Tuesday 13 May 2014

‘Repeat’ abortion and ‘late’ abortion: the reality behind the controversy

Two important new studies examine women’s reasons for having abortions, dispelling many the myths that surround abortions later in pregnancy, or women who have more than one abortion.

Access to later abortion in Scotland

Carrie Purcell of the University Edinburgh and colleagues conducted in-depth interviews with 23 women presenting for abortion at 16 or more weeks’ gestation in Scotland. Scottish women face a particular problem in accessing abortion, as abortion for reasons other than fetal anomaly is not usually provided in Scotland after 18-20 weeks.

The study found that some of the women did not realise they were pregnant until relatively late in pregnancy, sometimes because they were using contraception. Some of the women took ‘were ambivalent about both the pregnancy and the prospect of having an abortion’, which leading a delay in accessing services. A further group of women ‘had initially decided to carry their pregnancies to term experienced changes in life circumstances that were largely beyond their control, and the subsequent decision to have an abortion led to a later presentation for health services.’

These findings support those of other studies about British women’s reasons for seeking late abortion – notably, the work by Roger Ingham and colleagues, which revealed why, no matter how much access to abortion early in pregnancy is improved, a proportion of women will always need access to later abortions – because they don’t realise they are pregnant, or their circumstances change, or they need time to make their decision.

The new study by Purcell and colleagues additionally found that in Scotland, access issues in later abortion present a major additional problem. While 13 out of the 23 participants were able to have an abortion locally, others had to deal with the financial, logistical, and emotional burden of travelling to England. The authors write:

‘Women who did travel to England had to mobilize a range of resources, including financial, practical and emotional support, and access to these varied. Travel costs – train tickets or flights and 2–3 nights’ accommodation, booked at short notice – were high. The women who travelled were in a range of socioeconomic positions, but none found it easy to obtain such funds, and none was clear on how to claim reimbursement from health services. Una – who was 24 and had an abortion at 21 weeks –had been able to fund a trip to England, but she was informed while en route that because of a health complication, she could not have the procedure at that time. This necessitated her returning home (a 17-hour round-trip) and rebooking travel and accommodation for the following week.’

The authors also note the contradiction that women having treatment for miscarriage, or abortions for fetal anomaly, did not have to go to England for these procedures, and the women in their study ‘felt there was judgment in this disparity’. The authors’ conclusions are worth quoting in full:

‘Many reasons for later presentation at health services could not have been foreseen by the women we interviewed. Our findings suggest that women need adequate time to consider the conflicting candidacies of motherhood and having an abortion, and that the additional work required to obtaina later abortion is a source of inequity. Indeed, women who have to travel for an abortion are aware of the differential service provision between themselves and others being treated locally for later miscarriage or fetal anomaly. The burden of traveling to England presents one of the most significant barriers to later abortion for women in Scotland, exacerbates an already potentially difficult experience, and contributes to abortion stigma and discrimination. This study highlights that it is not only in countries with restrictive abortion laws that women face barriers to service access. Future efforts to improve health care services should include a policy focus on reducing barriers to abortion access and improving provision of later abortion.’

Young women’s contraceptive use after abortion
Another study, conducted for the reproductive health charity Marie Stopes International, looked at the contraceptive use of women aged 16-24 having one or more abortions. Interviews were completed by 430 women aged 16 to 24 who booked an abortion at its centres, 121 of whom had previously had an abortion.
This study found, strikingly, that more than half (57%) of women were using contraception when they became pregnant. The majority were using short-term methods, such as the pill (54%) or condoms (40%); and 12% had used emergency contraception.
The study further found that uptake of contraception at four weeks post-abortion was high, at 86%, but 67% used their chosen method for less than a year. Reasons for stopping included menstrual irregularities for long-acting reversible contraception (LARCs) and not renewing supply in time for pills and injections.
The full report of the MSI study has yet to be released. However, an excellent commentary by Lisa Hallgarten on the Reproductive Health Matters website provides some context. Hallgarten writes:
‘When I and a colleague at Education For Choice undertook research into the phenomenon of repeat conceptions leading to repeat abortion amongst teenagers in 2007, it became clear very quickly that the term “repeat abortion” is a misnomer. It suggests that a woman is in some way thoughtlessly or compulsively repeating a negative action, whereas the truth is that each abortion is a separate and unique event in a woman’s life. Whether her abortions take place within a year, or twenty years apart, her circumstances, health, the status of her relationship and her emotional attachment to the pregnancy may all be very different. The way in which she got pregnant, her chosen method of contraception and consistent or inconsistent use of that method may also have changed from one unintended pregnancy to the next. Having a “repeat abortion” may engender feelings of guilt at ‘failing’ to prevent a second pregnancy, or it may feel safe, straightforward and familiar the second time round. When we talk about “repeat abortion” we make this complexity and the stories of women’s real lives invisible.’
Hallgarten goes on to talk about the way in which the stigma surrounding ‘repeat’ abortion can have an adverse effect on women’s contraceptive decision-making. ‘Feeling bad about a first or “repeat” abortion is not a good basis for making a positive choice about future contraception,’ she writes. ‘It can result in feelings of fatalism (which is very bad for decision-making); lack of trust in service providers or feeling untrusted by them; or agreeing to, rather than positively choosing, a recommended method of contraception. Likewise professional anxiety about preventing future unintended pregnancy may result in promoting, rather than offering, long acting reversible contraceptive methods.’
Hallgarten concludes:
‘I only wish that we could lose the idea that the most effective way to reduce stigma is by reducing the incidence of “repeat abortion”. This idea reinforces the messages from politicians, funders and the media that tell us “abortion just about ok, repeat abortion bad”. But what if we can’t eradicate “repeat abortion” simply by improving contraceptive services? What if, as our research found, women’s complex and sometimes chaotic lives and relationships play as much part in unintended conceptions as contraceptive provision or lack of it? What if, as is increasingly being articulated, there are women who simply cannot find a contraceptive method that works for them. Shouldn’t we focus on reducing the stigma of “repeat abortion” in and of itself?

‘Abortion is not the onerous journey it once was: the procedures can be provided very early and are extremely safe. If a woman feels happiest using a less reliable contraceptive method such as condoms and doesn’t see having one, two or three abortions across her 35 fertile years as a problem, why should we?’

This post was originally published on the bpas Reproductive Review

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