenage pregnancy.
Several TPCs interviewed in the article expressed concern that, because some areas have succeeded in reducing teenage pregnancy rates, attention to the issue was being downgraded as a priority because the policy had succeeded. This is obviously a very flawed understanding of the need for ongoing work with those needing support and attention from among the many new young people who are growing up and starting to have sexual relations every year.
Here are some of the issues that emerge from this brief look at the issues:
1. Is repeat abortion a problem? Or, how frequently must it happen before it should be treated as a problem?
2. Isn’t the real problem poor or intermittent or no contraceptive use? If so, surely it is imperative to support consistent and correct contraceptive use rather than assume that only by pushing specific methods (LARC) you will solve the problem on its own.
3. What social support is needed by those perceived to have a problem? Are TPCs available locally? Should they be? What other support is needed? Is it available? Who should provide it, where?
4. Does contraceptive counselling, provision, and choice of method for young people need to be improved? Are there dedicated services for young people? What about for women of any age who are at risk and vulnerable? What are the barriers to good contraceptive access and use? How can services be improved? All local FP clinics should be examined from this point of view – those in the community in primary care centres, those in hospitals, and those attached to abortion clinics.
5. What is the quality of sex and relationships education on the subjects of both contraception and abortion locally? Does it speak to the problems of those who are perceived to be at risk of unintended and unwanted pregnancy? Does it give sufficient information about abortion and seeking an abortion? Or does it merely moralise on the subject?
Before acting we need to find out the extent of the problem and who is at risk; to talk to women themselves, find out what their needs are and then decide what to provide, and how. Just blaming women doesn’t help; the role of partners is also key, as is social and economic and family circumstances.
Complex doesn’t have to mean problematic
Consistent and correct use of contraception makes it possible to space and limit births, and the UK has a high prevalence of contraceptive use.
Internationally, it has been shown that young age, lack of experience, lack of information, poor sexuality and relationships education, difficult home and living situations, abusive partners, poverty, low sense of self-worth and self-efficacy, and limited life choices all contribute to less than effective contraceptive use.
Single adolescent girls who become pregnant unintentionally may welcome a pregnancy and baby, especially those with limited life choices, because a baby gives them something to live for and a sense of self-worth. Some may have thought they wanted to get pregnant, but when it happens, the reality of a baby makes them realise that they wouldn’t be able to cope with it. Many young women seek abortions when they learn they are pregnant precisely because they could not cope with a baby, and/or in order to pursue other life choices, whether work or further education.
The longer women stay single, the more likely they are not to want a baby. If they are also not using contraception effectively, the more likely it is that they may experience one or more unintended pregnancies and seek an(other) abortion. Abortion is a solution for an unwanted pregnancy. It is legal, it is available, and it does not adversely affect health or fertility in this country anymore.
Unintended pregnancies remain common because fertility lasts from as early as age 12 to as late as age 49, contraception fails, people fail to use it consistently and correctly, they may stop using a method and not replace it with another for some time, a new partner may refuse to accept using a method, and so on. The literature on this is extensive.
One in three women in Britain will have an abortion in their lifetime. It’s time to see abortion as a solution, not as the problem.
 Collier J. The rising proportion of repeat teenage pregnancies in young women presenting for termination of pregnancy from 1991 to 2007. Contraception 2009;79:393-96.
 Hoggart L, Phillips J. Young people in London: abortion and repeat abortion. Research report. Department for Children, Schools and Families; Government Office for London. January 2010. At: < http://www.bpas.org/js/filemanager/files/tpyoungpeopleinlondonabortionandrepeatabortion.pdf>.
 See: Hallgarten L, Misaljevich N. Reducing repeat teenage conceptions: a review of practice. Education for Choice, 2007. At: <http://www.efc.org.uk/professionals/efc_research.html>.
 Makenzius M, Tydén T, Darj E, Larsson M. Repeat induced abortion – a matter of individual behaviour or societal factors? A cross-sectional study among Swedish women. Eur J Contracept Reprod Health Care 2011 Jul 21. [Epub ahead of print]
 Roberts H, Silva M, Xu S. Post abortion contraception and its effect on repeat abortions in Auckland, New Zealand. Contraception 2010;82(3):260-5. Epub 2010 Apr 14.
 Das S, Adegbenro A, Ray S, Amu O. Repeat abortion: facts and issues. J Fam Plann Reprod Health Care 2009;35(2):93-95.
 Williams R. Cuts threaten to undo progress on reducing teenage pregnancies. The Guardian (Society). 10 August 2011. p.30-31.