The barrier to abortion is politics

In 1972, 100 American professors of obstetrics published a statement setting out the benefits they believed legalised abortion could deliver for their nation and for its women. Forty years later, the next generation of professors have weighed their colleagues’ expectations against their own professional experience, and state: “We have had 40 years of medical progress but have witnessed political regression that the 100 professors did not anticipate”

The 100 American professors writing today document a barrage of policy and legal assaults that have impeded the development of the abortion services that their mentors strived to achieve. Abortion per se, they conclude, is no cause for clinical concern – but political opposition to abortion is. Conservative resistance to abortion has, according to the authors of the statement, brought threats to: the autonomy of the doctor-patient relationship; evidence-based medical practice; the training of students and residents; and, ultimately, the health of patients.

In short, insofar as abortion is a problem today, it is a matter of its politics, not its practice.

Advances in technology 

Today's obstetrics and gynaecology professors know, as a matter of proven fact, that high-quality, affordable, acceptable abortion services can be developed and that they bring social and personal benefits. Their concern is whether such services may be developed. When it comes to abortion, the question is: will governments allow doctors to do their best for patients?

The tremendous advances in reproductive health during the past 40 years are indisputable. In most countries in the developed North, women are better able to prevent pregnancy with a wider choice of more effective contraceptive methods. If abortion is necessary, in early pregnancy mifepristone and misoprostol provide an experience of early abortion that is similar to a ‘spontaneous miscarriage’ and in later pregnancy allow a much improved, and safer, experience of medical induction. Manual vacuum aspiration equipment provides low-cost treatment in low-technology settings, while improved anaesthesia allows conscious sedation and has lessened the risks when a general anaesthetic is required. Early abortions can now be provided in settings equivalent to doctors’ offices. Second-trimester abortions seldom require an overnight stay. 

USA political pressures 

But while technology has progressed, the political discourse has regressed. In the 1960s and 1970s, medical developments took place in the context of the social reforms and more liberal attitudes that have come to be regarded as characteristic of the ‘permissive society’. Today, social and political views are more muddled, and seem more concerned with restriction than permission. Doctors in both the USA and the UK practise in an environment where they must balance pressure to perform evidence-based medicine with pressure to conform to a social consensus that still sees abortion as a ‘problem’, regardless of clinical evidence.

Abortion doctors exist in a difficult and contradictory space because abortion straddles two worlds – medicine and politics – and so is contested like no other safe and legal procedure that a doctor undertakes.

Today's American professors describe how, in 2011 alone, 24 states passed 92 restrictions on abortion. Waiting periods after consent are now law in 26 states, despite medical evidence that the few clinical risks of abortion increase with increasing gestation. Eight states require patients to view ultrasound images, and four require them to listen to fetal heartbeats. Laws in 27 states force doctors to provide “deceptive counseling including false statements about the risks of breast cancer, infertility and mental health”; some “include laws to limit second-trimester abortion under the guise of protecting the fetus from pain”. In Arizona, Kansas and Texas, laws prohibit abortion training in public institutions, and “another seven states ban abortion in public hospitals, precluding training in them”. All of this has taken place without challenge to the ruling on the Constitutional right to privacy, enshrined in the landmark 1973 Supreme Court decision in Roe v Wade, which provided women (conditional) rights to abortion. 

Is the UK environment as restrictive? 

In Britain, unlike the USA, the law has barely changed in the past 40 years. The only amendments to the 1967 Abortion Act were made in 1990, in the context of broader legislation to regulate embryology and assisted reproduction; and these amendments did little more than introduce a 24-week gestational limit for most abortions while removing the time limit for abortion for fetal anomaly. Despite this, UK abortion providers have experienced the consequences of a climate of ‘political regression’ very similar to that in the USA. Our abortion doctors, like their American colleagues, face political threats “to the autonomy of our patient relationships, to evidence-based medical practice, to the training of our students … and, ultimately, to the health of patients”.

Increasingly, British politicians have sought to intrude into issues of abortion-related clinical practice, fuelling concern that abortion is unsafe and poorly regulated, despite substantial evidence to the contrary. In the past 2 years alone, government ministers have initiated investigations into allegations that women are denied appropriate counselling prior to abortion and that doctors provide unlawful abortions for the purposes of sex selection. The latter investigation cost more than £1 million and diverted the health care regulator, the Care Quality Commission (CQC), from other work while it deployed almost all its inspectors on a 3-day swoop of unannounced inspections of all UK abortion clinics.

The CQC found no evidence of illegally authorised abortions; nor did the regulator find that “any women had poor outcomes of care”. However, an official investigation of doctors’ administrative practices regarding the certification of abortion has resulted in the suspension of several doctors from related duties and their referral to the General Medical Council, despite no evidence that a single unlawful abortion has been carried out as a result of ‘pre-signing’ of certification forms. A Department of Health working party is currently drafting guidance on this matter, despite the fact that doctors have managed to practise lawfully for the past 40 years.

While official resources have been thrown at unnecessary measures to reinforce restrictions on abortion, attempts to redesign service delivery in line with clinical practice have been strenuously opposed. In 2011, the Secretary of State for Health strenuously opposed a High Court challenge brought by British Pregnancy Advisory Service (bpas) that would have allowed women home administration of the misoprostol required to complete early medical abortion – the ‘abortion pill’, used at gestations of 9 weeks and under. The Government's intransigence means that women in Britain are unable to benefit from some of the advantages of these medications, such as the way that the relative flexibility of the ‘abortion pill’ can allow women to manage childcare and work commitments more easily, and improve access for women from rural areas.

The reason British women are denied these advantages of early medical abortion – which are taken for granted in the USA, Sweden and other parts of the world – is that politicians deem the change to be too controversial. We are told that officials understand that the current restrictions are clinically unnecessary, but are concerned that any move to lift them will attract allegations that abortion is being liberalised. In short, to avoid abortion-related controversy, women in Britain are exposed to increased inconvenience; and the NHS, which pays for more than 80,000 early medical abortions every year, is being subjected to unnecessary costs.

We face more restrictive limits than our US colleagues on who can perform abortions, and where they can do it. In the UK, the law dictates that only registered medical practitioners, not nurses, can perform abortions and the growing climate is not conducive to young doctors opting for this specialism, nor for hospitals to offer and promote abortion training. Without these restrictions, most (early and straightforward) procedures could be undertaken by nurses, and could be provided in a wider variety of settings, as they are in the USA.

As in the USA, there are parts of the UK where women are unable to access any legal services at all. Abortion is no less clinically safe or necessary in Newcastle County Down than in Newcastle-upon-Tyne. Yet the legislation that permits legal abortion for unwanted pregnancy in England, Scotland and Wales has never applied to the six counties of Northern Ireland.

The political environment in the USA is very different to that in the UK. But the dislocation between the potential of clinical developments in abortion care, and the brake that political conservatism places on its practice, is similar. We do not experience the extremity of anti-abortion protest that has become wearily familiar to our American colleagues, and the invective of British politicians is more subtle: British doctors wear regulatory straightjackets, not bullet-proof vests.

Yet on both sides of the Atlantic, the problem is the same. Politics is allowed to trump medicine. 

Not a problem but a solution 

The political establishment sees abortion as a problem. Some politicians see it as a moral wrong to be prevented; others see it as a controversial inconvenience to be avoided. We, who work to care for women with problem pregnancies, see things through a different lens. We understand that abortion is a necessary fact of life in a society that values planned families. Abortion is not a problem; it is a solution to the problem of unwanted pregnancies. Politicians need to stand with doctors to address how best to deliver safe legal services of the highest clinical standard. Any laws and regulations that fail to facilitate this have no place in a civilised society. How excellent it would be for 100 British professors of obstetrics and gynaecology to stand with their American colleagues and examine what needs to be done to achieve this here.

This article was written by bpas Chief Execuative Ann Furedi and was originally published in the Journal of Family Planning and Reproductive Health Care.

Maternity services survey shows more choice, information and support needed

Today, the CQC has released its report on the 2013 survey of women's experiences of maternity care. The full findings can be accessed here.

It is good to see evidence of improvements in maternity services over the last 3 years, and it is encouraging to see more women feeling that they were always involved in decisions about their care. There are however clearly areas which remain a cause for some concern.

Women are not always being given choices about where they give birth, or given the information they need to help them decide. Around one in five felt that when they raised concerns during labour and birth that these were not taken seriously. On pain relief, nearly one in ten women (8%) who did not use the method they had planned to said they were told there were no staff to provide it, or not given an explanation.

It is good news that 81% of women said their infant feeding choices were always respected, but troubling that nearly half of women felt they did not always receive consistent advice on the subject. Some of the women who commented felt overwhelmed by the pressure to breastfeed, with a number saying this made them feel isolated and guilty. It’s important that at this time women get the information and support they need to make the decisions that are right for them.

Our Christmas campaign

Seasonal safe sex messages tend to involve raucous parties and office stationery cupboards. The reality is (unfortunately) often rather more mundane - less fumble on a photocopier, more forgetting to pick up the pill.  

Unplanned festive conceptions can become much wanted pregnancies, and in fact autumn last year was the busiest period in for births. But for many women, starting the New Year with an unplanned pregnancy can be a cause for considerable distress – and older women are no exception to this.

In January and February this year we saw nearly 4,000 women over 30 for advice about unintended pregnancy, including an average of 13 women over 40 each working day.

More than 80% of the over-30s we see are already mothers. Many tell us that sorting out their contraceptive needs has come low down on the to-do list as they prepare for a family Christmas.

Emergency contraception, already harder to access free of charge for older women, may be even more difficult to obtain in this period. At the same time, persistent messages about infertility in your 30s or 40s lead some women to believe they can take chances after an episode of unprotected sex. While fertility does decline after the age of 35, in our experience women can vastly overestimate how hard it is to become pregnant in your late 30s and early 40s.

Unplanned pregnancy isn't just an issue for young women. It can affect any sexually active woman at any stage of her reproductive lifetime, at any time of the year. We want women to be prepared with their contraception this Christmas - and avoid unwanted surprises in the new year.

Women in Northern Ireland don’t need a consultation – they need their government to act.

Northern Ireland’s justice minister has announced today that there will be a public consultation on changing the abortion law to allow pregnant women who have received a diagnosis of fatal foetal abnormality to have a termination in their own country. The consultation may also cover abortion in cases of rape or incest.

Northern Irish women with a diagnosis of foetal anomaly in pregnancy are devastated by being forced to travel to England to get the care they need. These cases are some of the most heart-breaking we see. The Northern Ireland Assembly needs to act now so that women already in the most harrowing of circumstances can access the help they need at home, with their loved ones nearby.

No way to treat women

Today, we placed this ad in the Irish Times to urge the Irish government to stop washing its hands of the 4,000 women who have to travel to Britain to access abortion care every year. 
 
We have treated many thousands of women from Ireland since the 8th Amendment to the Irish Constitution banning abortion was passed in 1983.

The Protection of Life During Pregnancy Act, which has still not come into force, will do nothing to help the women we see in our clinics every day. Irish women come to our clinics with their own very personal set of circumstances – from contraception failure on the eve of university to a serious problem being diagnosed with a much longed for pregnancy. But they are united in the fact that their lives and predicaments are wilfully ignored by the political establishment, which at the same time relies on Britain to ensure no-one has to live with the consequences of forcing women to bear children they feel unable to care for.

Because they have had to make the arrangements and find the funding for travel and treatment, their abortions are often carried out further into their pregnancies than those for women in England. Nearly a third of abortions for women from Ireland are carried out at 10 weeks and later, compared with just over a fifth of abortions for women from England. Abortion is an extremely safe procedure and much safer than childbirth, but the earlier it can be performed the lower any risk to women.

Banning abortion does not end it. Women will always find ways to end unwanted pregnancies – whether traveling to bpas or buying pills on the internet. Abortion is as much a fact of life for women in Cork as for women in Coventry or Carlisle. The women we see from Ireland are just like those from England – but made more desperate by the financial and emotional cost of having to travel. No politician, in a civilised country, should force women to make a journey abroad for abortion care. The decision alone is a tough enough journey.

bpas clinics provide the best of care – but women need clinics in Ireland. Until that happens we’re proud to help.

Dignity in Childbirth

Last week, we attended Birthrights’ Dignity Forum, the event which launched their campaign to promote Dignity in Childbirth.

It is incredibly important that women are treated with respect and given support, information and choice in childbirth -we see women whose experience of birth, in particular those who suffer from birth trauma, impacts on their decision whether or not to continue with a subsequent pregnancy.

The conference explored the varied experience of women in childbirth, both across UK and globally, set childbirth rights in the context of human rights law, and pointed to work that needs to be done to improve the care and support offered to women at this point in their lives.

Why dignity in birth matters

Professor Lesley Page, President of the Royal College of Midwives, opened the conference by setting out very clearly that dignity in birth matters because it is bound up in better outcomes. Respect, kindness and consideration ensure that the care provided is right for each individual woman, leading to better physical and emotional outcomes for the woman, baby and family.

Dignity can be provided by simple actions such as medical staff introducing themselves or knocking before entering a private room. However, services have been hit by both a birth rate increase that has far outstripped any rise in midwife numbers, and also an increase in the number of women presenting with complex healthcare needs, such as those with high BMIs. This is making it more difficult for midwives to always be able to deliver the service they want to provide for women.

Professor Page acknowledged that the survey does indicate there is a distance to go to ensure choice, control and dignity in childbirth – but she stressed that maternity service workers are passionate about raising standards, and are already working hard to achieve this.

Dignity in childbirth is a human right

It was incredibly useful to hear childbirth discussed in the context of human rights. Helen Mountfield QC argued that whilst dignity may seem like an elusive concept, hard to pin down, it is at the heart of human rights with Article 1 of the UN Universal Declaration of Human Rights states that "all human beings are born free and equal in dignity and rights." Helen Wildbore of the British Institute of Human Rights also outlined the ways provisions in the Human Rights Act are applicable to childbirth, from Article 3 which prohibits inhumane or degrading treatment to Article 8 which protects the right to respect for private and family life.Yet despite dignity being a core right, it can prove difficult to exercise. Helen Mountfield QC argued that this was particularly true for women, who can unfortunately be used to being told that what they need or want to actualise their choices just isn't available. In our experience, this is certainly true with regards to a range of reproductive healthcare options, from what type of contraception women are able to access to their choice of where to give birth.

Respectful treatment and maternal health globally

The White Ribbon Alliance presented their Respectful Maternity Care campaign video, which we really recommend watching, and spoke about their Universal Rights of Childbearing Women Charter.

Childbirth is the biggest killer of women globally but real progress is being made - over the last ten years the rates of maternal mortality have halved. But, as Brigid McConville of the WRA said, “we need to reach the other half.”

Respectful care can play a vital role in reducing maternal mortality rates as fear and distrust of medical professionals acts a huge barrier to women attending health centres. Stories of abuse, such as women being held against their will because they were unable to pay for their care or being forcibly shaved during labour, have, understandably, an incredibly negative impact on women’s decision to use maternity care services. As fear can be a more powerful deterrent than geographical and finical obstacles, respectful care must be a priority to in the drive to reduce maternal mortality rates globally.

Choice in birth and the C-section question

The issue of choice in birth was central to the Dignity in Childbirth survey. The survey found that only 68% of women were given a choice of where to give birth, 31% of women said that they did not feel in control of their birth experience and 15% of women were unhappy with the availability of pain relief. The survey did find overall women that women were satisfied with the care they received, yet there were a significant variations and areas of concern.

Only half of the women surveyed said that they had the birth they wanted. Whilst a greater proportion of women who had caesarean sections reported they did not have the birth they wanted (64% of those surveyed), it would be useful to see more research in to this which differentiates between women’s experience of planned and emergency c-sections.

Pauline Hull, co-author of Choosing Cesarean, A Natural Birth Plan and editor of electivecesarean.com , raised the importance of this distinction in questions about caesareans. In her presentation, she suggested that dignity, respect and support are very much absent from discussions around elective c-sections. This is a rational birth choice that should be campaigned for by those who want to ensure dignity in childbirth for women, Hull argued. It was positive to hear from many speakers that choice should be at the centre of all discussions around childbirth, and that more must be done to ensure that women are able to exercise their autonomy at this time.

As Carrie Longton, the co-founder of Mumsnet, said during her presentation, birth is not the most important thing about becoming a parent, but it is a moment in a mother’s life and in her baby’s life that they will never be able to change. The idea that “as long as the baby is healthy that’s all that matters” is simply not true. Women need to feel part of the decision making process, they should have their views respected, and they should be able to make the choices that are right for them. They deserve nothing less.

Trusting women is the right choice for politicians of all parties

This is a post by our Chief Executive Ann Furedi in advance of our fringe events at Labour Party conference in Brighton on Tuesday 24th September at 12:45pm, and Conservative Party conference in Manchester on Monday 30th September at 1pm. Both events are open to all and not just for those attending the conferences.

State support is vital to family life. Women, especially, know this. Without access to reliable, affordable childcare, women can’t work. Without access to contraception and abortion women, can’t plan to have the number of children they want, or when to have them. Without access to good schools, women can’t ensure that their children will get the education they need. We all need social resources to draw on, and the more impoverished, excluded and disadvantaged we are, the more support we may need. But our need for resources does not confer a right or an obligation to meddle in the personal decisions we choose to make for ourselves and our families.

Today, some politicians and policy makers seem to assume that people, especially those from disadvantaged backgrounds, can’t be trusted to do what is right. And so increasingly policies are introduced that ‘nudge’ people towards what appropriate professionals decide are the ‘right’ choices, and away from the ‘wrong’ ones. This causes problems: what seems to be a quick-fix policy to influence behaviour can turn into a short-cut to calamity for individuals.

British Pregnancy Advisory Service (bpas) runs clinics and advisory centres that provide counselling and care for more than 60,000 women each trying to avoid or manage problem pregnancies. We see the impact of playing politics with people’s personal decision-making when it impacts on their sexual and reproductive health.

We see young women pregnant because their doctors, encouraged by targets intended to increase uptake of long-acting (super-effective) methods of contraception, have persuaded them to accept an implant which they didn’t really want and, having had it removed, are reluctant to go back for the (less effective, but good enough) pills they preferred.

We see new mothers pregnant because healthcare workers have exaggerated the contraceptive effects of breastfeeding in the drive to encourage women to resist formula feeding.

We see women pregnant unintentionally having become convinced they are infertile after  being subjected to exaggerated accounts of the risks posed by common infections, such as chlamydia, by campaigns trying to  scare them into ‘sexual responsibility’

We see the fallout of initiatives to deter heavy drinking in pregnancy that advise pregnant women to avoid alcohol altogether in the belief that women are unable to gauge their own alcohol consumption: women so terrified they have harmed their fetus they consider abortion.

We suffer interference from a few politicians convinced that women are incapable of making informed, personally-intelligent choices about whether to continue their pregnancy without the involvement of an ‘independent’ outsider to counsel them.

Women need evidence-based information on which to base their choices. Our message this year to politicians of all parties is this: tell people the naked truth and trust them to make decisions for themselves. When it comes to reproductive choices women are the ones best placed to make their own decisions, from what contraception she uses to prevent unwanted pregnancy to how she gives birth to a much wanted baby. Trusting women is the right choice for all of us.

The fertility "clock strikes 12" at 35

Today there has been another wave of articles generated from the latest “fertility time bomb” warning from reproductive scientists. However, we are concerned that these admonitions are issued in a way that completely ignores the reality of women’s lives and the very understandable reasons why women are choosing to have children later in their thirties. 

In our experience there are many factors which lead women to delay starting their families into their thirties. Career pressures may be among them, but this is often closely related to women wanting financial security before having a baby, and indeed their own home. The importance of being in the right relationship is for many women paramount, as few want to take on the responsibility of parenthood with a partner they are unsure about.

We also need to be wary of overstating the risks of later motherhood. If anything many women now overestimate the difficulties of getting pregnant after the age of 35 - we see many women in this age group with unplanned pregnancies after taking chances with contraception because they believed their fertility had declined dramatically. We need to work harder to understand the reasons for later motherhood and not scaremonger or stigmatise those who make the rational and considered choice to delay starting their families until they are ready.